Outpatient Surgery and Ambulatory Services Policy and Procedure Manual
Outpatient Surgery and Ambulatory Services Policy and Procedure Manual
About this Manual
Outpatient Surgery and Ambulatory Services Policy and Procedure Manual is a manual containing many of our policy and procedure templates for the medical office, hospital, and other healthcare organizations. The policies cover: Joint Commission (JCAHO or TJC) • CMS • HIPAA • CDC • AAAHC and more.Want access to all our manuals? Click here
SECTION I - ETHICS, RIGHTS AND RESPONSIBILITIES
Patient Rights and ResponsibilitiesPediatric Rights and Responsibilities of Parents/GuardiansExpected Patient OutcomesInformed ConsentEmancipated MinorsConsent RequirementsAuthorization for and Consent to Surgery or Special Diagnostic or Therapeutic ProceduresPhysician Responsibility for Obtaining Sterilization ConsentSterilization Consent RequirementsBlood/Blood Component - Informed ConsentBlood/Blood Component Transfusion Consent FormPhotographing/Videotaping PatientsAuthorization and Consent Form - Photograph and PublicationRefusal of Blood/Blood Component TransfusionRefusal to Permit Blood/Blood Component Transfusion FormAdvance DirectivesDo Not Resuscitate (DNR)CommunicationConflict ResolutionConfidentiality of Information - General IssuesSecurityPatient Rights and Responsibilities for Pain ManagementPain Management Policy StatementStaff Rights and Ethical Dilemmas in Patient CareResolution of Potential Conflict with Staff Member's Cultural/Ethical/Religious Belief System
SECTION II - PROVISION OF CARE, TREATMENT AND SERVICES
Admission/Assessment
Patient ReferralEligibility CriteriaOutpatient Surgery Admission CriteriaPreadmissionPediatric PrescreeningAdmission Process - Outpatient SurgeryOutpatient Surgery RequirementsAppropriateness of ProcedurePreoperative Diagnostic TestsHistory and Physical - Outpatient SurgerySupplemental Eye History and Physical Exam - Sample FormInitial Patient Assessment and ReassessmentOutpatient Surgery Preoperative Nursing Assessment FormCare of the Latex Sensitive PatientLatex Allergy Assessment FormLatex and Non-Latex AlternativesPain Assessment, Reassessment and ManagementPain Assessment in ChildrenPain Scale, Admission Pain HistoryPain Scale ExamplesBehavioral-Physiological Pain Scale for Nonverbal or Preverbal PatientsSuspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/ExploitationAbuse and Neglect Reporting
Planning Care, Treatment and Services
Patient Identification for Clinical Care and TreatmentCollection of Health Status Data for Nursing DiagnosisNursing DiagnosisPlan of CareImplementation of Plan of CareEvaluation of Plan of CareRevision of Plan of CareOutpatient Surgery Nursing Plan of Care FormStandard of Care - Outpatient Surgery - Fear and AnxietyStandard of Care - Outpatient Surgery - Patient/Family EducationStandard of Care - Outpatient Surgery - Nausea and/or Vomiting PostoperativelyStandard of Care - Outpatient Surgery - Appropriateness of Discharge
Administering Blood and Blood Components
Surgical and Anesthesia Policies
Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person SurgeryAttending Physician ResponsibilitiesInvasive Procedure Site IdentificationSurgical Site IdentificationAnesthesia ResponsibilitiesPre and Post Anesthesia Evaluation FormSedationSedation Monitoring FormAssessment Prior to Induction of Anesthesia/SedationAnesthesia AwarenessAnesthesia Record FormBody Piercing JewelrySkin AssessmentSurgical Checklist and Preoperative Nursing Record FormIntraoperative Nursing Record FormSample Bronchoscopy Procedure RecordAccountability for Sponges, Sharps and InstrumentsSkin Preparation ProtocolPatient PositioningUse of Immobilization DevicesUse of Pneumatic TourniquetPathology SpecimensFrozen Section ProtocolLegal Evidence - Chain of CustodyCardiopulmonary Resuscitation in the Operating RoomManagement of Patient with Malignant HyperthermiaMalignant Hyperthermia CartPediatric Patient in the OR (Parent Present During Induction)PACU Admission ProtocolPost Anesthesia Care Unit Record FormUse of PACU Scoring GuidelinesDischarge from PACUPost Endoscopic Procedure RecoveryPhysician Notification of Change in Patient ConditionTransport of PatientsTissue and Cell AcquisitionReceiving, Inspecting and Documentation of Tissue and Cells VerificationStorage of Tissues and CellsStorage of Tissue in the Event of the Loss of RefrigerationTissue Refrigerator/Freezer Maintenance ProceduresRequest for TissueDocumentation of Tissue ImplantationReporting Adverse Tissue Reactions
Other Patient Care Procedures
Bone Marrow Aspirations, Assisting withCritical Tests and Critical Results and Values Reporting"Hand-Off" Communication"Hand-Off" Communication in the Perioperative SettingIntravenous TherapyPrevention of Tubing/Catheter MisconnectionsRestraint Use for the Management of Nonviolent, Non-Self Destructive Behavior24-Hour Restraint Record FormTherapeutic PhlebotomyUse of Clinical Alarms on Medical EquipmentWaived Testing
Patient/Family Education
Discharge/Transfer
Discharge InstructionsOutpatient Post-Op Instructions and Physician's OrdersOutpatient Post-Op Instructions and Physician's Orders - CataractOutpatient Post-Op Instructions and Physician's Orders - D&COutpatient Post-Op Instructions and Physician's Orders - GI PatientsOutpatient Post-Op Instructions and Physician's Orders - HerniaOutpatient Post-Op Instructions and Physician's Orders - Laparoscopy - GYNOutpatient Post-Op Instructions and Physician's Orders - Orthopedic ProcedureOutpatient Post-Op Instructions and Physician's Orders - Post TransfusionOutpatient Post-Op Instructions and Physician's Orders - TonsillectomyDischarge Criteria - Surgical PatientsPostoperative Follow-Up EvaluationPostoperative Follow-Up Evaluation Form23-Hour Hold/Short Stay ObservationDischarge From Ambulatory Care Services DepartmentPatient Transfer to Another Facility - InterfacilityNursing Transfer Summary FormPatient Transfer and Referral Record FormSample Transfer AgreementList of Transfer Agreements
SECTION III - MEDICATION MANAGEMENT
Medication Reconciliation/VerificationMedication Reconciliation/Verification FormPatient Drug ProfilesProcurement of MedicationsOrdering and Receiving Radioactive MaterialsAutomated Dispensing Machines - Policies and ProceduresAutomated Dispensing Machines - Access ToAutomated Dispensing Machines - Stock MedicationAutomated Dispensing Machines - Controlled SubstancesControlled Drug ManagementNarcotic KeysDisposal of Controlled Substance PatchesConcentrated Electrolyte Solutions and Other Drug ConcentrationsEmergency Crash CartsEmergency Crash Cart Security and AccountabilitySample Crash Cart and Defibrillator Checklist Signature FormEmergency Medications ListTelephone, Verbal and Written Orders for MedicationPediatric Dosing - General GuidelinesPediatric Dosing Guidelines for Emergency MedicationsRange Orders for MedicationsMedication Ordered STAT and at Specified Time IntervalsStanding OrdersAutomated Dispensing Machines - Emergency/STAT Medication OrdersMedications Acquired from Outside Sources by an LIPMedication RecallUnusable and Outdated DrugsDrug Product DefectsMedication AdministrationMedication and Solution Administration - Invasive ProceduresMedication and Solution Administration in the ORAdministration of Preoperative AntibioticsAutomated Dispensing Machines - Removing MedicationsEMLAUse of Multiple Dose Vials (MDVs)Safe Medication PracticesDecreasing Medication ErrorsAdverse Drug Reaction ReportingAdverse Drug Reaction Reporting FormAdverse Drug Report FormPotential Adverse Drug Reaction FormMedication ErrorsMedication Inadvertent Incident ReportMedication Inadvertent Incident Report FormPerformance Improvement Analysis - Medication Inadvertent Incident FormMedication Error Analysis ToolHigh Alert Medication ManagementYour Facility's List of High-Risk/High Alert MedicationsMedication Management Program
SECTION IV - SURVEILLANCE, PREVENTION AND CONTROL OF INFECTION
Standard PrecautionsTransmission-Based Precautions (Isolation Precautions)Isolation Precautions in Outpatient SurgeryInfection ControlManagement of Patients with Methicillin Resistant Staphylococcus Aureus (MRSA)AsepsisAttire in the Operating RoomHand Hygiene - CDC GuidelinesSurgical Hand ScrubWaterless, Scrubless, Brush-Free Surgical Hand Rub AntisepticGowning and Gloving TechniqueClosed Gowning and Gloving TechniqueOpen Gloving TechniqueOperating Room TechniqueInfection Control Surveillance - Outpatient SurgerySurgical Wound ClassificationsVisitor ControlTraffic Patterns in the Surgical SuiteSelection of Barrier Materials for Surgical ProceduresEvent-Related Shelf Life - Sterile StorageFlash SterilizationReprocessing of Single-Use DevicesGlutaraldehyde MonitoringHigh-Level Disinfection of EndoscopesEndoscopic Equipment Preparation and InspectionHousekeeping ProceduresManagement of Accidental Blood or Body Fluid Exposure/ContaminationDisposal of SharpsSharps Injury Protection PlanSharps Injury LogDefinition of Biohazardous WasteHandling of Biohazardous Waste
SECTION V - IMPROVING ORGANIZATION PERFORMANCE
Performance Improvement PlanOutpatient Surgery/Ambulatory Care - PI Monitoring and Evaluation PlanOutpatient Surgery/Ambulatory Care - PI Trending SheetOutpatient Surgery/Ambulatory Care - PI Outcome EvaluationOutpatient Surgery/Ambulatory Care - PI Volume Measures/StatisticsAmbulatory Care Services Utilization Review for Appropriateness of CareAmbulatory Care Services - Patient Satisfaction Survey FormServicios Al Paciente Externo - Cuestionario de la Satisfaccion de la Paciente FormaMonth-End Statistics - ReportingAmbulatory Care Services Annual Statistics FormSentinel EventPerformance Improvement Department - Notification FormPerformance Improvement Incident Analysis FormIncident Reporting Staff Questionnaire Form
SECTION VI - LEADERSHIP
Mission and GoalsPhilosophy and ObjectivesAdministration of Ambulatory Care ServicesOperational Standards and Service - Specific Policies and ProceduresPlanning Process for Ambulatory Care ServicesOrganizational Components of Ambulatory Care ServicesOrganizational ChartPlan for Delivery of ServicesOrganization and AuthorityResponsibility of Medical Director for Ambulatory Care ServicesResponsibility and Accountability to the Medical Staff and AdministrationAnesthesia ServicesScope of Services OfferedOutpatient ProceduresProcedures Not Acceptable for Outpatient SurgeryGeneral PoliciesScheduling Outpatient SurgeriesDelivery of Nursing CareApproval and Use of Contracted ServicesFinancial Incentives/Clinical Decision Making
SECTION VII - MANAGEMENT OF THE ENVIRONMENT OF CARE
Emergency CodesAmbulatory Care Services SafetyPatient Safety in the Operating RoomHazardous Materials and Waste - TrainingHow to Read Safety Data Sheets (SDS)Compressed Gas and Oxygen UseMonthly Radiation Exposure Monitoring (Dosimeter)Facility Emergency Management ResponseFire SafetyTypes of Fire ExtinguishersFire Safety in an Oxygen Rich Environment - Operating RoomOperating Room Risk Assessment and Preventive Measures Checklist - Fire SafetyLaser Surgery - Practice and SafetyElectrosurgical Unit SafetyElectrical Equipment SafetyInfusion Pumps - Equipment Inspection, Care and MaintenanceMaintenance and Repair of Patient Care EquipmentRequired Life Support EquipmentWarming CabinetsLine Isolation Monitor SystemMedical Device Reporting and TrackingMedical Device Recall
SECTION VIII - MANAGEMENT OF HUMAN RESOURCES
Position Description/Performance Evaluation - Ambulatory Care Services DirectorPerformance Evaluation - Population-Specific/Age-Related Competency - Ambulatory Care Services DirectorAnnual Competency Clinical Skills Assessment - Ambulatory Care Services DirectorPosition Description/Performance Evaluation - Ambulatory Care Services Nurse ManagerPerformance Evaluation - Population-Specific/Age-Related Competency - Ambulatory Care Services Nurse ManagerAnnual Competency Clinical Skills Assessment - Ambulatory Care Services Nurse ManagerPosition Description/Performance Evaluation - Ambulatory Care Outpatient Surgery RNPerformance Evaluation - Population-Specific/Age-Related Competency - Ambulatory Care Outpatient Surgery RNAnnual Competency Clinical Skills Assessment - Ambulatory Care Outpatient Surgery RNPosition Description/Performance Evaluation - Ambulatory Care Outpatient Surgery LPN/LVNPerformance Evaluation - Population-Specific/Age-Related Competency - Ambulatory Care Outpatient Surgery LPN/LVNAnnual Competency Clinical Skills Assessment - Ambulatory Care Outpatient Surgery LPN/LVNPosition Description/Performance Evaluation - Ambulatory Care Operating Room TechnicianPerformance Evaluation - Population-Specific/Age-Related Competency - Ambulatory Care Operating Room TechnicianAnnual Competency Clinical Skills Assessment - Ambulatory Care Operating Room TechnicianPosition Description/Performance Evaluation - Ambulatory Care Pain Management RNPerformance Evaluation - Population-Specific/Age-Related Competency - Ambulatory Care Pain Management RNAnnual Competency Clinical Skills Assessment - Ambulatory Care Pain Management RNPosition Description/Performance Evaluation - Ambulatory Care Services SecretaryPerformance Evaluation - Population-Specific/Age-Related Competency - Ambulatory Care Services SecretaryAnnual Competency Skills Assessment - Ambulatory Care Services SecretaryNew Employee OrientationOutline of Inservice Orientation to Ambulatory Care for RNs and LPNs/LVNsOutpatient Surgery Orientation and Skills ChecklistStaff Qualifications and CompetencyOutpatient Surgery Clinical Competency Test - Annual ReviewRestraint Application/Removal Competency Checklist - Acute Medical Surgical SettingEducation and TrainingEducation ProfilesContinuing EducationAnnual Required Training UpdateCardiopulmonary Resuscitation Training RequirementsStudent Role/PreceptorshipsMedical Management and Clinical Direction of Patient Care in the Ambulatory Care SettingDress Code
SECTION IX - MANAGEMENT OF INFORMATION
Medical Record ContentAmbulatory Care Medical Record RequirementsUse of Summary ListSample Summary List - Ambulatory Care ServicesDocumentation of Operative and Other High-Risk ProceduresLegibility of Medical Record DocumentationVerbal and Written Orders - GeneralAcceptable Abbreviations ListUnacceptable Abbreviation and Symbol ListSurgical Logbook