The medical director shall develop and implement medical treatment protocols for common surgical procedures. In developing these protocols, the medical director shall ensure that the medical treatment protocols include:

(1) Provisions defining procedures that are considered to be major surgery;

(2) Provisions requiring that all inmates needing major surgery are referred to appropriate specialists and facilities outside of the department for that surgery;

(3) Provisions requiring the implementation of pain management measures within an appropriate time after the completion of surgical procedures;

(4) Provisions requiring that all decisions by the health care staff regarding whether or not surgery should be performed are based on a community standard of health care; and

(5) Provisions requiring the health care staff to carefully document the rationale for each of their decisions to resort to surgery or to refrain from surgery as a treatment option.