[HOSPITAL NAME]
NORA / Out-of-OR Anesthesia Services
FORM F-14
Daily / Shift Documentation
NORA Site Readiness Checklist
Required prior to initiating anesthesia/sedation in remote locations.
NORA Location (Select One)
Oxygen Pipeline / Supply Connected
Adequate wall pressure confirmed and flowmeter functional.
Backup Oxygen Cylinder Present
Verified > 1000 psi. Wrench/key attached if required.
Suction Apparatus Functional
Vacuum reaches adequate pressure. Canister, tubing, and Yankauer attached.
Standard Monitors Available & Functional
ECG, NIBP cuffs (various sizes), SpO2 probes. Remote display functional (if MRI/CT).
Capnography (EtCO₂) Available
Sampling lines present. Monitor calibrated/functional.
Infusion Pumps / IV Poles
Plugged into emergency power. Battery charged.
Emergency & Rescue Medications Present
Standard NORA drug tray sealed/checked (Vasopressors, Atropine, Reversals, Sux).
Airway Cart / Kit Access
Laryngoscopes (DL/VL), ETTs, SGAs, Bougie, Bag-Valve-Mask (Ambu) present in room/immediate vicinity.
Defibrillator & Code Cart Access
Location known. Checked by nursing. Defib pads available.
Communication / Call for Help System
Code blue button, intercom, or dedicated emergency phone line identified and working.
Transport Plan & Equipment
Transport monitor and portable oxygen cylinder available for safe transfer to PACU/ICU.
MRI Safety Clearance (Applicable to MRI only)
All anesthesia equipment verified MRI compatible (Zone IV). Extraction plan known.
Defect Log & Corrective Actions (If any check marked FAIL)
NORA Site Clearance
Do not proceed with anesthesia/sedation if safety-critical items fail.
Checked By (Anesthesia Tech / Nurse)
Signature / Print Name
Verified By (Anesthesia Provider)
Signature / Print Name
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