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Surgical Services & Operating Room Compliance Audit

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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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