MCN Healthcare: Policy Management and Compliance Tools

Home » Policy Library » Surgical Services Policy Procedure Manual

View Policies By Last Update

Surgical Services Policy and Procedure Manual

Surgical 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.

One Year Online Subscription

$229.99

Changes

Surgical Services.11.changes Most current changes

Table of Contents - TJC, NIAHO standards Table of Contents - JCI standards Copyright Disclaimer Approval/Signature Sheet Introduction

SECTION 01 - EMERGENCY MANAGEMENT

Surgical Services Emergency Response Surgical Services Nurse Manager Responsibilities During an Emergency Staff Call-Back Tree Emergency Management Call-Back Tree Sample Emergency Management Responder List

SECTION 02 - ENVIRONMENT OF CARE

Surgical Services Safety Body Mechanics Training Body Mechanics - Staff Education Handout Patient Safety in the Operating Room Monthly Radiation Exposure Monitoring (Dosimeter)Hazardous Materials and Waste - Training How to Read Safety Data Sheets (SDS)Chemical Training Record Form Formalin Use in the OR Chemotherapy Handling - Surgical Services Methyl Methacrylate Bone Cement Compressed Gas and Oxygen Use Fire Safety - Surgical Services Types of Fire Extinguishers Fire Safety in an Oxygen Rich Environment - Operating Room Operating Room Risk Assessment and Preventive Measures Checklist - Fire Safety Electrical Equipment Safety Electrosurgical Unit Safety Air- or Gas-Pressurized Sprayers in the Operating Room Warming Cabinets Maintenance and Repair of Patient Care Equipment Required Surgical Services Life Support Equipment Line Isolation Monitor System Laser Surgery - Practice and Safety Medical Device Reporting and Tracking Medical Device Recall Notification

SECTION 03 - HUMAN RESOURCES

Position Description/Performance Evaluation - Surgical Services Nurse Manager Performance Evaluation - Population-Specific/Age-Related Competency - Surgical Services Nurse Manager Annual Competency Clinical Skills Assessment - Surgical Services Nurse Manager Position Description/Performance Evaluation - Surgical Services Charge Nurse Performance Evaluation - Population-Specific/Age-Related Competency - Surgical Services Charge Nurse Annual Competency Clinical Skills Assessment - Surgical Services Charge Nurse Position Description/Performance Evaluation - Surgical Services Circulating RN Performance Evaluation - Population-Specific/Age-Related Competency - Surgical Services Circulating RN Annual Competency Clinical Skills Assessment - Surgical Services Circulating RN Position Description/Performance Evaluation - Surgical Services Scrub Nurse Performance Evaluation - Population-Specific/Age-Related Competency - Surgical Services Scrub Nurse Annual Competency Clinical Skills Assessment - Surgical Services Scrub Nurse Position Description/Performance Evaluation - Surgical Services Operating Room Technician Performance Evaluation - Population-Specific/Age-Related Competency - Surgical Services Operating Room Technician Annual Competency Clinical Skills Assessment - Surgical Services Operating Room Technician Position Description/Performance Evaluation - Surgical Services Pain Management RN Performance Evaluation - Population-Specific/Age-Related Competency - Surgical Services Pain Management RN Annual Competency Clinical Skills Assessment - Surgical Services Pain Management RN Position Description/Performance Evaluation - Surgical Services Unit Secretary Performance Evaluation - Population-Specific/Age-Related Competency - Surgical Services Unit Secretary Annual Competency Skills Assessment - Surgical Services Unit Secretary Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol Restraint and Seclusion - Staff Training and Competency Requirements Restraint Application/Removal Competency Checklist - Restraint for Management of Nonviolent, Non-Self Destructive Behavior Staff Qualifications and Competency New Employee Orientation Outline of Inservice Orientation to the OR and PACU for RNs and LPNs/LVNs Orientation Checklist - Surgical Services Staff Education and Training Education Profiles Annual Required Training Update BCLS/ACLS Resuscitation Certification Student Role/Preceptorships in the Operating Room

SECTION 04 - INFECTION PREVENTION AND CONTROL

Standard Precautions Transmission-Based Precautions (Isolation Precautions)Hand Hygiene - CDC Guidelines Asepsis Infection Prevention and Control Measures - Surgical Services Surgical Wound Classifications Management of Patients with Methicillin Resistant Staphylococcus Aureus (MRSA)Visitor Control Attire in the Operating Room Surgical Hand Scrub Alcohol-Based Antiseptic Surgical Hand Rub Gowning and Gloving Technique Closed Gowning and Gloving Technique Open Gloving Technique Traffic Patterns in the Surgical Suite Selection of Barrier Materials for Surgical Procedures Event-Related Shelf Life - Sterile Storage Flash Sterilization Reprocessing of Single-Use Devices Glutaraldehyde Monitoring Glutaraldehyde Precautions High-Level Disinfection of Endoscopes Endoscopic Equipment - Preparation and Inspection Creutzfeldt-Jacob Disease Precautions Management of Accidental Blood or Body Fluid Exposure/Contamination Disposal of Sharps Sharps Injury Protection Plan Sharps Injury Log Definition of Biohazardous Waste Handling of Biohazardous Waste Cleaning the Surgery Department Central Service

SECTION 05 - LEADERSHIP

Organizational Structure of the Surgical Services Department Organizational Chart Scope of Services of the Surgical Services Department Vision Statement of the Surgical Services Department Focus Statement of the Surgical Services Department Surgical Services Nursing - Philosophy and Goals Scope of Responsibility - Chairpersons of Surgical and Anesthesia Services Committees Practitioner Privileges Roster of Surgeons' Surgical Privileges Anesthesia Coverage Anesthesia Coverage - Captured Call Perioperative Nursing Practice Perioperative Nursing Standards and Process Staffing Patterns On-Call Staffing Types of Operative and Invasive Procedures Performed Staff Rights and Ethical Dilemmas in Patient Care Patient Safety Plan Sentinel Event Surgical Charges Cost Containment Checklist Scheduling Surgical Procedures Scheduling Emergency Cases After-Hours Scheduling Emergency Cases After-Hours (Captured Call)

SECTION 06 - MEDICATION MANAGEMENT

High Alert Medication Management Concentrated Electrolyte Solutions and Other Drug Concentrations Automated Dispensing Machines - Policies and Procedures Automated Dispensing Machines - Access to Automated Dispensing Machines - Stock Medication Automated Dispensing Machines - Inspection and Inventory Automated Dispensing Machines - Controlled Substances Medication and Controlled Substance Storage and Access in the Surgical Environment Security of Medications - Anesthesia Carts Emergency Crash Carts Emergency Crash Cart Security and Accountability Sample Crash Cart and Defibrillator Checklist Signature Form Emergency Medications List Telephone, Verbal and Written Orders for Medication Automated Dispensing Machines - Pharmacist Order Verification and Drug Distribution Automated Dispensing Machines - Emergency/STAT Medication Orders Medication Administration Patient Medication Information/Reconciliation Patient Medication Information/Reconciliation - Outpatient Patient Medication Information/Reconciliation Form Antibiotic Administration Pediatric Dosing - General Guidelines Medication and Solution Administration in the OR Automated Dispensing Machines - Removing Medications Use of Multiple Dose Vials (MDVs)Safe Medication Practices Decreasing Medication Errors Adverse Drug Reaction Reporting Adverse Drug Reaction Reporting Form (Internal)Medication Errors Medication Inadvertent Incident Report Medication Inadvertent Incident Report Form Medication Error Analysis Tool Performance Improvement Analysis - Medication Inadvertent Incident Form

SECTION 07 - PERFORMANCE IMPROVEMENT

Performance Improvement Plan Hospital Quality Initiatives Surgical Services/Operative and Invasive Procedure Review PI Monitoring and Evaluation Plan Surgical Services/Operative and Invasive Procedure Review PI Trending Sheet Surgical Services/Operative and Invasive Procedure Review PI Outcome Evaluation Surgical Services/Operative and Invasive Procedure Review PI Volume Measures/Statistics Surgical Site Infections PI Monitoring and Evaluation Plan Surgical Complications Reporting Incident Reporting - Surgical Services Performance Improvement Indications and Notification Form - Surgery - Anesthesia - PACU Performance Improvement Incident Analysis Form Performance Improvement Operative/Invasive Procedure Review Form Incident Reporting Staff Questionnaire Form

SECTION 08 - PROVISION OF CARE, TREATMENT AND SERVICES

Outpatient Surgery Admission Criteria Preoperative Testing/Assessment for Inpatients History and Physical Patient Identification for Clinical Care and Treatment Assessment and Reassessment - Surgical Patient Skin Assessment Photographing Pressure Ulcers Surgical Checklist and Preoperative Nursing Record Preoperative Patient Assessment for Emergency Surgical Procedures Pain Assessment, Reassessment and Management Pain Assessment in Children Pain Scale, Admission Pain History Pain Scale Examples Behavioral-Physiological Pain Scale for Nonverbal or Preverbal Patients Care of the Latex Sensitive Patient Latex Allergy Assessment Form Latex and Non-Latex Alternatives Recognizing and Reporting Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation Suspected Elder Abuse Reporting Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery Surgical Preparedness Admission to Surgery Body Piercing Jewelry Surgical Site Identification Invasive/Surgical Procedure Verification/Time Out Checklist Pre and Post Anesthesia Evaluation Policy Pre and Post Anesthesia Evaluation Form Assessment Prior to Induction of Anesthesia Anesthesia Awareness Intraoperative Nursing Record Form Collection of Health Status Data for Nursing Diagnosis Formulation of Nursing Diagnosis Derived from Health Status Data Nursing Diagnosis Surgical Services Plan of Care Implementation of Surgical Services Plan of Care Evaluation of Surgical Services Plan of Care Revision of Surgical Services Plan of Care Surgical Services Nursing Plan of Care (Sample Form)"Hand-Off" Communication in the Perioperative Setting Accountability for Sponges, Sharps and Instruments Instrument Count Sheet Patient Temperature Skin Preparation Protocol Patient Positioning Radiation Exposure - Patients Prevention of Tubing/Catheter Misconnections Abdominal Draping Placement of Upper Extremity Drapes Lower Extremity Draping Placement of Drapes for Lower Extremity Amputation Radical Mastectomy Draping Vaginal Surgery Draping Pathology Specimens Frozen Section Protocol Legal Evidence - Chain of Custody Disposal of Anatomical Remains Blood/Blood Components - Patient's Guide to Blood Transfusions Acquisition, Identification and Administration of Blood Products Bloodless Surgery Care of Immunosuppressed Patients Management of Patient with Malignant Hyperthermia (MH)Malignant Hyperthermia (MH) Cart Use of Clinical Alarms on Medical Equipment Pediatric Patients in the OR (Parent Present During Induction)Forensic (Prisoners) Patients Postmortem Operative Care Use of Pneumatic Tourniquet Knee Arthroscopy Equipment Set-up and Operation Care of Patients with Implanted Electronic Devices (IEDs)Surgeon's Operating Room Equipment and Supplies Preference List Preparing Surgical Services Case Carts Transfer/Transport of Surgical Patients Education of Patient and Family Patient and Family Education - Surgical Site Infections Preoperative In-Home Evaluation Form - Total Hip Arthroplasty or Total Knee Outpatient Surgery Preoperative Instructions Form Cardiopulmonary Resuscitation in the Operating Room Use of Immobilization Devices Restraint or Seclusion Use 24-Hour Restraint Record Sedation Sedation Monitoring Form Incapacitated Surgeon/Anesthetist

SECTION 09 - RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL

Patient Rights and Responsibilities Pediatric Rights and Responsibilities of Parents/Guardians Patient Privacy Confidentiality of Information - General Issues Patient Rights and Responsibilities for Pain Management Pain Management Policy Statement Informed Consent Authorization for and Consent to Surgery or Special Diagnostic or Therapeutic Procedures Autorizacion Y Consentimiento De Cirugia O Procedimientos Diagnosticos O Terapeuticos Especiales Physician Responsibility for Obtaining Sterilization Consent Sterilization Consent Requirements Blood/Blood Component - Informed Consent Blood/Blood Component Transfusion Consent Form Refusal of Blood/Blood Component Transfusion Refusal to Permit Blood/Blood Component Transfusion Form Recordings, Films or Other Images of Patients Authorization and Consent Form - Recordings, Films or Other Images, and Publication Advance Directives Do Not Resuscitate, or Allow Natural Death Orders

SECTION 10 - RECORD OF CARE, TREATMENT AND SERVICES/INFORMATION MANAGEMENT

Documentation Required for a Surgical Case Documentation of Operative and Other High-Risk Procedures OR Nursing Documentation Surgical Logbook Legibility of Medical Record Documentation Verbal and Written Orders - General Documentation and the Use of Abbreviations, Acronyms and Symbols Unacceptable Abbreviation and Symbol List

SECTION 11 - TRANSPLANT SAFETY

Organ/Tissue/Eye Donation Organ/Tissue/Eye Donation - Nursing Staff Responsibilities Privileges for Organ Recovery Physicians Organ Transplantation, Recovery, Receipt and Patient Management - CMS Regulations Organ Transplant Waitlist Management Living Person Organ Donation Tissue and Cell Acquisition Receiving, Inspecting and Documentation of Tissue and Cells Verification Storage of Tissues and Cells Storage of Tissue in the Event of the Loss of Refrigeration Tissue Refrigerator/Freezer Maintenance Procedures Request for Tissue Documentation of Tissue Implantation Reporting Adverse Tissue Reactions

SECTION 12 - WAIVED TESTING