Sample Documents (Cardiac Electrophysiology)
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. Click on the name of the file to download the document.
- Report Completeness Report (Word) (757KB)
- Test Appropriateness Letter (Word) (44KB)
- Sample QI Policy (59KB)
- Sample QI Meeting Minutes (46KB)
- Peer Review QI Form (83KB)
- Sample QI Evaluation Forms
- Patient Complaint Policy (33KB)
- Patient Confidentiality Policy (52KB)
- Preliminary Policy (30KB)
- Preliminary vs Final Report Policy (53KB)
- Primary Source Verification Policy (53KB)
- 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.