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007.05.10-26. Specialized Services: Surgical Services.

AR ADC 007.05.10-26Arkansas Administrative CodeEffective: February 5, 2021

West's Arkansas Administrative Code
Title 007. Department of Health
Division 05. Health Facility Services
Rule 10. Rules for Critical Access Hospitals in Arkansas (Refs & Annos)
Effective: February 5, 2021
Ark. Admin. Code 007.05.10-26
007.05.10-26. Specialized Services: Surgical Services.
A. Organization and Supervision.
1. An organizational plan shall be developed.
2. Surgical Services shall be under the medical direction of a qualified physician or a physician committee.
3. A Surgical Services Registered Nurse supervisor shall be accountable and responsible for patient care.
4. Surgical Services shall have written policies and procedures that include:
a. Operative and special consents;
b. Fire and disaster plans;
c. Environmental control;
d. Visitor and traffic control to include allowance for no one other than staff or professionals without the expressed consent of the physician and operating room supervisor;
e. Safety practices;
f. Infection prevention and control measures;
g. Care and disposition of surgical specimens, cultures and foreign bodies;
h. Care of special equipment including preventive maintenance contracts and records;
i. Emergency management;
j. Orientation of all personnel; and
k. Medication accountability. (Refer to Section 11, Patient Care Service and Section 16, Pharmacy.)
5. Clinically relevant educational programs shall be conducted on a regularly scheduled basis not less than 12 per year. There shall be evidence of program dates, attendance, and subject matter.
6. A surgery schedule shall be maintained in the surgery suite.
7. There shall be a continuous QA/PI program that is specific to the patient care administered.
8. A current roster of physicians and dentists with a delineation of each physicians and dentists surgical privileges shall be accessible and available in the confidential files of the Surgical Services Registered Nurse and in the files of the hospital administrator.
9. The following information shall be maintained in the surgery services log:
a. Patient's full name;
b. Hospital number;
c. Surgeon;
d. Assistant surgeon;
e. Type of anesthetic and person administering;
f. Pre and postoperative diagnoses;
g. Circulating nurse;
h. Scrub nurse(s);
i. Procedures;
j. Complications;
k. Sponge, needle, and instrument count;
l. Time of beginning and ending of case; and
m. Other persons present.
B. Environment, Equipment and Supplies.
1. A safe operating room environment shall be established, controlled and consistently monitored.
2. At a minimum, the following general equipment and supplies shall be in the surgical suite:
a. Call-in system;
b. Crash cart;
c. Cardiac monitor
d. Defibrillator;
e. Resuscitating equipment;
f. Suction equipment; and
g. Thoracotomy set.
3. Equipment and supplies necessary to meet the requirements of the services provided:
a. Stretcher;
b. Anesthetic equipment and supplies;
c. Adjustable operating table with waterproof pad;
d. Side tables;
e. Approved surgical light;
f. Medical gases;
g. 24-hour supply of sterile linen;
h. Wall clock; and
i. Equipment and supplies for timed scrubbing technique.
C. Staffing.
1. Surgical personnel including a Registered Nurse shall be available to provide emergency surgical services on a 24-hour basis.
2. A Registered Nurse shall be present in the operating room for the duration of the surgical procedure. Additional auxiliary personnel shall be available as necessary.
3. Only qualified Registered Nurses may perform circulating duties in the operating room.
4. There shall be documentation of training and/or experience for all operating room personnel assigned to surgical procedures.


Amended Jan. 1, 2016; Feb. 5, 2021.
<Statutory authority: Promulgated under the Authority of Ark. Code Ann. ยง 20-7-123, 20-9-201 et seq.>
Current with amendments received through May 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 007.05.10-26, AR ADC 007.05.10-26
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