| 7.8 |
Operative Reports
The following shall apply:
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| 7.8(a) |
Procedures in the operating room with general anesthesia, monitored anesthesia or conscious sedation require a dictated operative report and an operative note;
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| 7.8(b) |
Endoscopy, ERCP and bronchoscopy procedures require a completed operative form;
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| 7.8(c) |
Procedures under local or no anesthesia require an operative note;
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| 7.8(d) |
All other procedures require an operative note form or progress note.
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| 7.9 |
All tissues or specimens removed at the time of surgery shall be sent to the attending pathologist accompanied by a clinical history and pre- and post-operative clinical diagnoses which the surgeon must ascertain have been incorporated into the medical record.
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| 7.9(a) |
Specimens need not be sent for pathologist analysis if:
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