106Clinical records

106 Clinical records

106 Clinical records

(1) A facility must have a clinical record for each patient at the facility on whom a surgical class procedure is carried out.

(2) The clinical record must include the following—

(a) if anaesthesia is administered—the anaesthetic record, which must comply with the PG06(A) Guideline on the anaesthesia record published by the Australian and New Zealand College of Anaesthetists in 2020,

(b) the procedural report for the surgical procedure carried out on the patient, including pre-procedural and post-procedural diagnoses, and a description of the findings, technique used and tissue removed or altered,

(c) if the patient’s tissue or body fluid is removed—a pathological report on the tissue or body fluid,

(d) a record of the swab, sponge and instrument count,

(e) the post-procedural recovery record.