The patient’s medical record contains documentation on any operative or other high-risk proce...

(1)

The hospital has a complete and up-to-date operating room register or equivalent record that includes the following: - Patient's name - Patient's hospital identification number - Date of operation - Inclusive or total time of operation - Name of surgeon and any assistants - Name of nursing staff - Type of anesthesia used and name of person administering it - Operation performed - Pre- and postoperative diagnosis - Age of patient

(2)

An operative report is written or dictated immediately following surgery and signed by the surgeon. The report includes the following: - Name and hospital identification number of the patient - Date and times of the surgery - Name(s) of the surgeon(s) and assistants or other practitioners who performed surgical tasks (even when performing those tasks under supervision) and a description of the specific significant surgical tasks that were conducted by practitioners other than the primary surgeon/practitioner (significant surgical procedures include opening and closing, harvesting grafts, dissecting tissue, removing tissue, implanting devices, altering tissues) - Preoperative and postoperative diagnosis - Name of the specific surgical procedure(s) performed - Type of anesthesia administered - Complications, if any - Description of techniques, findings, and tissues removed or altered - Prosthetic devices, grafts, tissues, transplants, or devices implanted, if any - Any estimated blood loss Note 1: The exception to this requirement occurs when an operative or other high-risk procedure progress note is written immediately after the procedure, in which case the full report can be written or dictated within a time frame defined by the hospital. Note 2: If the physician or other licensed practitioner performing the operation or high-risk procedure accompanies the patient from the operating room to the next unit or area of care, the report can be written or dictated in the new unit or area of care.