Deciphering the "Black Box": Compliance and the Operating Room, Part I

Surgeons face multiple compliance issues that impact their daily activities. The entire patient workflow for surgery is impacted by rules, regulations, policies, and procedures related to compliance, quality, and patient safety. In this first of two articles, the authors will review the workflow for a scheduled, elective surgical procedure. The physician's order for surgery is the catalyst that gets the process started. The order must contain, at a minimum, the name of the patient, procedure to be performed, reason for the procedure, the provider's signature, and the date and time the order was written. A properly executed informed consent for surgery must be obtained prior to the operation. In addition to entering a brief operative report into the medical record following completion of the surgical procedure, the surgeon should be encouraged to dictate a detailed operative report the same day as the surgical procedure was performed.