MedSim™ General Surgery • Criterion Readiness • Criterion Readiness™
General surgery staff make compliance-critical decisions every shift. Pre-op consent gaps. Post-op disclosure obligations. Billing code questions at the front desk. The wrong decision in a private practice has no hospital system to absorb it.
🩹 Live Scenario Preview -- Informed Consent
A patient is in pre-op holding. The surgeon is scrubbed in on a previous case running long. The patient is asking new questions about the risks of their procedure -- questions that were not discussed during the office consultation. They are asking you to explain the risks. You are the pre-op nurse. The OR is waiting. What do you do?
Surgical Staff
Nurses • Scrub Tech • OR Coord
Front Office
Scheduling • Billing • Auth
Clinical Staff
MAs • LPNs • Pre-op RNs
Practice Leadership
Office Mgr • Practice Admin
What Gets Measured
Built from HIPAA Privacy and Security Rules, CMS Conditions of Participation, Joint Commission ambulatory standards, state medical board guidelines, surgical informed consent law, and CPT/ICD-10 coding compliance requirements.
HIPAA in a Small Practice
Incidental disclosure in a shared waiting room, minimum necessary in a small staff environment, personal device use, verbal discussions overheard in hallways, family member inquiries at the front desk.
Sample Scenario
A patient's employer calls the front desk asking to confirm whether the patient had surgery. The receptionist recognizes the caller's name. The patient has not signed a release. The caller says it is for FMLA paperwork.
Informed Consent
Scope of consent validity, procedure changes intraoperatively, consent obtained under sedation, patient capacity assessment, documentation of risks discussed, translator requirements, consent for minors.
Sample Scenario
During a laparoscopic procedure, the surgeon finds an unexpected finding requiring an additional procedure not on the original consent. The patient is under general anesthesia. The surgeon asks the scrub tech for additional instruments.
Surgical Documentation
Operative note timeliness, H&P expiration before surgery, pre-op checklist completion, implant documentation, surgical counts, late entry policy, verbal order authentication timelines.
Sample Scenario
The surgeon asks you to pull a patient to the OR. You notice the H&P was completed 32 days ago -- two days past the 30-day requirement. The surgeon says the patient has not changed, just update the date. The OR is already booked and running on time.
Medication Management
Pre-op medication holds, allergy verification in the OR, controlled substance waste documentation, anesthesia hand-off, post-op prescription authority, sample drug compliance, DEA regulations in the practice setting.
Sample Scenario
A post-op patient calls the office requesting a refill of their opioid prescription two days early. They say they dropped the bottle. The surgeon is in surgery all day. The MA has the prescription pad accessible. The patient is in pain.
Infection Control
Sterile field maintenance, surgical site infection protocols, sterilization documentation, instrument tracking, OSHA bloodborne pathogen standards, SSI reporting obligations, scope reprocessing compliance.
Sample Scenario
During a procedure, a non-sterile team member bumps the sterile back table. The surgeon does not appear to notice. The circulating nurse sees it happen. Pointing it out will require reprocessing instruments and delay the case by 20 minutes.
Billing and Coding
CPT code accuracy, upcoding and unbundling recognition, modifier application, co-pay collection obligations, insurance verification before elective procedures, balance billing compliance, ABN requirements.
Sample Scenario
The surgeon dictates a complex wound closure. The billing coordinator notices the code the surgeon selected is higher than what the documentation supports. Billing with the surgeon's code would mean $800 more per case. The surgeon says it is close enough.
Surgical Communication
Pre-op briefing and time-out protocol, intraoperative communication breakdown, post-op handoff to recovery, critical finding communication to family, discharge instruction comprehension verification.
Sample Scenario
The surgical tech calls the time-out. One item on the checklist -- the site marking -- is not visible because the prep drapes are already placed. The surgeon says to proceed, the site is correct. Two team members exchange a look. The case is running late.
Scope of Practice
MA vs RN authorization in a surgery office, phone triage limits, who can discuss results with patients, surgical tech scope in the OR, PA and NP prescribing authority, supervision requirements for mid-levels.
Sample Scenario
A patient calls post-op with a question about their wound. The MA who answers the phone has seen this type of wound hundreds of times and knows the answer. The surgeon is with a patient. The patient is anxious and wants an answer now.
Adverse Event Reporting
Surgical complication disclosure obligations, never event classification, state medical board reporting timelines, peer review process, patient notification after a sentinel event, apology laws, documentation during active investigation.
Sample Scenario
A patient returns to the office with signs of a surgical site infection following a hernia repair. Review of the OR record shows the instrument count was incorrect at close. The case was completed without resolving the discrepancy. The surgeon operated that day.
Data Security
EHR access in a small practice environment, text message communication with patients, fax security, shared workstations, breach response in a practice with no dedicated IT, mobile device encryption, vendor access controls.
Sample Scenario
A staff member realizes they sent a patient's post-op instructions to the wrong fax number. The fax went to a local business. The staff member is not sure if the fax was received. The patient's name, DOB, and surgical history are on the document.
Patient Rights in Surgery
Right to refuse surgery in pre-op, withdrawal of consent, advance directive recognition before elective cases, patient dignity in the OR environment, cultural and religious objections to blood products or specific procedures.
Sample Scenario
A patient is in pre-op and tells the nurse they have changed their mind about the surgery. They are nervous but say their family will be upset if they cancel. The surgeon has blocked two hours for this case. OR staff are ready. The patient has not signed the cancellation form.
Workplace Dynamics
Surgeon authority vs. staff safety culture, speaking up in the OR, fatigue and impairment recognition in a small team, after-hours on-call boundaries, workplace harassment in a practice where the surgeon is the owner.
Sample Scenario
The surgeon arrives for a 7 AM case and a team member believes the surgeon's behavior is not consistent with their usual manner. The observation is subtle -- not obvious impairment, but something feels off. The patient is already in the OR. You are the charge nurse.
Care Profiles
Your behavioral pattern across 12 categories maps to a Care Profile -- a decision signature built from how you actually respond under surgical pressure, not how you think you would.
The Protocol Anchor
Most common: Surgical Tech • OR Nurse
"We follow the checklist. Every time."
✓ Surgical documentation and infection control strongest
⚠ Freezes when the checklist does not cover the situation
The Communicator
Most common: Pre-op RN • Discharge Coordinator
"The patient needs to understand what is happening."
✓ Informed consent and patient rights awareness
⚠ Oversteps scope when trying to reassure patients
The Escalator
Most common: Office Manager • Charge Nurse
"This needs to go to the surgeon right now."
✓ Adverse event reporting and incident escalation
⚠ Over-escalates routine questions, disrupts case flow
The Operator
Most common: Billing Coordinator • Scheduler
"Let me get this done so we can move."
✓ Efficiency under pressure, scheduling compliance
⚠ Misses billing compliance issues to avoid conflict
The Documenter
Most common: Clinical MA • LPN
"If it is not in the chart, it did not happen."
✓ Documentation accuracy and data security highest
⚠ Slows clinical flow with documentation requests
The Steady Hand
Most common: Experienced OR Nurse • PA
"Stay calm. Work the problem. Then document it."
✓ Infection control and scope of practice balance
⚠ Absorbs risk quietly rather than escalating appropriately
Who Uses MedSim General Surgery
General Surgery Practices
Private practice general surgery offices carry full compliance liability without the legal and compliance infrastructure of a hospital system. MedSim identifies behavioral risk patterns across every staff role before a Joint Commission surveyor or plaintiffs attorney does. Compliance documentation generated automatically.
Ambulatory Surgery Centers
ASCs face the same CMS Conditions of Participation as hospitals with a fraction of the staff and training budget. MedSim delivers scenario-based compliance assessment for every role in the ASC -- surgical tech, pre-op nurse, billing coordinator, and practice administrator -- in one platform.
Surgical Staffing Agencies
Per-diem surgical techs and travel OR nurses arrive at practices with unknown compliance backgrounds. MedSim provides a standardized baseline assessment before placement. The compliance certificate travels with the clinician. Practices get documented proof of readiness before the first case.
MedSim™ General Surgery
MedSim General Surgery is in development. Express interest for your practice, ASC, or staffing agency and be among the first to deploy it.