N.J. Admin. Code § 8:43A-12.8

Current through Register Vol. 56, No. 24, December 18, 2024

Section 8:43A-12.8 - Records

(a) The facility shall maintain a record of all surgical procedures performed which shall include the type of procedure performed, operative diagnosis, type of anesthesia used, personnel participating, postoperative diagnosis, and any unusual or untoward occurrence.

(b) A preanesthesia note, reflecting evaluation of the patient and of the patient record prior to administration of anesthesia, shall be made or reviewed by the physician administering or supervising the administration of anesthesia and entered into the medical record of each patient receiving anesthesia at any anesthetizing location.

(c) A record of anesthesia that conforms with policies and procedures developed by the medical staff shall be made for each patient receiving sedation or anesthesia at any anesthetizing location.

(d) Upon arrival in the postanesthesia care unit, a postanesthesia note shall be entered into the patient's anesthesia record by a member of the facility's anesthesia team.

(e) The patient's medical record shall include a pathologist's report of gross and microscopic tissue surgically removed.

(f) A discharge note shall be entered into the patient's medical record by an anesthesia team member prior to discharge from the facility.

N.J. Admin. Code § 8:43A-12.8

Recodified from N.J.A.C. 8:43A-12.5 and amended by R.2003 d.56, effective 2/3/2003.
See: 34 New Jersey Register 224(a), 35 New Jersey Register 857(a).
Former N.J.A.C. 8:43A-12.8, Anesthesia supplies and equipment; maintenance and inspections, recodified to N.J.A.C. 8:43A-12.11. Rewrote (d) and added (f).