42 CFR §416.52

1. (a)Standard: Patient assessment and admission.
   1. (1)The ASC must develop and maintain a policy that identifies those patients who require a medical history and physical examination prior to surgery. The policy must—
      1. (i)Include the timeframe for medical history and physical examination to be completed prior to surgery.
      2. (ii)Address, but is not limited to, the following factors: Patient age, diagnosis, the type and number of procedures scheduled to be performed on the same surgery date, known comorbidities, and the planned anesthesia level.
      3. (iii)Be based on any applicable nationally recognized standards of practice and guidelines, and any applicable State and local health and safety laws.
   2. (2)Upon admission, each patient must have a pre-surgical assessment completed by a physician who will be performing the surgery or other qualified practitioner in accordance with applicable State health and safety laws, standards of practice, and ASC policy.
   3. (3)The pre-surgical assessment must include documentation of any allergies to drugs and biologicals.
   4. (4)The patient's medical history and physical examination (if any) must be placed in the patient's medical record prior to the surgical procedure.
2. (b)Standard: Post-surgical assessment.
   1. (1)The patient's post-surgical condition must be assessed and documented in the medical record by a physician, other qualified practitioner, or a registered nurse with, at a minimum, post-operative care experience in accordance with applicable State health and safety laws, standards of practice, and ASC policy.
   2. (2)Post-surgical needs must be addressed and included in the discharge notes.
3. (c)Standard: Discharge. The ASC must—
   1. (1)Provide each patient with written discharge instructions and overnight supplies. When appropriate, make a followup appointment with the physician, and ensure that all patients are informed, either in advance of their surgical procedure or prior to leaving the ASC, of their prescriptions, post-operative instructions and physician contact information for followup care.
   2. (2)Ensure each patient has a discharge order, signed by the physician who performed the surgery or procedure in accordance with applicable State health and safety laws, standards of practice, and ASC policy.
   3. (3)Ensure all patients are discharged in the company of a responsible adult, except those patients exempted by the attending physician.