Surgical Services Policy and Procedure Manual

MCN's Surgical Services Policy and Procedure Manual helps you simplify the standards and NPSGs as they apply to the Surgical Services Department. Policies are current and cross-referenced to the latest Joint Commission and NIAHO standards, CMS regulations, and meet CDC requirements and AORN standards and recommendations. This comprehensive reference guide has over 280 proven policies, procedures and forms that are ready-to-customize to your specific organization.

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Table of Contents - TJC Standards and CMS RegulationsTable of Contents - NIAHO Standards and CMS RegulationsTable of Contents - JCI StandardsCopyrightDisclaimerApproval/Signature SheetIntroduction
SECTION 03 - HUMAN RESOURCES
3001 - Position Description/Performance Evaluation - Surgical Services Nurse Manager3002 - Performance Evaluation - Population-Specific/Age-Related Competency - Surgical Services Nurse Manager3003 - Annual Competency Clinical Skills Assessment - Surgical Services Nurse Manager3004 - Position Description/Performance Evaluation - Surgical Services Charge Nurse3005 - Performance Evaluation - Population-Specific/Age-Related Competency - Surgical Services Charge Nurse3006 - Annual Competency Clinical Skills Assessment - Surgical Services Charge Nurse3007 - Position Description/Performance Evaluation - Surgical Services Circulating RN3008 - Performance Evaluation - Population-Specific/Age-Related Competency - Surgical Services Circulating RN3009 - Annual Competency Clinical Skills Assessment - Surgical Services Circulating RN3010 - Position Description/Performance Evaluation - Surgical Services Scrub Nurse3011 - Performance Evaluation - Population-Specific/Age-Related Competency - Surgical Services Scrub Nurse3012 - Annual Competency Clinical Skills Assessment - Surgical Services Scrub Nurse3013 - Position Description/Performance Evaluation - Certified Surgical Technologist3014 - Performance Evaluation - Population-Specific/Age-Related Competency - Certified Surgical Technologist3015 - Annual Competency Clinical Skills Assessment - Certified Surgical Technologist3016 - Position Description/Performance Evaluation - Surgical Services Unit Secretary3017 - Performance Evaluation - Population-Specific/Age-Related Competency - Surgical Services Unit Secretary3018 - Annual Competency Skills Assessment - Surgical Services Unit Secretary3019 - Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol3020 - Restraint and Seclusion - Staff Training and Competency3021 - Restraint Use Competency Checklist - Restraint for Management of Nonviolent, Non-Self Destructive Behavior3022 - Staff Qualifications and Competency3023 - New Employee Orientation3024 - Outline of Inservice Orientation to the OR and PACU for RNs and LPNs/LVNs3025 - Orientation Checklist - Surgical Services3026 - Staff Education and Training3027 - Education Profiles3028 - Annual Required Training Update3029 - BCLS/ACLS Resuscitation Certification3030 - Student Role/Preceptorships in the Operating Room
SECTION 04 - INFECTION PREVENTION AND CONTROL
SECTION 06 - MEDICATION MANAGEMENT
6001 - High Alert Medication Management6002 - Concentrated Electrolyte Solutions and Other Drug Concentrations6003 - Automated Dispensing Machines - Policies and Procedures6004 - Automated Dispensing Machines - Access To6005 - Automated Dispensing Machines - Stock Medication6006 - Automated Dispensing Machines - Inspection and Inventory6007 - Automated Dispensing Machines - Controlled Substances6008 - Medication and Controlled Substance Storage and Access6009 - Security of Medications - Anesthesia Carts6010 - Emergency Crash Carts6011 - Emergency Crash Cart Security and Accountability6012 - Sample Crash Cart and Defibrillator Checklist Signature Form6013 - Emergency Medications List6014 - Telephone, Verbal and Written Orders for Medication6015 - Automated Dispensing Machines - Pharmacist Order Verification and Drug Distribution6016 - Automated Dispensing Machines - Emergency/STAT Medication Orders6017 - Automated Dispensing Machines - Removing Medications6018 - Medication Patient Information and Reconciliation6019 - Medication Patient Information and Reconciliation - Outpatient6020 - Medication Patient Information and Reconciliation Form6021 - Medication Administration6022 - Pediatric Dosing - General Guidelines6023 - Medication and Solution Administration in the OR6024 - Antibiotic Administration6025 - Use of Multiple Dose Vials (MDVs)6026 - Safe Medication Practices6027 - Decreasing Medication Errors6028 - Adverse Drug Reaction Reporting6029 - Adverse Drug Reaction Reporting Form (Internal)6030 - Medication Errors6031 - Medication Inadvertent Incident Report6032 - Medication Inadvertent Incident Report Form6033 - Medication Error Analysis Tool6034 - Performance Improvement Analysis - Medication Inadvertent Incident Form
SECTION 08 - PROVISION OF CARE, TREATMENT AND SERVICES
8001 - Outpatient Surgery Admission Criteria8002 - Preoperative Testing/Assessment for Inpatients8003 - History and Physical8004 - Patient Identification for Clinical Care and Treatment8005 - Assessment and Reassessment - Surgical Patient8006 - Skin Assessment8007 - Photographing Pressure Ulcers/Suspected Physical Abuse8008 - Surgical Checklist and Preoperative Nursing Record8009 - Preoperative Patient Assessment for Emergency Surgical Procedures8010 - Pain Assessment, Reassessment and Management8011 - Pain Assessment in Children8012 - Pain Scale8013 - Pain Scale Examples8014 - Pain Scale - Behavioral-Physiological Scale for Nonverbal or Preverbal Patients8015 - Latex Sensitive Patient - Care of8016 - Latex Allergy Assessment Form8017 - Latex and Non-Latex Alternatives8018 - Child, Adult, Disabled Person or Elderly Abuse - Recognition and Reporting8019 - Suspected Elder Abuse Reporting8020 - Surgical Preparedness8021 - Admission to Surgery8022 - Body Piercing Jewelry8023 - Surgical Site Identification8024 - Invasive/Surgical Procedure Verification/Time Out Checklist8025 - Pre and Post Anesthesia Evaluation Policy8026 - Pre and Post Anesthesia Evaluation Form8027 - Assessment Prior to Induction of Anesthesia/Sedation8028 - Anesthesia Awareness8029 - Intraoperative Nursing Record Form8030 - Collection of Health Status Data For Nursing Diagnosis8031 - Formulation of Nursing Diagnosis Derived from Health Status Data8032 - Nursing Diagnosis8033 - Surgical Services Plan of Care8034 - Implementation of Surgical Services Plan of Care8035 - Evaluation of Surgical Services Plan of Care8036 - Revision of Surgical Services Plan of Care8037 - Surgical Services Nursing Plan of Care (Sample Form)8038 - "Hand-Off" Communication in the Perioperative Setting8039 - Accountability for Sponges, Sharps and Instruments8040 - Instrument Count Sheet8040A - Prevention and Management of Unretrieved Device Fragments (UDFs)8041 - Patient Temperature8042 - Skin Preparation Protocol8043 - Positioning of Patient8044 - Radiation Exposure - Patients8045 - Tubing/Catheter Misconnections - Prevention of8046 - Venous Thromboembolism - Prevention of8047 - Abdominal Draping8048 - Placement of Upper Extremity Drapes8049 - Lower Extremity Draping8050 - Placement of Drapes for Lower Extremity Amputation8051 - Radical Mastectomy Draping8052 - Vaginal Surgery Draping8053 - Pathology Specimens8054 - Frozen Section Protocol8055 - Legal Evidence - Chain of Custody8056 - Disposal of Anatomical Remains8057 - Blood/Blood Components - Patient's Guide to Blood Transfusions8058 - Acquisition, Identification and Administration of Blood Products8059 - Bloodless Surgery8060 - Malignant Hyperthermia (MH) - Management of8061 - Malignant Hyperthermia (MH) Cart8062 - Clinical Alarms - Maintenance and Use of8063 - Pediatric Patient in the OR (Parent Present During Induction)8064 - Forensic Patients (Prisoners)8065 - Postmortem Operative Care8066 - Pneumatic Tourniquet - Use of8067 - Knee Arthroscopy Equipment Set-Up and Operation8068 - Implanted Electronic Devices (IEDs) - Care of Patients8069 - Surgeon's Operating Room Equipment and Supplies Preference List8070 - Preparing Surgical Services Case Carts8071 - Transfer/Transport of Surgical Patients8072 - Education of Patient and Family8073 - Patient and Family Education - Surgical Site Infections8074 - Preoperative In-Home Evaluation Form - Total Hip Arthroplasty or Total Knee8075 - Outpatient Surgery Preoperative Instructions Form8076 - Cardiopulmonary Resuscitation in the Operating Room8077 - Immobilization Devices - Use of8078 - Restraint or Seclusion Use8079 - 24-Hour Restraint Record8080 - Sedation8081 - Sedation Monitoring Form8082 - Incapacitated Surgeon/Anesthetist
SECTION 12 - WAIVED TESTING