§ 555.22. Preoperative care.
(a) Pertinent medical histories and physical examinations, and supplemental information regarding drug sensitivities shall be documented the day of surgery or one of the following:
(1) If medical evaluation, examination and referral are made from a private practitioner’s office, hospital or clinic, pertinent records thereof shall be available and made part of the patient’s clinical record at the time the patient is registered and admitted to the ASF. This information is considered valid only if the evaluation was performed no more than 30 days prior to date of surgery.
(2) A practitioner shall examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. The information shall be clearly documented in the medical record.
(b) A written statement indicating informed consent, obtained by the practitioner, and signed by the patient, or responsible person, for the performance of the specific procedures shall be procured and made part of the patient’s clinical record. It shall contain a statement which evidences the appropriateness of the proposed surgery, as well as any alternative treatments discussed with the patient. It shall also identify any practitioner who will participate in the surgery.
(c) Written instructions for preoperative procedures, which have been approved by the medical staff, shall be given to the patient or responsible person, and shall include:
(1) Applicable restrictions upon food and drink before surgery.
(2) Special preparations to be made by the patient.
(3) The required proximity of the patient to the ASF for a specific time following surgery, if applicable.
(4) An understanding that the patient may require admission to the hospital in the event of medical need.
(5) Upon discharge of a patient who has received sedation or general anesthesia, a responsible person shall be available to escort the patient home. With respect to patients who receive local or regional anesthesia, a medical decision shall be made regarding whether these patients require a responsible person to escort them home.
(d) Preoperative diagnostic studies, if performed, shall be evaluated, annotated, signed and entered into the patient’s medical record before surgery.
(e) Prior to the administration of anesthesia, it is the responsibility of the primary operating surgeon and the person administering anesthesia to properly identify the patient and the procedure to be performed and to document this identification in the patient’s medical record. This procedure shall be in written policies designating the mechanism to be used to identify each surgical patient.
Source The provisions of this § 555.22 amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial pages (256563) to (256564).
Cross References This section cited in 28 Pa. Code § 553.22 (relating to admission criteria); and 28 Pa. Code § 555.24 (relating to post-operative care).
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