Office Based Surgery - Adverse Event Reporter

Training Videos

Training video for mandated reporters who are a member of the OBS practice:

Training video for mandated reporters who are NOT a member of the OBS practice:

1.0 Mandated Reporter

A mandated reporter is any physician, physician assistant or specialist assistant, or podiatrist directly or indirectly involved in an OBS procedure associated with a reportable adverse event. Mandated reporters are expected to complete the OBS adverse event form within 72 hours of the occurrence of the adverse event and/or within 72 hours of becoming aware of these events.

1.1 Type of Report

Select the type of report. Newly reported adverse event.Update to previously reported adverse event.

Provide the previous AER report ID reference number.

1.2 Mandated Reporter Information

Complete the fields below to identify the mandated reporter for this adverse event.

Last name:

First name:

Credentials:

License number (include all leading and/or trailing zeros):

Is the mandated reporter a member of the OBS practice or participated in the procedure(s)?

If not a member of the OBS practice, what is the association of the mandated reporter to the adverse event?

Other association specified.

2.0 Practice Information

2.1 Accreditation Information

Private physician practices that perform office-based surgery as defined by PHL §230-d require accreditation by an agency designated by the New York State Department of Health.

Provide the accreditation information for the practice site where the procedure was performed.

Was the OBS practice accredited at the time of the procedure?

This practice is accredited by the following agency.

What is the practice accreditation ID number
(as it appears on the practice accreditation certificate).

2.2 Practice Information

Provide the practice site information where the procedure was performed.

Practice Name ( Legal Name of Practice)

Practice is Doing Business As (DBA Name)

Street Address

Suite or floor number

City

State (Do not change)

Zip code

Phone number

Fax number

What is your practice specialty?

Other specified

4.0 Procedure

Complete the following sections regarding pre-procedure, procedure, and follow-up information.

4.1 Pre-procedure Information

Date of Procedure

What was the initial or primary indication for the scheduled procedure?

What was the primary pre-procedure ICD-10 diagnosis code for this patient?

Pre-procedure diagnosis description.

Did the patient receive a pre-procedure medical or cardiac evaluation?

4.2 Procedure Information

Were all the scheduled procedure(s) performed?

What were the CPT/HCPCS code for procedures scheduled and/or performed for this case?

Click here to search for CPT codes (opens in new window/tab)

CPT/HCPCS code

CPT/HCPCS description

CPT/HCPCS code

CPT/HCPCS description

CPT/HCPCS code

CPT/HCPCS description

If liposuction was performed what volume was removed

Length of procedure (Time into the procedure room to time out of procedure room.)

Hours

Minutes

Length of recovery (Time from arrival in the recovery room until discharge from OBS Practice.)

Hours

Minutes

4.3 Discharge and Follow-up Information

Did the patient return to pre-procedure baseline and/or meet discharge criteria prior to discharge or transfer from the OBS practice?

Was a post-procedure follow up call conducted?

How many days post procedure was the first follow-up contact made?

Discharge and follow up comments.

6.0 Participating Staff

Please complete the sections below for all who participated in the procedure, including MDs, CRNAs, NPs, PAs and other staff.

6.1 Proceduralist

Check here if the proceduralist and the mandated reporter are the same person.

Proceduralist last name:

Proceduralist first name:

Credentials:

License Number (include all leading and/or trailing zeros):

Is the proceduralist a member of the practice where the OBS procedure occurred?

Provide the practice information the proceduralist is affiliated with.

Practice name (legal name of practice):

Practice phone number

6.2 Assisting Proceduralist

Check here if this staff member was responsible for monitoring the patient during the procedure.

Assisting proceduralist last name:

Assisting proceduralist first name:

Credentials:

License number (include all leading and/or trailing zeros):

Is the assisting proceduralist a member of the practice where the OBS procedure occurred?

Provide the practice information the assisting proceduralist is affiliated with.

Practice name (legal name of practice):

Practice phone number

6.3 Sedation/Anesthesia Prescriber

Check here if the proceduralist and the sedation prescriber are the same person.

Check here if this staff member was responsible for monitoring the patient during the procedure.

Prescriber last name:

Prescriber first name:

Credentials:

License number (include all leading and/or trailing zeros):

Is the sedation/anesthesia prescriber a member of the practice where the OBS procedure occurred?

Provide the practice information the sedation/anesthesia prescriber is affiliated with.>

Practice name (legal name of practice):

Practice phone number

6.4 Sedation/Anesthesia Administrator

Check here if the practitioner prescribing and administering the sedation/anesthesia are the same person.

Check here if this staff member was responsible for monitoring the patient during the procedure.

Administrator last name:

Administrator first name:

Credentials:

License number (include all leading and/or trailing zeros):

Is the sedation/anesthesia administrator a member of the practice where the OBS procedure occurred?

Provide the practice information the sedation/anesthesia is affiliated with.

Practice name (legal name of practice):

Practice phone number

6.5 Other Participating Staff

How many other staff were present in the OR during the procedure?

7.0 Patient Demographics

Complete the fields below regarding the patient involved in the adverse event.

7.1 Patient Name

Last name:

First name:

Middle name:

Suffix:

Alias Last name:

Alias First name:

Alias Middle name:

7.2 Patient Address

Resident type:

Address:

City:

State:

Zip code:

7.3 Patient Demographics

Date of birth

Gender:

Last 4 SSN digits:

Race:

Ethnicity:

Preferred Language: Indicate the language the patient is comfortable using to communicate health care information, which may differ from the patient's native language.

Primary payer:

9.0 Home Medications

Please provide both the patients prescription and over-the-counter home medications.

9.1 Home Medications

Provide the home medications, both prescriptions and over-the-counter, taken by the patient.

Select all medication types/classes that apply and enter the name of each medication in the space provided to the right.

Examples of medication names are available by hovering over the “?”.

Check None if the patient is not taking any home medications.

None

9.2 Medication(s)

Please check all Medication Type/Class boxes that apply to indicate the patients current home medications. Enter the name of each medication in the space provided. Examples of medication names are available by hovering over the ? mark.

	Description of Medication Type/Classes	Name of medication(s). (List all medications for each Medication Type/Class)
	CARDIOVASCULAR Used to treat high blood pressure (hypertension), heart failure, chest pain, angina, kidney disease in diabetes, migraines, and abnormal heart rhythms (i.e. atrial fibrillation). Ace Inhibitors Angiotensin II Receptor Antagonists (ARB) Antiarrhythmics Beta Blockers Calcium Channel Blockers Nitrates Thiazide Diuretics & Diuretics
	RESPIRATORY Used to treat asthma and chronic obstructive pulmonary disease (COPD) Bronchodilators Corticosteroids
	ENDOCRINE Used to treat diabetes, parathyroid, and thyroid disease (hyperthyroid/hypothyroid) Insulin Oral Hypoglycemic Agents (diabetic medications) Antithyroid Thyroid Hormones
	GASTROINTESTINAL/GENITOURINARY Used to treat acid reflux, gastrointestinal reflux disease (GERD), peptic ulcers, duodenal ulcers, and h-pylori. H2 Antagonists Proton Pump Inhibitors (PPI)
	Pain Nonsteroidal Anti-inflammatory Drugs (NSAIDs)/Aspirins (ASA) Used to treat pain, arthritis, headache, fever Opiates Used to treat pain
	Other Anticoagulants/Antiplatelet Used to reduce the risk of blood clots (i.e. pulmonary embolism, deep vein thrombosis) Steroids Used to treat arthritis, autoimmune diseases, skin conditions Benzodiazepines Used to treat anxiety, insomnia, seizures, restless leg syndrome, symptoms of alcohol withdrawal
	Other Home Medications - Please specify

11.0 Supporting/Additional Documents

Additional documentation regarding this adverse event may be included by uploading documents here (optional). Examples of documentation helpful in the review of reported adverse events are: history & physical, pre-procedure assessments, intra– op and post procedure documentation, anesthesia/sedation records, and discharge documentation.

The NYS DOH OBS Program frequently requests medical records as part of the review of Adverse Event Reports. The type of events for which medical records are most frequently requested are:

Death or Serious Physical Injury
Cardiac/Respiratory Arrest
Need for Rescue; Airway Management, Unanticipated Cardiovascular and Hemodynamic Management, or Pharmaceutical Management
Altered Level of Consciousness; Loss of Consciousness
Hemorrhage class II or higher
Unplanned return to OR prior to discharge from the OBS practice
Unplanned return to the OR after discharge from an OBS office for a procedure related to the OBS procedure
Any adverse event defined by the +National Quality Forum's (NQF) Serious Reportable Event for Surgery or Invasive procedures
Malignant Hyperthermia
Bloodborne Pathogen Transmission

Are you uploading medical records/supporting/additional documentation?

File type

Upload a file connected to this AER

Uploaded files will not be retained if errors occur in any section of the form upon submission. Files will need to be uploaded again following correction of errors and prior to resubmission of the form

12.0 Contact

Please complete the fields below to identify the primary contact person for any necessary follow-up on this adverse event report.

Check here if the Mandated Reporter is also the Contact

Last name

First name

Credentials

Other credential specified

Phone number

Email

13.0 Attestation

Before submitting the Adverse Event Report, the attestation statement below must be completed.

Check here to confirm that ALL the mandated reporters involved in the OBS procedure are aware that a single adverse event report is being submitted and that each licensee may file a seperate adverse event report.

Please read the attestation statement below and enter the full name of the person completing the form and attesting to the accuracy of the information submitted.

I hereby attest that the information submitted on this adverse event report is true, accurate, and complete to the best of my knowledge.

Check here if the person attesting to the accuracy of this adverse event report is the mandated reporter.

Completed by:

Date:

Welcome to the NYS DOH Office Based Surgery Adverse Event Report Database

Overview

Who Must Report Adverse Events:

Event Reporting:

Training Videos

1.0 Mandated Reporter

1.1 Type of Report

1.2 Mandated Reporter Information

2.0 Practice Information

2.1 Accreditation Information

2.2 Practice Information

3.0 Event Detail

3.1 Date of Discovery

3.2 Adverse Event Type and Details

Hospital(s) Information

3.3 Observed Signs and Patient Symptoms

3.4 Suspected or Known Complications

4.0 Procedure

4.1 Pre-procedure Information

4.2 Procedure Information

4.3 Discharge and Follow-up Information

5.0 Sedation/Anesthesia

5.1 Pre-Procedure Information

5.2 Sedation/Anesthesia Technique

5.3 Intra-Procedural Sedation/Anesthesia Medications

5.4 Other Intra-Procedural and Post-Procedural Medications

5.5 Additional Intra-Procedural and Post-Procedural Medications

6.0 Participating Staff

6.1 Proceduralist

6.2 Assisting Proceduralist

6.3 Sedation/Anesthesia Prescriber

6.4 Sedation/Anesthesia Administrator

6.5 Other Participating Staff

7.0 Patient Demographics

7.1 Patient Name

7.2 Patient Address

7.3 Patient Demographics

8.0 Patient's Health History

8.1 Patient Height and Weight

8.2 Medical History

8.2.1 Cardiovascular

8.2.2 Respiratory

8.2.3 Gastrointestinal/Genitourinary

8.2.4 Endocrine/Hematology/Neuromuscular

8.2.5 OB/GYN

8.2.6 Other Pertinent Conditions

9.0 Home Medications

9.1 Home Medications

9.2 Medication(s)

10.0 Quality Improvement

10.1 Contributing Factors

10.2 Quality Improvement

11.0 Supporting/Additional Documents

12.0 Contact

13.0 Attestation