R4-16-703. Administrative Provisions

A. A physician who performs office-based surgery using sedation in the physician’s office or other outpatient setting that is not part of a licensed hospital or licensed ambulatory surgical center shall: 1. Establish, document, and implement written policies and procedures that cover: a. Patient’s rights, b. Informed consent, c. Care of patients in an emergency, d. The transfer of patients; e. Obtaining a preoperative history and physical examination within 30 days before the procedure and validating the history and physical examination within 24 hours before the procedure; f. Intra-operative and post-operative monitoring and documentation; and g. Discharge criteria based on national standards. 2. Ensure a staff member who assists with or a healthcare professional who participates in office-based surgery using sedation: a. Has sufficient education, training, and experience to perform duties assigned; b. If applicable, has a current license or certification to perform duties assigned; and c. Performs only those acts that are within the scope of practice established in the staff member’s or health care professional’s governing statutes; 3. Ensure the office where the office-based surgery using sedation is performed has all equipment necessary: a. For the physician to perform the office-based surgery using sedation safely, b. For the physician or health care professional to administer the sedation safely, c. For the physician or health care professional to monitor the use of sedation, d. For the physician and health care professional administering the sedation to rescue a patient after the sedation is administered to the patient and the patient enters into a deeper state of sedation than was intended by the physician, and e. Resuscitation of a patient if that becomes necessary. 4. Ensure a copy of the patient’s rights policy is provided to each patient before performing office-based surgery using sedation; 5. Obtain informed consent from the patient before performing an office-based surgery using sedation that authorizes: a. The office-based surgery, b. The office-based surgery to be performed in the physician’s office, and c. The use of sedation during the procedure; and 6. Review all policies and procedures every 12 months and update as needed. B. A physician who performs office-based surgery shall comply with: 1. The local jurisdiction’s fire code; 2. The local jurisdiction’s building codes for construction and occupancy; 3. The biohazardous waste and hazardous waste standards in 18 A.A.C. 13, Article 14; and 4. The controlled drug administration, supply, and storage standards in 4 A.A.C. 23.