INSTRUCTIONS: ALABAMA OFFICE-BASED SURGERY ADVERSE EVENT REPORT FORM

Following an office-based surgery in Alabama which results in an adverse event, the report form discussed in this article should be filed. This document can be obtained from the website maintained by the Alabama Board of Medical Examiners.

Alabama Office-Based Surgery Adverse Event Report Form Step 1: Enter your name on the first blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 2: Enter your Alabama license number on the second blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 3: Enter your street address, city, state and zip code on the third blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 4: Enter your specialty as a physician on the fourth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 5: Enter the date of surgery on the fifth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 6: Enter the type of surgery on the sixth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 7: Enter the type of anesthesia used on the seventh blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 8: Enter the name and title of the person administering anesthesia on the eight blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 9: Enter the date of the adverse event on the ninth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 10: Enter the type of adverse event on the tenth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 11: Indicate whether the patient was hospitalized with a check mark.

Alabama Office-Based Surgery Adverse Event Report Form Step 12: Indicate whether the patient experienced a full recovery, disability, death or whether the outcome is pending with a check mark.

Alabama Office-Based Surgery Adverse Event Report Form Step 13: In the blank space provided, enter a brief narrative description of what occurred during this event and any changes in office protocol that have been implemented to prevent a repetition of this event. Attach additional sheets if necessary.

Alabama Office-Based Surgery Adverse Event Report Form Step 14: Enter your signature on the next blank line and the date on the last blank line. File the form by emailing it to the address given at the bottom of the page or mailing it to the address given at the top of the page.