The office inspection/anesthesia evaluation program is a continuous process that all KSOMS members must participate in. The goal is to ensure that all KSOMS members provide anesthesia in the office in a safe manner using all appropriate equipment and procedures. Members undergo an inital evaluation upon acceptance into membership and a re-evaluation every 5 years. These evaluations are performed by other members of the KSOMS. The anesthesia evaluation and office inspection is required for membership in AAOMS and to qualify for malpractice insurance through OMSNIC.


When a doctor requests KSOMS membership, he/she is provided application information including membership forms to be completed. He/she is also advised to request an on-site anesthesia visit. That request goes to the Anesthesia Chair person. The actual evaluation requires that the doctor be reviewed by a peer and demonstrate his/her ability to administer anesthesia on a patient. The examining doctor forwards to the KSOMS office the completed checklist and a letter on the examining doctor’s letterhead verifying that the doctor was successful in the examination process. (See sample letter.)


The process for recertification is very similar to the original certification. Recertification, as mandated by AAOMS, occurs every five years. Again the doctor is examined by a peer with the same checklist but is not required to administer anesthesia on a patient. At this time staff is present and must also know where all equipment is kept and office procedures for handling emergencies.


It is the responsibility of the KSOMS Executive Director to keep a file for each doctor with the completed anesthesia checklist, a letter from the examining doctor stating the status of the examination  and a copy of the letter sent by the KSOMS office to the examined doctor that he/she passed the anesthesia examination

After the doctor has completed original anesthesia examination, he/she will be voted for membership at the next KSOMS general meeting after which AAOMS is sent verification that Dr. John Doe is a member in good standing in the KSOMS.

Once a year AAOMS will send an excel spreadsheet with the status of all members. At this time the KSOMS office must verify each member’s status. At a later date, AAOMS will send a certificate for the doctors who have been recently recertified to the KSOMS office. This certificate must then be distributed to the doctors.

It is also the responsibility of the KSOMS staff to keep the Anesthesia Chair informed of which members are due their five year anesthesia recertification.



Schedule the appointment at a mutually convenient time for you and the doctor(s).

  1. Evaluation must be done in the surgeon’s office with staff present.

  2. The anesthesia review checklist has been provided to all doctors. (See attached file.) This needs to be reviewed with doctor and staff.

  3. All drugs and equipment listed must be verified. A brief review of anesthesia emergency protocol with staff must be done. This should not take more than an hour. No patient interaction need be observed for anesthesia recertification. Be certain to include the date of the review.

  4. If the doctor(s) have satellite offices, have the doctor complete the Attestation on Equivalence of Satellite Office form. (See attached file.) This needs to be sent to the KSOMS office along with the anesthesia review checklist.

  5. Once this paperwork has been completed, the reviewer will sign the documentation. Give the date of the review and the doctor’s name reviewed.

  6. The reviewer will send all documentation and  very brief letter on letterhead to the KSOMS office. (See enclosed sample letter.)

  7. A copy of this needs to be sent to Tony Sivori, D.M.D., M.D. , KSOMS Anesthesia Chair, 3101 Breckenridge Lane Suite 2D, Louisville, Kentucky40220 or e-mail  As stated above, send the original to the KSOMS, Attn: Dr Richard Pape, P.O. Box 753, Crestwood, KY 40014-0753. Dr Pape will send the doctor a letter of confirmation on KSOMS letterhead and will keep this information on file. 



Sample Letter for Examiners

Peer Review Form

Satellite Attestation Form

Emergency Protocols