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ASC Accreditation Tip: Time-Out Checklist Documentation

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The ASC is required to conduct a standardized "time out" process before every surgical procedure to ensure that the right patient, right procedure, right equipment, right medications, right surgical marking and the right physician are present.

The surgical site is to be marked by the surgeon with a standardized surgical marking. A "time out" checklist is required to be used to ensure that all of the time out steps are consistently followed, says Donna Tiberi-Blaszczyk, RN, BS, MHA, a standards interpretation staff member with the Healthcare Facilities Accreditation Program.

"Sometimes the time out process is being performed, but staff fails to document it, or elements of the time out are missing," she said. "When a surveyor is on site, they will review charts to verify that time-out was documented." The verification process should begin from the time a patient is scheduled for a procedure through to the time of surgery. "You always want to ensure that you have the right patient," she said. "You need to follow consistent policies, and procedures."

More Articles on Accreditation:
Georgia's University Hospital Receives Gold Seal of Approval
PCMH Receives Joint Commission Gold Seal of Approval
William W. Backus Hospital Earns Blue Distinction

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