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.

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Administrative Protocols

Clinical Competency | Download Sample (113k)

Communicable Diseases/Infection Control/Hazardous Materials
— Exposure Control Plan for Bloodborne Pathogens (5.6, 5.7) |Download Sample (109k)

Confidentiality Policy | Download Sample (60k)

Critical Results Policy | Download Sample (56k)
View a sample policy for notification of patient test results.

Drug Administration Error Policy | Download Sample (56k)

Emergency Equipment Policy| Download Sample (78k)
View a sample form defining actions and responsibilities to maintain emergency equipment.

Hours of Operation | Download Sample (53k)
View a sample policy establishing the hours of operation and availability of test and results.

Informed Consent| Download Sample (181k)
View a sample policy establishing guidelines for obtaining informed consent from patients prior to administering stress tests.

Medical Emergency Policy| Download Sample (54k)

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 (44k)

Request For Services | Download Sample (53k)
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 (242k)
View a sample policy for keeping individual and collective doses as low as is reasonably achievable (ALARA).

Personnel Monitoring and Protection Policy | Download Sample (104k)

Pregnant Employee Policy | Download Sample (56k)

Theft Or Loss Of Radioactive Materials | Download Sample (57k)
It is the responsibility of each nuclear medicine laboratory to have a policy in place in the event of lost or missing radioactive materials.

Radioactive Materials Receipt Policy | Download Sample (105k)

Radioactive Spill Procedure | Download Sample (113k)

Radioactive Waste And Disposal Policy | Download Sample (101k)

Radiopharmaceutical Administration Policy | Download Sample (45k)

RSO Duties And Responsibilities | Download Sample (77k)

Radiation Safety Training - Annual| Download Sample (179k)

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 (60k)

Reporting

ERNA Normal | Download Sample (204k)

ERNA Abnormal | Download Sample (221k)

MPI Exercise Stress Abnormal | Download Sample (224k)

MPI Pharm Abnormal | Download Sample (224k)

MPI Report Template: Stress | Download Sample (61k)

MPI Report Template: Pharm | Download Sample (60k)

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. These templates were endorsed by the ICANL Board Of Directors on April 28, 2000.
Read more | Download Sample: Nuclear Cardiology Reports (20k)

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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