Safe Surgery Checklist Information

ASCs are required to report the use of a safe surgery checklist for all patients, not just those covered by Medicare. The safe surgery checklist must indicate that ASCs have implemented safe surgery practices during each of the three critical perioperative periods. CMS provides the examples below. Because CMS is not dictating that ASCs use a particular checklist, ASCs are free to select a checklist (or multiple checklists) that meets their individual needs.

It is also important to note that, although CMS uses the name safe “surgery” checklist, the measure applies to all ASC procedures, including those that are generally considered to be diagnostic and pain management procedures (e.g., certain endoscopies and injections for controlling pain).

Several organizations have developed boiler plate checklists that can be adjusted to suit the needs of a particular ASC:

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