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We
are pleased to introduce a series of sample documents to assist
laboratories in providing quality care to their patients. These
documents meet the requirements of The Standards, and
they may be used as a guide to develop laboratory policies and
reporting forms, whether your laboratory is seeking accreditation
or simply working to standardize or improve current practices.
**
PLEASE NOTE **
The following documents are SAMPLES
only. Protocols submitted with the application must be customized
to reflect current practices of the laboratory. These samples are examples only and not suggested practice.
Administrative Protocols
Adverse Drug Events Policy | Download
Sample (109k)
Clinical
Competency | Download
Sample (114k)
Communicable Diseases/Infection Control/Hazardous Materials
— Infection Control I
|Download
Sample (113k)
— Infection Control II
|Download
Sample (218k)
Confidentiality
Policy | Download
Sample (171k)
Critical
Results Policy |
Download
Sample (57k)
View a sample policy for notification of patient test results.
Drug
Administration Error Policy | Download
Sample (57k)
Emergency
Equipment Policy|
Download
Sample (78k)
View a sample form defining actions and responsibilities to
maintain emergency equipment.
Informed
Consent|
Download
Sample (189k)
View a sample policy establishing guidelines for obtaining
informed consent from patients prior to administering stress
tests.
Lab Overview/Organizational Chart | Download
Sample (60k)
Medical
Emergency Policy|
Download
Sample (55k)
Medication
Control | Download
Sample (51k)
View a sample form for a policy to define, control and secure
the handling of all medications.
Non-Radioactive
Pharmaceuticals Policy | Download
Sample (45k)
Procedure Availability & Hours
of Operation | Download
Sample (55k)
View a sample policy establishing the hours of operation and
availability of test and results.
Request
For Services | Download
Sample (58k)
View a sample policy establishing the rules to be followed
for scheduling and performing tests.
Clinical Protocols
Nuclear
Cardiology
Download Sample:
Adenosine Stress Test (478k)
Download Sample:
Exercise Stress Test (439k)
Download Sample:
Exercise Stress Test II (151k)
Download Sample:
Myocardial Perfusion Imaging (865k)
General
Nuclear Medicine
Download Sample:
Bone Scan Procedure (52k)
PET,
PET/CT, & SPECT/CT
Download Sample:
PET and PET/CT 18F-FDG Oncology Protocol
(27k)
Download Sample:
Procedure Guideline for Tumor Imaging with 18F-FDG
PET/CT 1.0 (100k)
Download Sample:
Procedure Guideline for SPECT/CT Imaging 1.0 (86k)
Provided courtesy of SNM and ASNC. For reference, please
visit the ASNC
website and the SNM
website.
Patient Identification Protocols
Patient Identification|
Download
Sample (53k)
View a sample policy established to provide accurate identification
of patients, minimizing related medical errors and patient
harm.
Pregnancy and Breastfeeding Protocols
Pregnant
And/Or Breastfeeding Patients | Download
Sample (265k)
The pregnant, potentially pregnant, or breastfeeding patient
is not to have Nuclear Medicine procedures performed unless
it is absolutely essential for a diagnosis or treatment.
Quality Control Protocols
QC
Imaging (Camera) Protocol | Download
Sample (558k)
QC
Non-imaging Protocol|
Download
Sample (314k)
Quality Improvement
Quality
Assurance: QA Report |
Download
Sample (7k)
Quality
Assurance: QA Plan|
Download
Sample (12k)
Radiation Safety
ALARA Policy|
Download
Sample (197k)
View a sample policy for keeping individual and collective
doses as low as is reasonably achievable (ALARA).
Personnel
Monitoring and Protection Policy | Download
Sample (58k)
Pregnant
Employee Policy
| Download
Sample (103k)
Radiation
Safety Training | Download
Sample (161k)
Radioactive
Spill Procedure | Download
Sample (117k)
Radioactive
Waste And Disposal Policy | Download
Sample (105k)
Radiopharmaceutical
Administration Policy | Download
Sample (47k)
Receipt of Radioactive
Materials Receipt Policy | Download
Sample (109k)
RSO
Delegation of Authority | Download
Sample (59k)
RSO
Duties And Responsibilities
| Download
Sample (79k)
Safe Use Of Radioactive Materials Policy
| Download
Sample (58k)
Sealed Source Inventory And Leak Test Policy
| Download
Sample (57k)
Survey And Wipe Test Policy
| Download
Sample (59k)
Theft
Or Loss Of Radioactive Materials | Download
Sample (99k)
It is the responsibility of each nuclear medicine laboratory
to have a policy in place in the event of lost or missing
radioactive materials.
Reporting
Cardiac Reporting:
ASNC MPI Report Template: Stress | Download
Sample (61k)
ASNC MPI Report Template: Pharm | Download
Sample (60k)
ERNA Abnormal | Download
Sample (221k)
ERNA Normal | Download
Sample (204k)
MPI Exercise Stress Abnormal | Download
Sample (224k)
MPI Pharm Abnormal | Download
Sample (224k)
Nuclear Cardiology Report Standardization
The most important purpose of a nuclear cardiology report
is to communicate the findings and clinical implications of
the stress test and nuclear images to a referring physician.
The second purpose of a report is to document, for reimbursement
purposes, the kind of services provided.
Read
more
General Nuclear Medicine Reporting:
Bone Scan | Download
Sample (160k)
Bone Scan II| Download
Sample (161k)
Bone Scan III| Download
Sample (159k)
Gastric Emptying Study| Download
Sample (160k)
Hepatobiliary Scan| Download
Sample (160k)
Hepatobiliary Scan with Cholecystokinin| Download
Sample (160k)
I123 Thyroid Scan and Uptake| Download
Sample (162k)
I131 Therapy| Download
Sample (161k)
I131 Whole Body Scan| Download
Sample (160k)
In111 Leukocyte-Bone Scan| Download
Sample (163k)
Parathyroid Scan| Download
Sample (160k)
Parathyroid Scan II| Download
Sample (161k)
Pulmonary Ventilation - Perfusion (VQ) Scan| Download
Sample (160k)
Pulmonary Ventilation - Perfusion (VQ) Scan II| Download
Sample (161k)
Renal Scan| Download
Sample (162k)
Renal Scan II| Download
Sample (163k)
Renal Scan with Lasix| Download
Sample (160k)
PET Reporting:
PET Whole Body Abnormal | Download
Sample (157k)
PET-CT Reporting:
PET-CT Whole Body
Initial Staging of Lung Carcinoma | Download
Sample (319k)
Restaging Colorectal Carcinoma | Download
Sample (320k)
Evaluation of Treatment Response Breast Carcinoma | Download
Sample (319k)
Tumor Imaging | Download
Sample (318k)
Sample Auditor/Reviewer/Site Visitor Checklists
Sample Auditor Checklist | Download
Sample (88k)
Sample Reviewer Checklist
| Download
Sample (178k)
Sample Site Visitor Checklist
| Download
Sample (147k)
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