Surgical Site Marking

  1. The surgeon/ person performing the procedure(s) or his designee are responsible for marking the site.
  2. In cases, where more than one procedure is scheduled for the same patient, and will be performed by someone other than the surgeon of record, each clinician is responsible for marking their own surgical site.
  3. The process of site marking for the surgical site should occur with the involvement of the patient, awake & aware if possible, and/ or patient representative/ family when possible, and should be done prior to giving the patient narcotics, sedation, pre-medication or anesthesia.
  4. Site marking cannot be delegated to a registered nurse.
  5. The surgeon/ person performing the procedure(s) or his designee will mark with an arrow pointing the correct site or near the incision site with an appropriate surgical marking pen as noted below:
    1. Procedures involving, laterality (right/ left distinction) multiple structures (e.g. finger, toes) or level as in spinal procedure.
    2. In cases of bilateral organ, limb, or anatomic site, multiple digits, or spinal levels, the performing physician will mark the site such that, once the patient is prepped and draped, the markings are visible in the operative field.
  6. Mark side of the neck, front, back or midline in all cranial surgery/ cases including transphenoidal and post fossa midline approach.
  7. Ophthalmic operations will be identified by a dot above the designated eye.
  8. Operative sites on the face will be marked with a dot and initialed by the Clinician or designee.
  9. The appropriate site must be verified before any cast is split. For relevant orthopedic cases, the skin/ site should be marked immediately after cast/ splint is removed.
  10. Exemptions to Skin or Site marking are as follows:
    1. Dental and intraoral surgical procedures, as there is no practical or reliable way to mark teeth or oral tissue. Teeth — indicate operative tooth name(s) on documentation or mark the operative tooth/ teeth on the dental radiographs or dental diagram or specified in the operative consent.
    2. Premature infants, for whom the mark may cause a permanent tattoo.
    3. Interventional cases for which the catheter/ instrument site is not predetermined (e.g. cardiac catheterization).
    4. Procedures done through or immediately adjacent to a natural body orifice (e.g. endoscopy, dental procedures, tonsillectomy, Hemorrhoidectomy, or procedures on the genitalia) or other situations in which marking the site would be impossible or technically impractical.
    5. Procedures which do not relate to laterality, digits, or levels, such as Cesarean section, laparotomy, diagnostic laparoscopy, and other interventional procedures for which the site of insertion is not predetermined.
    6. Marking of then surgical site is not required when the site is so clearly evident that it cannot be confused, e.g. traumatic open fracture of femur with bone extension.
  11. The anticipated level(s) for spinal surgery should be indicated on the operative schedule and the operative consent form. Levels may be modified later if operative findings indicate differences. X-rays that mark the exact vertebral level (site) of surgery should be available for verification purposes.
  12. When invasive procedures are performed under emergency or urgent conditions, the practitioner performing the procedure will be in continuous attendance with the patient from the point of decision to do the procedure. Under those circumstances, marking the site would not be necessary.
  13. For double verification of all surgical cases, the site then should be identified in the medical record by use of body diagram signed by the physician & patient/ family member’s verifying the site . The body diagram form will then be attached to the consent form & to be placed on top of the patient chart/ file for reference during the surgical procedure.
  14. If the patient or responsible party refuses to have the site marked, the clinician must document the reason for refusal and any interventions attempted (e.g. social worker referral). Note: Placement of an “X” as skin or site marking is not acceptable as it can be confused as a mark by the patient to not perform surgery on this site.