• Every patient will be admitted by and remain under the care of a member of the medical staff.
  • Patients will be admitted to Urology Surgery Center of Colorado for treatment without regard to race, color, religion, sex, age, national origin, disability or sexual preference.
  • Patients who receive anesthesia, whether general, regional, local, or conscious sedation which will result in impaired mental status, must be accompanied upon discharge by a responsible individual.
  • Patients will only be admitted to the Surgery Center for those surgical procedures, including relevant diagnostic and therapeutic procedures, included on the procedure list, which is attached hereto and made a part of these rules and regulations. The procedure list may be amended from time to time by the Board of Managers as recommended by the Medical Advisory Committee.
  • It is the responsibility of the Physician to obtain written informed consent from the patient, or his or her authorized representative prior to the performance of any procedure, including relevant diagnostic and therapeutic procedures, at Urology Surgery Center of Colorado.
  • Patients who are candidates for outpatient surgery must meet the following criteria:
    1. The patient's health must be such that, in the opinion of the operating Physician and anesthesiologist, any systemic disease is under adequate control and requires no special management when considered regarding the degree of severity of the procedure and type of anesthetic.
    2. The patient and/or person signing the consent for surgical procedure, including diagnostic and therapeutic procedures, must understand the concept of outpatient surgery/anesthesia and must exhibit the ability to use judgment and follow instructions.
    3. The patient's physical and emotional home environment must be conducive to a successful outcome.
  • Procedures will be allowed at Urology Surgery Center of Colorado that do not generally result in extensive blood loss, require major or prolonged invasion of body cavities, directly involve major blood vessels, or constitute an emergency or life threatening procedure.
  • Laboratory Requirements: Individual patients require additional preoperative testing as defined by Urology Surgery Center's Preoperative Testing for Surgical Procedures Policy:
    1. Pregnancy testing is required for all females of child bearing years. Consent will be obtained.
    2. Procedures requiring local anesthesia with or without conscious sedation shall have diagnostic work as ordered at the discretion of the operating Physician.
  • A history and physical examination, current within 30 days, which contains a provisional diagnosis, allergies, and current medications shall be provided by the Physician on all patients.
  • Patients not acceptable for admission to this Surgery Center are as follows:
    1. Infection: Patients having infections which require isolation and additional professional help in surgical or PACU services. Surgery may be canceled if patients show any significant evidence of respiratory infection based upon the discretion of the operating Physician and/or anesthesiologist (i.e. known active TB or MRSA infection)
    2. Patients requiring off-site pre-planned transfers in order to continue their care.
    3. Children under the age of six months or under one year of age who were not full term infants or with significant maxillofacial anomalies.


  • All treatment provided at Urology Surgery Center of Colorado shall be on an elective and pre-scheduled basis.
  • Patients for surgical procedures shall be admitted not less than one (1) hour before the scheduled operation or within a prearranged time frame in order to allow adequate time for preoperative preparation.
  • Urology Surgery Center of Colorado shall maintain a scheduling and staffing plan that facilitates quality of care and minimizes patient waiting time.
  • All scheduled procedures must be listed on the Center's Approved Procedure List, a copy of which is attached hereto.


  • Procedures may be performed under the following categories of anesthesia at Urology Surgery Center:
    1. General Anesthesia
    2. Regional Anesthesia
    3. Monitored Anesthesia Care
    4. Topical Anesthesia
    5. Local Anesthesia with and without pre-medication and/or intra-operative medications (amounts of local anesthesia and intra-operative medication shall not exceed toxic levels)
    6. Conscious Sedation
  • Anesthesia practitioners shall be available at the Surgery Center in time to adequately evaluate patients prior to surgery.
  • On the day of surgery, all patients shall be personally interviewed by the anesthesia practitioner who, following review of the patient's medical record and preadmission test results, will determine whether or not to authorize the patient for surgery.
  • Anesthesia will not be started until the operating Physician is present at Urology Surgery Center of Colorado.
  • Only the Anesthesia Staff or appropriately trained Physicians shall administer induction anesthetic agents consistent with Surgery Center's Conscious Sedation policy.
  • Administration of local, topical, and/or infiltrative anesthesia for local cases shall be the sole responsibility of the operating Physician. Continuous monitoring of the patient undergoing local anesthesia shall be the responsibility of the operating Physician but may be performed by a registered nurse. In addition to the monitoring nurse, a circulating registered nurse shall also be present during the entire operative procedure.
  • No explosive agents will be available at the Surgery Center.
  • Strict adherence to the recommended safety precautions outlined in the latest edition of the NFPA Life Safety Code is in effect at the Surgery Center


  • Pharmaceuticals used shall meet the standards of the U.S. Pharmacopoeia, National Formulary and New and Non-Official Remedies.
  • Pharmaceuticals will be available for use only in the Surgery Center. The Surgery Center will not dispense drugs or fill outpatient prescriptions.


Supervisory Radiologist: Delineation of Privileges to comply with facility Bylaws and Section 482.26 Condition of Participation: Radiologic services. Urology Surgery Center of Colorado will maintain, or have available, diagnostic radiologic services. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications.

The Center will maintain, or have available, radiologic services according to needs of the patients.

The radiologic services, particularly ionizing radiology procedures, will be free from hazards for patients and personnel.

Proper safety precautions will be maintained against radiation hazards. This includes adequate shielding for patients, personnel, and facilities, as well as appropriate storage, use and disposal of radioactive materials.

Periodic inspection of equipment will be made and hazards identified will be promptly corrected.

Radiation workers will be checked periodically, by the use of exposure meters or badge tests, for amount of radiation exposure.

Radiologic services will be provided only on the order of practitioners with clinical privileges or, consistent with State law, of other practitioners authorized by the medical staff and the governing body to order the services.

A qualified full-time, part-time, or consulting radiologist will supervise the ionizing radiology services and will interpret only those radiologic tests that are determined by the medical staff to require a radiologist's specialized knowledge.

Only personnel designated as qualified by the medical staff may use the radiologic equipment and administer procedures.

Records of radiologic services will be maintained.

The radiologist or other practitioner who performs radiology services will sign reports of his or her interpretations.

The center must maintain the following for at least 5 years, as State regulations mandate: Copies of reports and printouts, and; films, scans, and other image records, as appropriate.


  • The patient's medical record must contain an operative summary with a complete description of the operative procedure, any complications, and the operating Physician's signature. Prognosis and infection classification, when appropriate, should be included. Such records shall be current and legible.
  • The Physician shall see that the record is completed and signed within thirty (30) days from the date of the procedure. Medical records remaining incomplete for one month following the patient's discharge will be considered delinquent. Physicians with delinquent charts will be notified by registered letter, return receipt requested. If charts are not completed within 30 days after receipt of this letter, admitting privileges will be automatically suspended until records are completed.
  • Three (3) automatic suspensions of admitting privileges within a calendar year for failure to timely complete or prepare records will be deemed a voluntary resignation of Medical Staff appointment and clinical privileges. Physicians who are deemed to have voluntarily resigned Medical Staff appointment and clinical privileges are not entitled to the procedural rights and processes outlined in the Medical Staff Bylaws. Physicians who so resign may immediately submit an application of appointment. Any such application shall be treated and processed as an application for initial appointment. All information relating to the Physician's actions and conduct during his/her previous appointments or voluntary resignation to the Medical Staff may be considered.
  • Telephone and verbal orders shall be designated as such, signed and dated by a registered nurse, and must be countersigned by the ordering Physician.
  • All orders for medication and treatment shall be in writing or dictated to a registered nurse. All orders (whether written or dictated) must be signed by the attending Physician within forty-eight (48) hours.
  • All procedures performed shall be fully described by the Physician within forty-eight (48) hours and placed in the patient's chart.
  • All tissue (except as noted on the tissue exempt list) removed during the operative procedure shall be sent to the Surgery Center's consulting lab, who shall make such examinations as may be considered necessary to arrive at a pathological diagnosis. The pathologist at the consulting lab shall sign an interpretive report, which shall become a part of the permanent medical record.
  • All records shall remain the property of Urology Surgery Center of Colorado and shall not be taken from the Surgery Center.
  • In the case of re-admission of a patient, all previous records shall be made available for the use of the attending Physician. This shall apply whether the patient is to be attended by the same or another Physician.
  • Members of the medical staff, who are in good standing, shall have access to medical records of all patients under their care.
  • In accordance with applicable laws, former members of the medical staff shall be permitted access to information from the medical records of their patients with respect to all procedures in which they attended their patients at the Surgery Center.
  • Only those abbreviations listed on the Abbreviations Approved for Use by the Medical and Nursing Staffs may be used in the medical record.
  • Errors during documentation in the medical record shall be corrected in the proper manner. The method shall include: a) a single line through the part to be corrected; b) labeled "error"; and c) initials of person making the change.
  • Consultations: Each consultative report shall show evidence of a review of the patient's record by the consultant and shall have documented pertinent findings on examination of the patient, the consultant's opinion and recommendations. It shall be signed and made a part of the patient's medical record. Consultations shall be written or dictated.

PACU (Post Anesthesia Care Unit)

  • The PACU will be under the direction of the medical director or his/her designee.


  • Patients shall be discharged only on written order of the Physician as outlined in the policies and procedures recommended by the medical staff and approved by the Board of Managers.
  • Patients who receive anesthesia, whether general, regional, local, or conscious sedation which will result in impaired mental status, must be accompanied upon discharge by a responsible individual.
  • A descriptive discharge status summary is required by the anesthesia practitioner.
  • A Physician must remain in the Surgery Center until all patients have met PACU discharge criteria.
  • At the time of discharge, the patient and any responsible individual accompanying the patient shall be provided with complete, written, post-operative instructions, which have been reviewed with the patient. The written postoperative instructions shall be signed by the patient and/or responsible adult accompanying the patient to signify their acceptance of the instructions given.
  • Should the patient leave the Surgery Center against the advice of the attending practitioner or the anesthesia practitioner, the administrator and the Medical Director shall be promptly notified. The patient should sign the Against Medical Advice ("AMA") form and the form shall be placed in the patient's medical record.
  • In the case of a transfer of a patient to a hospital for admission, a copy of the patient's chart, descriptive narrative of the events leading to the need for hospitalization, and transfer summary form must accompany the patient to the hospital.


  • Patients may be treated only by Physicians who have been duly appointed to the medical staff of Urology Surgery Center of Colorado by the Board of Managers.
  • Temporary privileges may be granted to a Physician at the time of application receipt and approval of the medical director as described in section 3.3 and 4.4 of the Medical Staff Bylaws. Temporary privileges remain in effect until the next Medical Advisory Committee and in no case longer than 120 days.
  • Physicians shall be in the operating room or on the premises and ready to commence the procedure at the time scheduled. If the Physician is later than 15 minutes after the time scheduled, the case may be cancelled by the Medical Director.
  • All Physicians will be required to submit any reports of post procedure infection or complications to the Surgery Center on a monthly basis.
  • All members of the medical staff must abide by the Bylaws, Rules and Regulations, and Policies and Procedures of Urology Surgery Center of Colorado.
  • The members of the medical staff of the Surgery Center shall abide by the ethical standards adopted by the American Medical Association, the Accreditation Association of Ambulatory Health Care, and the American College of Surgeons.
  • Provisional status is granted at the recommendation of the Medical Advisory Committee and approved by the Board of Managers. To move from provisional to active status and successful completion of the peer review process, the practitioner must have performed five (5) procedures during the twelve (12) month period.
  • Active status and re-appointments are granted at the recommendation of the Medical Advisory Committee and approved by the Board of Managers. To retain active status, the practitioner must complete the peer review process and have performed ten (10) procedures during the specified time period.
  • Consulting Pathologists, while appointed to the Medical Staff, have no rights to vote or hold office within the Medical Staff and shall not be eligible to serve on committees of the medical staff. Consulting Pathologists are unable to perform cases within the surgery center that would appropriately meet the criteria for the peer review process, therefore case requirements will be waived for Consulting Pathologists.