Sample Documents (CT)
The IAC is pleased to include sample documents to assist facilities in providing quality care to their patients. These documents meet or exceed the requirements of the Standards, and they may be used to develop facility policies and reporting forms, whether your facility 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 facility.
- Acute Medical Emergency Policy (49KB)
- Contrast and Medication Administration Policy (47KB)
- CT Reporting Policy (63KB)
- Incident/Adverse Events Policy (41KB)
- Low Dose CT (LDCT) Lung Cancer Screening Policy (56KB)
- Patient Complaint Policy (27KB)
- Patient Confidentiality Policy (61KB)
- Patient Identification Policy (43KB)
- Primary Source Verification Policy (37KB)
- Patient Pregnancy Policy (61KB)
- Preliminary Reports Policy (43KB)
- Radiation Safety (Conventional CT Scanners) Policy (51KB)
- Radiation Safety (Volume Cone Beam Scanners) Policy (49KB)
- Medical Director Attestation for Consultant Use [SAMPLE] (58KB)
*Facilities are required to attach a letter from the facility's Medical Director (on the facility's letterhead) providing the consultants permission to complete the application for accreditation on the facility's behalf.
CT Report Template
- CT Report Template (62KB)
- IAC Quality Improvement (QI) Self-Assessment Tool
Created to help your facility employ and document continuous process improvement, this free tool provides a mechanism for facilities to meet the quality measures required by the Standards.
- Sample QI Policy (72KB)
- Sample QI Meeting Minutes (58KB)
- Facility CT Dose Tracker (19KB) (Updated 6-21-16)
- Guidance for Radiation Protection Survey & Dose Assessment (10KB)
- Medical Physicist or Qualified Expert Report (104KB)
Site Visit Documents
- Site Visitor Agenda (15KB)
- Protecting Access to Medicare Act (PAMA)
The Protecting Access to Medicare Act (H.R. 4302; P.L. 113-93), also known as PAMA, enacted in 2014, amended the Social Security Act (the Act) to extend Medicare payments to physicians and other providers of the Medicare and Medicaid program. Section 218(a) of the Protecting Access to Medicare Act (PAMA) requires that ADI suppliers and hospital outpatient areas providing CT services must meet safety requirements under NEMA Standard XR-29-2013 beginning on January 1, 2016. ADI suppliers and hospital outpatient departments that are non-compliant with these safety requirements must use a Current Procedural Terminology (CPT) code modifier on their Medicare billing to attest to non-compliance. These non-compliant ADI suppliers will receive a decrease in their Medicare payment of 5% in 2016 with a further reduction to 15% in 2017 and thereafter.
- Excerpts specific to CT from HR Bill 4302
- The AAPM Policy on CT Whole Body Screening
- MITA Smart Dose CT
The MITA Smart Dose standard offers health care providers a reference to identify important tools to optimize and manage radiation dose delivery when using computed tomography (CT) equipment.
- FDA Information Regarding Cone-Beam Computed Tomography
On this webpage, the FDA is providing: information about the use of cone-beam computed tomography in dentistry particularly in the pediatric population; information for patients, parents and health care providers to help reduce unnecessary radiation exposure from dental cone-beam computed tomography; and, resources for manufacturers of dental cone-beam computed tomography devices.
- Clinical Practice Guideline: Adult Sinusitis
A report from the American Academy of Otolaryngology - Head and Neck Surgery. (414kb)
- Alliance for Radiation Safety in Pediatric Imaging
The Alliance for Radiation Safety in Pediatric Imaging – the Image Gently Alliance -is a coalition of health care organizations dedicated to providing safe, high quality pediatric imaging nationwide. The primary objective of the Alliance is to raise awareness in the imaging community of the need to adjust radiation dose when imaging children.
- ACCF/AHA Clinical Competence Statement on Cardiac CT and MR
A report of the American College of Cardiology Foundation/ American Heart Association/American College of Physicians Task Force on Clinical Competence and Training.
- ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging — A report of the American College of Cardiology Foundation Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions and Society of Interventional Radiology.