The Patient's Checklist for Ambulatory Procedures

from the Institute for Safety in Office-Based Surgery (ISOBS)

Inquire The Procedure Have I explored all treatment options regarding my condition?
Yes No
Is my procedure typically done in the ambulatory/office facility or the hospital?
Yes No
My doctor Who will be giving me sedation/anesthesia and watching my vital signs during the procedure?
_____
What is my doctor board-certified in?
_____
Ask my doctor: How many times recently have you performed my type of procedure?
_____
I know about my doctor's reputation
Yes No
Stable My medical conditions Is my medical condition stable for this procedure?
Yes No
Office The facility Is the facility accredited and licensed as required by my state's regulations?
_____
Best The best place for my procedure Is this ambulatory facility the right place for my procedure versus a hospital?
Yes No
Suited Dealing with emergencies Is this facility prepared for an unexpected emergency, such as drugs, equipment and training?
Yes No
If I need additional medical care, where will I be transferred?
_____
Plan Plan for my recovery after the procedure Who will monitor my recovery and supervise my discharge home?
_____
Will I be given discharge instructions and contract information in case I have questions?
Yes No
Communication Follow up after the procedure Who should I follow-up with after my visit?
_____
Who do I call if I have a problem after the procedure?
_____

This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.
*Adapted from the WHO Surgical Safety Checklist. (C) Institute for Safety in Office based Surgery, 2013.