to main content Sedation and Anesthesia - Understanding the Assessment Requirements | Ambulatory | Provision of Care Treatment and Services PC | The Joint Commission
Coronavirus Resources
  • Careers
  • E-Alerts
  • Contact Us
Main Menu
The Joint Commission
Visit Joint Commission ResourcesVisit Joint Commission InternationalQuality Check
Login
  • Who We Are
    Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm.
    • Who We Work With
      • Our Partnerships
      • Payor Relations
      • State Recognition
    • Why Work With Us
    • Facts About The Joint Commission
      • History of The Joint Commission
      • Joint Commission FAQs
      • Board of Commissioners
      • Joint Commission Advisory Groups
      • Quality Check and Quality Reports
    • Policies and Financials
      • Code of Conduct
      • Conflict of Interest Policy
      • Designated Copyright Agent Policy
      • Financial Statements
      • Firewall Policy Summary
      • Linking to The Joint Commission Website
      • Public Information Policy
      • Reprint Permission Policy
    • Federal Relations and Public Policy
    • Joint Commission Officers
      • Jonathan B. Perlin
      • David Baker
      • Brian Enochs
      • Michael Kaba
      • Kin Lee
      • Ana Pujols McKee
      • Paige Rodgers
      • Deborah A. Ryan
      • Margaret VanAmringe
      • Lisa Vandecaveye
    • Joint Commission Resources
    • Joint Commission International
    A doctor reviews information on a tablet with a nurse

    Who We Work With

    Learn more about the communities and organizations we serve.

    A group of business professionals collaborate on a project in a conference room

    Why Work With Us

    See how our expertise and rigorous standards can help organizations like yours.

  • What We Offer
    In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care.
    • How We Can Help
    • Accreditation
      • Health Care Settings
      • Become Accredited
      • Accreditation Guide
      • Accredited
    • Certification
      • What is Certification
      • Certifications by Setting
      • Explore Eligibility
      • Learn the Process
      • After your Review
      • Certifications without Accreditation
    • Verification
      • Improve Maternal Outcomes at Your Health Care Facility
      • Maternal Levels of Care Verification
      • Publicity Kit
    • Complimentary Resources
      • Webinars
      • Newsletters
      • R3 Reports
      • Sentinel Event Alerts
      • Patient Safety Topics
      • DASH
    Female nurse holding senior woman's hand.

    How We Can Help

    Learn how working with the Joint Commission benefits your organization and community.

    Shot of a group of medical practitioners having a discussion in a hospital.

    Accreditation Guide

    Find the exact resources you need to succeed in your accreditation journey.

  • Our Priorities
    Learn about the priorities that drive us and how we are helping propel health care forward.
    • Health Care Equity
      • Accreditation Standards & Resource Center
    • Emergency Management
    • Infection Prevention and Control
    • Suicide Prevention
    • Workplace Violence Prevention
    An elderly woman in a wheelchair is helped by a friendly nurse

    Health Care Equity

    Drive performance improvement using our new business intelligence tools.

    Veterinarian washing hands with soap at sink

    Infection Prevention & Control

    Find evidence-based sources on preventing infections in clinical settings.

  • Standards
    Set expectations for your organization's performance that are reasonable, achievable and survey-able.
    • About Our Standards
    • Standards Field Reviews
      • Proposed Requirements Related to Environmental Sustainability Field Review
    • National Patient Safety Goals
      • Ambulatory Health Care: 2023 National Patient Safety Goals
      • Assisted Living Community: 2023 National Patient Safety Goals
      • Behavioral Health Care and Human Services: 2023 National Patient Safety Goals
      • Critical Access Hospital: 2023 National Patient Safety Goals
      • Home Care: 2023 National Patient Safety Goals
      • Hospital: 2023 National Patient Safety Goals
      • Laboratory Services: 2023 National Patient Safety Goals
      • Nursing Care Center: 2023 National Patient Safety Goals
      • Office-Based Surgery: 2023 National Patient Safety Goals
    • Prepublication Standards
      • New Requirements for Certified Community Behavioral Health Clinics
      • Revision to MS.06.01.05, EP 7
      • The Term Licensed Independent Practitioner Eliminated
      • Updates to the Patient Blood Management Certification Program Requirements
      • New Assisted Living Community Accreditation Memory Care Certification Option
      • Revisions to PI.01.01.01, EP 4
      • Health Care Equity Standard Elevated to National Patient Safety Goal
      • New and Revised Emergency Management Standards
      • New Health Care Equity Certification Program
      • Updates to the Advanced Disease-Specific Care Certification for Inpatient Diabetes Care
      • Updates to the Assisted Living Community Accreditation Requirements
      • Updates to the Comprehensive Cardiac Center Certification Program
    • R3 Report
    • Standards FAQs
    • Universal Protocol
    • Patient Safety Systems PS Chapter
    Nurse and doctor talking to happy hospital patient after surgery

    National Patient Safety Goals

    Find out about the current National Patient Safety Goals (NPSGs) for specific programs.

    doctor chatting to sales rep in hospital corridor

    FAQs about the Standards

    We help you measure, assess and improve your performance.

  • Measurement
    Learn about the "gold standard" in quality. We develop and implement measures for accountability and quality improvement.
    • Measures
      • Assisted Living Community Measures
      • Cardiac Care
      • Emergency Department
      • Health Care Staffing Services
      • Hospital Outpatient Department
      • Hospital-Based Inpatient Psychiatric
      • Immunization
      • Palliative Care
      • Perinatal Care
      • Spine Surgery
      • Stroke
      • Substance Use
      • Tobacco Treatment
      • Total Hip and Knee Replacement
      • Venous Thromboembolism
    • Specifications Manuals
      • Electronic Clinical Quality Measures
      • Chart Abstracted Measures
    • Reporting
      • Accreditation - Hospital
      • Certification
    • Pioneers in Quality
      • Facts
      • Proven Practices
      • Expert to Expert Series
      • Recognition
    • Resources
    • ORYX FAQs
    • Quality Measurement Webinars & Videos
      • Video Shorts
    • Assisted Living Community (ALC)
    Business information and info-graphics concept.

    Measures

    Learn about the development and implementation of standardized performance measures. View them by specific areas by clicking here.

    Happy Medical Team Looking at Laptop in Doctor's Office.

    Pioneers in Quality

    Gain an understanding of the development of electronic clinical quality measures to improve quality of care.

  • Resources
    Obtain useful information in regards to patient safety, suicide prevention, infection control and many more.
    • Health Care Equity
    • Publicity Kits
    • Patient Safety Topics
      • Zero Harm
      • Emergency Management
      • Health Care Workforce Safety and Well-Being
      • Infection Prevention and Control
      • Report a Patient Safety Concern or Complaint
      • Suicide Prevention
      • Workplace Violence Prevention
    • News & Multimedia
      • The Joint Commission Stands for Racial Justice and Equity
      • Blogs
      • Joint Commission Saves Lives
      • Events
      • Fact Sheets
      • Newsletters
      • News Releases
      • Podcasts
      • Speakers Bureau
      • Video Resources
      • Webinars
      • The Joint Commission and Social Media
    • Patient Safety
      • 2022 Patient Safety Awareness Week
    • Sentinel Event
    • The Physical Environment
      • Utility Systems - EC.02.05.01
      • Means of Egress - LS.02.01.20
      • Built Environment - EC.02.06.01
      • Fire Protection - EC.02.03.05
      • General Requirements - LS.02.01.10
      • Protection - LS.02.01.30
      • Automated Suppression - LS.02.01.35
      • Life Safety Code
    • For Nurses
    • For Physicians
      • Physician Leader Monthly March 2023
      • Physician Leader Monthly February 2023
      • Physician Leader Monthly January 2023
      • Physician Leader Monthly December 2022
      • Physician Leader Monthly November 2022
      • Physician Leader Monthly October 2022
      • Physician Leader Monthly September 2022
      • Physician Leader Monthly August 2022
      • Physician Leader Monthly July 2022
      • Physician Leader Monthly June 2022
      • Physician Leader Monthly May 2022
      • Physician Leader Monthly April 2022
    • For Consumers
      • Speak Up Campaigns
      • COVID-19 Vaccines
      • TakeCHARGE
      • The Joint Commission Journal on Quality and Patient Safety
      • The Smart Parents Guide
      • You The Smart Patient
    • Research
      • Operations Support Research
      • Evaluation Research
      • Health Services Research
      • DataMart
    • Awards
      • Ernest Amory Codman Award
      • John M. Eisenberg Patient Safety and Quality Award
      • Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity
    • Continuing Education Credit Information
      • Continuing Education Credit Information FAQs
    Talking to audience.  One member of the board speaking in microphone among other participants of meeting.

    News & Multimedia

    Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications.

    Group of young creative people collaborating in modern office.

    Patient Safety Topics

    We can make a difference on your journey to provide consistently excellent care for each and every patient.

  1. Home >
  2. Standards >
  3. Standards FAQs >
Sedation and Anesthesia - Understanding the Assessment Requirements
Print

What are the assessment requirements organizations need to understand?

Back to FAQs
Any examples are for illustrative purposes only.

Definitions^
 
Moderate sedation - A drug-induced depression of consciousness during which patients respond to purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Reflex withdrawal from a painful stimulus is not considered a purposeful response. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
 
Deep sedation/analgesia - A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance and maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
 
Anesthesia - Consists of general anesthesia and spinal or major regional anesthesia, does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuro-muscular function. Cardiovascular function may be impaired.
 
While each level shares some common accreditation requirements, deep sedation and general and regional anesthesia assessments/administration require an anesthesia provider or a Licensed Practitioner (LP) with Medical Staff privileges in accordance with hospital's policy and state scope-of-practice laws. 

Medications
Irrespective of the medications administered, the level of sedation/anesthesia achieved determines the applicability of the accreditation requirements as discussed in this FAQ.

Assessments
Pre-sedation or pre-anesthesia (deep sedation, regional or general anesthesia): 
  • The Joint Commission is not specific as to the required elements of the assessment, the expectation is that the assessment is based on established or recommended professional practices. (Examples of professional organizations that provide guidance for clinical practice are the American Society of Anesthesiologists, American Association of Nurse Anesthetist, American Dental Association.) Typically, the assessment includes, vital signs, status of the airway and response to any pre-procedure medications.
  • Moderate Sedation: The organization determines who is qualified to perform the assessment consistent with competencies of staff, scope of practice, rules and regulation and State. 
  • Deep Sedation/Regional Blocks/General Anesthesia: must be performed by an anesthesia provider or LP with medical staff privileges to administer deep sedation, regional or general anesthesia in accordance with hospital policy and state scope of practice laws.  This assessment may not be delegated to a non-privileged individual.   
Immediate pre-sedation, anesthesia assessments
  • The purpose is to confirm that there have been no changes in the patient's status since the initial assessment. This re-evaluation occurs immediately prior to (meaning without delay) the initiation of the moderate, deep or general anesthesia.  The organization determines the required elements and documentation format. (Examples may include vital signs, status of the airway and response to any pre-procedure medications.) This assessment is most often the first entry on the procedure or anesthesia record. 
  • Moderate Sedation: the organization may determine who can perform this assessment based on staff competencies scope of practice and law and regulation.
  • Deep Sedation, Regional anesthesia and Anesthesia: assessments must be performed by a qualified individual and consistent with state law and regulation.
Post anesthesia (deep sedation, regional and general anesthesia) assessments
  • In deemed(^^) organizations, completion of the post- anesthesia assessment for both inpatient and outpatient must be completed within 48 hours by an anesthesia practitioner or credentialed LP. This assessment may not be delegated
  • The calculation of the 48-hour timeframe begins at the point the patient is moved into the designated recovery area. The evaluation generally should not be performed immediately at the point of movement from the operative area to the recovery area. The assessment should not begin until the patient is sufficiently recovered from the administration of the anesthesia so as to participate in the evaluation, e.g., answer questions appropriately, perform simple tasks, etc. 
  • Components of the evaluation may include, but are not limited to: respiratory function, including respiratory rate, airway patency and oxygen saturation; cardiovascular function, including pulse rate and blood pressure; mental status; temperature; presence of nausea and/or vomiting; pain' and post-operative hydration. Depending on the specific surgery or procedure performed, additional types of monitoring and assessment may be necessary.
  • In non-deemed organization post-anesthesia assessments for patients receiving moderate, deep, regional and general anesthesia care are evaluated by criteria established by the medical staff based on State law and professional organizations recommended practices. e.g. American Society of Anesthesiologists.
Discharge assessments
  • Discharge assessments are completed by a LP, or the patient may be discharged upon a LP's order based on criteria established by the medical staff. 
^The definitions are also published in the glossary of the accreditation manual.
^^ Deemed Status:  Status conferred by the Centers for Medicare & Medicaid Services (CMS) on an organization whose standards and survey process are determined by CMS to be equivalent to those of the Medicare program or other federal laws, such as the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88). Accreditation is voluntary and seeking deemed status through accreditation is an option, not a requirement. 

 
Manual: Ambulatory
Chapter: Provision of Care Treatment and Services PC
Last reviewed by Standards Interpretation: November 17, 2022 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: April 11, 2016 This Standards FAQ was first published on this date.
This page was last updated on January 19, 2023 with update notes of: Editorial changes only Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.
Back to FAQs

If no, please comment on how we could improve this response.

If you have additional standards-related questions regarding this topic, please use the Standards Online Submission Form
A group of nurses in a hospital hallway

Go Above and Beyond with Certification

Reduce variation and risk while improving quality care. Certifications from The Joint Commission represent the most stringent, comprehensive and evidence-based proof of the success of your program available.
Certification
A group of medical professionals seen on a video call on a laptop computer

Ambulatory Health Care Webinars

Get the latest on the Comprehensive Accreditation Manual for Ambulatory Care, including all you need to know for a successful survey, tips for implementation, preparing your team, in addition to sustaining your accreditation.
Webinars
A business professional reads off a laptop computer and takes notes on a notepad

PolicySource: P&Ps for Compliance with Joint Commission Requirements

Get access to dozens of downloadable, sample policies and procedures required by Joint Commission standards on this easy-to-navigate web-based portal.
PolicySource
Chat Bot Icon
Joint Commission Virtual Assistant
This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. Get more information about cookies and how you can refuse them by clicking on the learn more button below. By not making a selection you will be agreeing to the use of our cookies.
  • Joint Commission International
  • Joint Commission Resources
  • Visit us on Facebook facebook
  • Visit us on Twitter twitter
  • Visit us on LinkedIn linkedin
  • News Room
  • Careers
  • E-Alerts
  • Contact Us
  • Accessibility
  • Terms of Use
  • Privacy & Cookies Statement
©2023 The Joint Commission, All Rights Reserved

The Joint Commission is a registered trademark of the Joint Commission enterprise.