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Care of the Patient Undergoing Surgical or Other Invasive Procedure

 Categories:  Clinical Practice   Adopted: Sep 1991  | Amended: May 2021  Print Friendly Version  |   Share this item

The evaluation, diagnosis, and care of the surgical patient undergoing surgery or other invasive procedure* is primarily the responsibility of the licensee performing the procedure (e.g. “proceduralist”**) . The proceduralist bears responsibility for ensuring the patient undergoes a pre-procedure assessment appropriate to the surgery/procedure. The assessment shall include a review of the patient’s history, physical exam, and other data relevant to the procedure. The proceduralist shall have a detailed discussion with each patient regarding the diagnosis and the nature of the surgery/procedure, advising the patient fully of the risks involved. It is also the responsibility of the proceduralist to reevaluate the patient immediately prior to the procedure.

It is the responsibility of the proceduralist to assure safe and readily available postoperative care for each patient on whom he or she performs surgery or procedure. It is not improper to involve other licensed health care professionals in postoperative/post-procedure care so long as the proceduralist maintains responsibility for such care. The postoperative/postprocedure note must reflect the findings encountered in the individual patient and the surgery/procedure performed.

*Invasive procedures are medical acts performed for the purpose of structurally altering the human body by incision or destruction of tissues, including therapeutic treatment of conditions or disease processes by any instruments causing localized alteration or transportation of live human tissue. This includes endoscopies, cardiac catheterizations, interventional radiology procedures, and other procedures.

**Proceduralist refers to the licensee performing the procedure.