The Top 25 Policies and Procedures for Outpatient Surgery - Chapter One - Patient Care

Oct 28, 2026

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Outpatient surgery policy framework focused on patient care, emphasizing pain management, sedation, and patient education as core elements for safe, individualized outcomes. The chapter explains how caregiver actions, communication, and mediation influence clinical results and why written policies must be accessible to all staff. It also connects patient safety priorities to medical error patterns and to accreditation and regulatory requirements from major ambulatory surgery accreditors, including guidance on surgical site marking.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages29

Reading Time1 h 13 min

AccessFree to download

Chapter One: Patient Care

1. Pain Management Policy and Procedure

2. Patient Assessment Policy and Procedure

3. Moderate Sedation Policy and Procedure

4. Patient and Family Education Policy

Attachment A: Patient/Family Teaching Report

The Top 25 Policies and Procedures for Outpatient Surgery Laura Harrington, RN, BS, MHA, CPHQ Contents About the Author ............................................................... v Special Acknowledgements ................................................... vii Introduction .................................................................. ix Chapter One: Patient Care ..................................................... 1 1. Pain Management Policy and Procedure ............................................. 3 2. Patient Assessment Policy and Procedure ........................................... 7 3. Moderate Sedation Policy and Procedure ........................................... 11 Sedation Audit Tool............................................................ 21 4. Patient and Family Education Policy ............................................... 23 Attachment A: Patient/Family Teaching Report ..................................... 27 Chapter Two: Patient Rights .................................................. 29 5. Advance Directive Policy ......................................................... 31 Advance Directive Form ........................................................ 34 6. Informed Consent Policy ......................................................... 35 7. Abuse/Neglect Policy ............................................................ 39 8. Patient Confidentiality Policy ..................................................... 47 9. Patient Rights and Responsibilities Policy .......................................... 51 Chapter Three: Human Resources ............................................. 55 10. Assessment of Competency Policy................................................ 57 a. Orientation to the Center ..................................................... 59 b. Business Office Staff Orientation .............................................. 65 c. Nursing Orientation .......................................................... 67 Master Competency List ........................................................ 68 The Top 25 Policies and Procedures for Outpatient Surgery 􀀱 Chapter Four: Patient Safety .................................................. 69 11. Correct Patient, Procedure, and Site Verification Policy .............................. 71 Patient, Procedure, and Site Verification Checklist .................................. 73 12. Medication Management Policy .................................................. 75 13. Sentinel Event Management Policy ............................................... 81 Attachment A: Minimum Scope of Root-Cause Analysis for Specific Types of Sentinel Events.............................................. 86 Chapter Five: Medical Staff ................................................... 87 14. Confidential Credentialing Information Policy ...................................... 89 Attachment A: Credentialing Committee Confidentiality Agreement for Committee Members ........................................................ 92 Attachment B: Peer Review and Credentialing Confidentiality Agreement............... 93 15. Incapacitated Surgeon Policy .................................................... 95 Chapter Six: Health Information Management ................................... 97 16. Medical Record Documentation Policy ............................................ 99 Medical Record Documentation Audit Tool ....................................... 101 Chapter Seven: Performance Improvement ..................................... 103 17. Waived Laboratory Testing Policy ............................................... 105 18. Infection Control Policy ........................................................ 107 19. Performance Improvement Plan ................................................. 109 20. Risk Management Policy .................................................

FAQs

What is the overall goal of Chapter One: Patient Care?

The goal is to perform an assessment and develop a plan of care that improves patient outcomes through caregiver observations, teaching, actions, and mediation.

Why do written policies matter for safe outpatient care?

Medical error statistics link many problems to poor communication, and written policies function as communication that must be understood and accessible to all staff.

Which areas does this chapter address for safe patient care?

It covers policies for pain management, sedation, and education, supporting individualized patient-specific care and reflecting current practice.

Oct 28, 2026

Upload by sagouaw