1. (1)       Every physician who performs or proposes to perform office-based surgery or procedures shall be trained to perform the surgery or procedure and possess an active, unrestricted medical license.
2. (2)       Evidence of the physician’s training and continuing medical education shall be documented and readily available to patients and the Board.
3. (3)       When evaluating whether a physician is properly trained to perform a certain surgical procedure, the Board shall consider the following criteria:
4. (a)       Training or certification in the procedures to be performed; OR
5. (b)       Specialty board certification by an American Board of Medical Specialties board, an American Osteopathic Association specialty board, or other credible certifying body; OR
6. (c)        Possession of credentialing to perform the same surgery or procedure at a nearby hospital or ambulatory care facility with whom the physician has privileges or an emergency transfer agreement; OR
7. (d)       Completion of an accredited residency or a fellowship relating to the surgery or procedure to be performed or in which the procedure was an integral part of the formal training program; OR
8. (e)       Accreditation by a credentialing body chosen by the physician and approved by the Board.
9. (4)       When a physician proposes to provide a new office-based surgical procedure, he or she shall conduct specific training for all personnel involved in the care of patients prior to performing the procedure. Education must be specifically tailored to the new procedure and must include, at a minimum:
10. (a)       Formal training regarding a basic understanding of the procedure being introduced, including risks and benefits of the procedure;
11. (b)       Signs and symptoms of postoperative complications; and
12. (c)        A basic understanding of the management and care of patients by a review of the office’s policies and protocols.
13. (5)       Physicians performing office-based surgery shall have qualified call coverage at all times by a physician who is responsible for the emergency care of his or her patients in his or her absence.
14. (a)       The physician providing call coverage must be trained to manage the full range of complications associated with the procedures being performed.
15. (b)       Transfer agreements can be used to supplement call coverage but cannot be used as a substitute for a call schedule.
16. (6)       Medical Record Maintenance and Security: Each physician office shall have a procedure for initiating and maintaining a health record for every patient evaluated or treated. The record shall include a procedure code or suitable narrative description of the procedure and must have sufficient information to identify the patient, support the diagnosis, justify the treatment, and document the outcome and required follow-up care. For procedures requiring patient consent, there shall be a documented informed written consent. If analgesia/sedation, minor or major conduction blockade, or general anesthesia are provided, the record shall include documentation of the type of anesthesia used, drugs (type, time and dose) and fluids administered, the record of monitoring of vital signs, level of consciousness during the procedure, patient weight, estimated blood loss, duration of the procedure, and any complications related to the procedure or anesthesia. Procedures shall also be established to ensure patient confidentiality and security of all patient data and information.
17. (7)       Infection Control Policy: Each physician office shall comply with state and federal regulations regarding infection control. For all surgical procedures, the level of sterilization shall meet current OSHA requirements. There shall be a procedure and schedule for cleaning, disinfecting, and sterilizing equipment and patient care items. Personnel shall be trained in infection control practices, implementation of universal precautions, and disposal of hazardous waste products. Protective clothing and equipment must be readily available.
18. (8)       Federal and State Laws and Regulations: Federal and state laws and regulations that affect the practice shall be identified and procedures developed to comply with those requirements. The following are some of the key requirements upon which office-based practices should focus:
19. (a)       Non-Discrimination (see Civil Rights statutes and the Americans with Disabilities Act).
20. (b)       Personal Safety (see Occupational Safety and Health Administration information).
21. (c)        Controlled Substance Safeguards.
22. (d)       Laboratory Operations and Performance (CLIA).
23. (e)       Personnel Licensure Scope of Practice and Limitations.

Author: Alabama Board of Medical Examiners

Statutory Authority: Code of Ala. 1975, §34-24-53.

History: New Rule: Filed October 17, 2003; effective November 21, 2003. Repealed and New Rule: Published January 30, 2026; effective March 16, 2026.