1. An operating theater large enough to adequately accommodate the patient on a table or in an operating
chair and permit an operating team consisting of at least three individuals to freely move about
the patient?
Yes No
2. An operating table or chair that permits the patient to be positioned so the operating team can maintain
the airway, quickly alter patient position in an emergency, and provide a firm platform for the
management of cardiopulmonary resuscitation?
Yes No
3. A lighting system that is adequate to permit evaluation of the patient’s skin and mucosal color and a
backup lighting system which is battery powered and of sufficient intensity to permit completion of an
operation underway at the time of general power failure?
Yes No
4. Suction equipment, which permits aspiration of the oral and pharyngeal cavities, and a backup
suction device that can operate at the time of general power failure?
Yes No
5. An oxygen delivery system with adequate full face masks and appropriate connectors that is capable of
allowing the administering of greater than 90% oxygen at a 10 liter/minute flow at least 60 minutes (650
liter “E” cylinder) to the patient under positive pressure, together with adequate backup system that
can operate at the time of general power failure?
Yes No
6. A recovery area that has available oxygen, adequate lighting, suction, and electrical outlets? The
recovery area can be the operating theater.
Yes No
7. Ancillary equipment including all of the following
Yes
No
(a) Emergency airway equipment (oral airways, laryngeal mask airways or combitubes,
cricothyrotomy device).
(b) Tonsillar or pharyngeal type section tips adaptable to all office outlets.
(c) Sphygmomanometer and stethoscope
(d) Adequate equipment for the establishment of an intravenous infusion.
(e) Precordial/pretracheal stethoscope.
(f) Pulse oximeter.
5. RECORDS- Do you maintain the following records?
Yes No
1. Adequate medical history and physical evaluation records
Must be updated prior to each administration of sedation and shall include but are not limited to the
recording of the age, sex, weight, physical status (American Society of Anesthesiologists Classification),
medication use, any known or suspected medically compromising conditions, rationale for sedation of the
patient, and visual examination of the airway.
2. Sedation records that show:
Yes No
(a) A time-oriented record with preoperative, multiple intraoperative, and postoperative pulse
oximetry
(b) Multiple blood pressure and pulse readings.
(c) Drugs administered, amounts administered, and time administered.
(d) Length of procedure.
(e) Any complications of sedation.
(f) Statement of patient’s condition at time of discharge.
3. Written informed consent of the patient, or if the patient is a minor, the parent or guardian.
Yes No
