ࡱ> JLI bjbj 40ee BBBBBVVV8<,VMOOOOOO$xsBsBBuuuFBBMuMuuu`CERu90u(M(u(Bu"u ss( :  STATE OF TENNESSEE DEPARTMENT OF HEALTH 665 Mainstream Drive NASHVILLE, TENNESSEE 37243 www.tennessee.gov (800) 778-4123, ext. 532-4384 or (615) 532-3202, ext. 532-4384 Office Based Surgery Level II AND LEVEL III Unanticipated events report as RequirED by TENNESSEE CODE ANNOTATED 63-6-221(q) T.C.A. 63-6-221(q) requires physicians who perform Level II or Level III office-based surgery to report certain unanticipated events to the Board of Medical Examiners within fifteen (15) calendar days following the physicians discovery of the event. Under the law, you must report: (1) The death of a patient during any Level II or Level III office-based surgery or within seventy-two (72) hours thereafter; (2) The transport of a patient to a hospital emergency department except those related to a natural course of the patient's illness or underlying condition; (3) The unplanned admission of a patient to a hospital within seventy-two (72) hours of discharge, only if the admission is related to the Level II or Level III office-based surgery, except those related to a natural course of the patient's illness or underlying condition; (4) The discovery of a foreign object erroneously remaining in a patient from a Level II or Level III office-based surgery at that office; or (5) The performance of the wrong surgical procedure, surgery on the wrong site, or surgery on the wrong patient. . Please Check One: Level II ______________ Level III____________ Please provide the information below. Failure to comply with these requirements constitutes grounds for disciplinary action by the board in its discretion pursuant to T.C.A. 63-6-214. Physician's name: ____________________________________ License number: Date and time of the occurrence or discovery of the incident: _________________ at Clinic name and address where the procedure took place: Name and address of the patient: Age of Patient ______________________________________ ASA Class of Patient: _________________________________ Type of level II office-based surgery that was performed (if level II): Type of level III office-based surgery that was performed (if level III): Type and dosage of sedation or anesthesia utilized during the procedure: Incident to be Reported: Expired with 72 Hours Transport to Hospital ER Foreign Object Retained Unplanned Hospital Admit Wrong Procedure/Site/Patient The circumstances surrounding the incident (attach additional pages if necessary): _________________________________________________ Physician Date Please mail your report to the Boards administrative office at: State of Tennessee, Health Related Boards Board of Medical Examiners 665 Mainstream Drive, 2nd Floor Nashville, TN 37243 NOTICE: The filing of this report as required does not, in and of itself, constitute an acknowledgement of admission of health care liability, error or omission. Upon receipt of this report, the Board may, in its discretion, obtain patient and other records pursuant to authority granted to it in T.C.A. 63-1-117. This reporting form and any supporting documentation reviewed or obtained by the Board shall be confidential and not subject to discovery, subpoena or legal compulsion for release to any person or entity; nor shall they be admissible in any civil or administrative proceeding, other than a disciplinary proceeding by the board; nor shall they be subject to the any open records request made pursuant to title 10, chapter 7, part 5 or any other law.     PH 4071 RDA 1786 +?\mnĶīzozozozozaO=#h h 5;B*CJaJph#h h 5;B*CJaJphh!h<5@CJaJhBnh5@CJaJh<h 5@CJaJh!h @h!h 5@CJh!h 5@CJaJhBnh5@CJaJh!hq5@CJaJh!h 5@CJaJhj Zh @CJOJQJhj Zh @OJQJ!jhj Zh}-@OJQJU+@\n- . 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