Healthcare Facility Compliance 14 items
Surgical Services & Operating Room Compliance Audit
Perioperative audit covering surgical services organization, informed consent, the Universal Protocol time-out, and OR environment controls.
CMS 42 CFR 482.51AORN GuidelinesThe Joint Commission Universal Protocol
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Organization & Staffing
- Are surgical services well organized and provided in accordance with acceptable standards of practice? *
- Is the operating room supervised by an experienced registered nurse or a doctor of medicine/osteopathy? *
- Is a roster of practitioners specifying the surgical privileges of each maintained and current? *
Informed Consent & Assessment
- Is a properly executed informed consent form in the patient's record before surgery (except emergencies)? *
- Is a pre-anesthesia evaluation completed by an individual qualified to administer anesthesia within 48 hours prior? *
- Is an updated medical history and physical examination completed and documented before surgery? *
Universal Protocol & Counts
- Is a pre-procedure verification, surgical site marking, and time-out performed for every operative procedure? *
- Are surgical sponge, sharp, and instrument counts performed and reconciled before closure? *
- Are specimens correctly labeled, handled, and tracked to pathology? *
- Is an operative report written or dictated immediately after surgery and placed in the record? *
OR Environment & Sterility
- Are OR temperature, humidity, and positive air pressure monitored within acceptable ranges? *
- Is surgical attire, including surgical masks and head coverings, worn according to policy in restricted areas? *
- Are prophylactic antibiotics administered within the recommended window before incision? *
- Is traffic in and out of the OR minimized during procedures to control contamination?
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