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North Carolina Society of Oral and Maxillofacial Surgeons
Office Anesthesia Evaluation Form
A. PERSONNEL
1. ACLS Certificate - (Please have doctor's ACLS Certification available) 2. List of surgical staff's credentials, (OMFSAAP, BLS): B. RECORDS
Please have available five charts of patients who have been treated in your office with IV sedation or general anesthesia. Charts must show documentation of the following: ‰ An adequate medical history of the patient. ‰ An adequate physical evaluation of the patient ‰ Anesthesia records showing: continuous monitoring of heart rate and rhythm, blood pressure, peripheral oxygen saturation and respiration. ‰ Registration of monitoring every 5 minutes. ‰ Accurate recording of medications administered, including amounts and time administered. ‰ Records illustrating length of procedure. ‰ Records reflecting any complications of anesthesia ‰ Evidence of continuous recovery monitoring with notation of patient’s condition upon discharge and who escorted the patient C. OFFICE FACILITY AND EQUIPMENT
‰ NIBP Monitor and back up
‰ ECG Monitor and back-up
‰ Defibrillator or AED
‰ Pulse Oximeter and back-up
‰ Pre-cordial stethoscope or end-tidal CO2 monitor
Operating Theater
‰ Is operating theater large enough to accommodate the patient on a table or in an operating ‰ Does the operating theater permit an operating team consisting of at least three individuals to Operating Chair or Table
‰ Does operating chair or table permit the patient to be positioned so the operating team ‰ Does operating chair or table permit the team to alter the patient's position quickly in an ‰ Does operating chair or table provide a firm platform for the management of Lighting System
‰ Does lighting system permit evaluation of the patient's skin and mucosal color? ‰ Is there a battery-powered backup lighting system? ‰ Is the backup lighting system of sufficient intensity to permit completion of any operation underway at the time of general power failure? Suction Equipment
‰ Does suction equipment permit aspiration of the oral and pharyngeal cavities? ‰ Is there a back-up suction device available ‰ Are there various suction tips, (Yankauer…) Oxygen Delivery System
‰ Does the oxygen delivery system have adequate full-face masks and appropriate connectors, and is it capable of delivering oxygen to the patient under positive pressure? ‰ Is there an adequate backup oxygen delivery system? Recovery Area (recovery area can be the operating theater)
‰ Does the recovery area have available oxygen? ‰ Does the recovery area have available adequate suction? ‰ Does the recovery area have adequate lighting? ‰ Does the recovery area have available adequate electrical outlets? ‰ Can a member of the staff observe the patient at all times during recovery? Airway Management
‰ Laryngoscope with various blades, stylet , back-up batteries and bulbs IV Access
‰ Are there appropriate IV catheters available ‰ Are there appropriate IV tubing, connectors etc ‰ Are there appropriate IV fluids available ‰ Various sized tourniquets and tape MEDICATIONS
The following are examples of drugs that may be helpful in the treatment of anesthetic emergencies. The list should not be considered mandatory or all-inclusive. • Epinephrine 1:1,000 or 1:10,000(1 mg = 1:1,000) • Phenylephrine (Neo-Synephrine®) 10 mg/mL
‰ Corticosteroid drug ‰ Bronchodilator drug ‰ Muscle relaxant drug ‰ Intravenous medication for treatment of cardiopulmonary arrest ‰ Narcotic antagonist drug ‰ Anti-Seizure drug • Flumazenil (Romazicon) 0.1 mg/mL
‰ Antihistamine drug ‰ Anticholinergic drug ‰ Coronary artery vasodilator drug • Hydralazine (Apresoline) 50 mg/mL
• Labetalol (Trandate) 5 mg/mL (20-mL single-dose vial)
ƒ Propanolol, (Inderal) 1mg/ml
• Prochlorperazine (Compazine) 10 mg/mL
• Ondansetron (Zofran) 4 mg/mL
‰ Malignant Hyperthermia Agents if using triggering agents • Dantrolene (Dantrium®) 20-mg vial, six vials readily available if utilizing MH triggering agents
NCSOMS Office Anesthesia Inspection Program
OVERALL FACILITY
ADEQUATE
INADEQUATE
ADEQUATE PENDING CORRECTION

Source: http://ncoms.i4adev.com/files/documentlibrary/Anesthesia%20Evaluation%20Inspection%20Form.pdf

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