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Moderate Sedation & Anesthesia Services Audit
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Audit of anesthesia and moderate sedation services covering pre-sedation assessment, qualified providers, physiologic monitoring, rescue capability, and post-anesthesia recovery under CMS anesthesia CoPs.
CMS 42 CFR 482.52ASA Practice GuidelinesTJC PC.03.01.0142 CFR 482.13
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Organization & Provider Qualification
- Are anesthesia services organized under a single anesthesia service directed by a qualified physician? *
- Is anesthesia administered only by qualified practitioners permitted under the CoP (anesthesiologist, CRNA, AA, or qualified physician)? *
- Are practitioners performing moderate sedation privileged and competent to rescue patients from deeper-than-intended sedation? *
Pre-Sedation / Pre-Anesthesia Evaluation
- Is a pre-anesthesia evaluation completed by a qualified provider within 48 hours prior to surgery requiring anesthesia? *
- Is an airway assessment and ASA physical status classification documented before sedation? *
- Is the patient's NPO (nothing by mouth) status assessed prior to sedation? *
Intra-Procedure Monitoring
- Are oxygenation, ventilation (including capnography for moderate/deep sedation), and circulation continuously monitored? *
- Is a designated qualified individual responsible for monitoring the patient throughout the procedure? *
- Are emergency equipment, reversal agents, and suction immediately available at the point of sedation? *
Post-Anesthesia Recovery
- Is a post-anesthesia evaluation completed within 48 hours after surgery by a qualified provider? *
- Are patients monitored in recovery and discharged using documented discharge criteria (e.g., Aldrete or equivalent)? *
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