Reprocessing Recommendations

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Storage & Documentation,

Documentation & Tracking

This page includes summaries that should not be used to create policies and procedures. Please refer to the original source documents for exact language. Links can be found here.

Multisociety, 2016

Maintain a log of procedures that includes patient name and MRN (if avail), date and type of procedure, serial # or other identifier for scope used, the AER #(if used) and the name of the person performing the cleaning and HLD.

HICPAC, 2016

Identify all endoscopes and processing methods at the facility. Document patient and endoscope identifiers, date, procedure end time and manual cleaning start time to determine if delayed reprocessing to be followed. Be sure to include "loaner" scopes from other facilities or manufacturers. Document effectiveness of products, locations of processing, equipment used, records of preventive maintenance of equipment, and the investigation of critical or potentially critical events.

AORN, 2016

Maintain record of model, serial number and facility identifier of endoscope, the patient upon whom the scope was used, date and time of use, location of use, physician, type of procedure, and also model and serial number of AER or sterilizer and person(s) responsible for processing.

ANSI/AAMI ST91, 2015

Maintain record of model, serial number and facility identifier of endoscope, the patient upon whom the scope was used, date and time of use, location of use, physician, type of procedure, and also model and serial number of AER or sterilizer and person(s) responsible for processing.

APIC/JCR, 2017

All endoscopes must be trackable from reprocessing through use on a patient. Create a master list of all scopes in the facility; adding scopes to the list or removing them from the list should be consistent throughout the facility. Base protocols on current evidence-based recommendations.

CMS, 2016

The hospital should have a system in place to identify which endoscope was used on a patient for each procedure.

TJC Booster Pak, 2015

Scope processing log to be maintained, including scope #, test strip results, immersion, initials, and dates; may refer to and use HLD manufacturer provided log form.

Guideline Details

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