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Notice of New Courtesy Reporting Form

Effective January 1, 2017, the reporting of a hospitalization or death for cases in which patients received anesthesia must include the required information listed below. This information may be submitted in letter format, or by using the Courtesy Reporting Form provided by the Board.

Pursuant to Business and Professions Code 1680(z)(2), the required information shall include, but not be limited to:

  1. The date of the procedure;
  2. The patient’s age in years and months, weight, and sex;
  3. The patient’s American Society of Anesthesiologists (ASA) physical status;
  4. The patient’s primary diagnosis;
  5. The patient’s coexisting diagnoses;
  6. The procedures performed; the sedation setting;
  7. The medications used;
  8. The monitoring equipment used;
  9. The category of the provider responsible for sedation oversight;
  10. The category of the provider delivering sedation;
  11. The category of the provider monitoring the patient during sedation;
  12. Whether the person supervising the sedation performed one or more of the procedures;
  13. The planned airway management;
  14. The planned depth of sedation;
  15. The complications that occurred;
  16. A description of what was unexpected about the airway management;
  17. Whether there was transportation of the patient during sedation;
  18. The category of the provider conducting resuscitation measures; and
  19. The resuscitation equipment utilized.