National Standards For Clinical Neurophysiology

To be used in conjunction with IRCP 2009

National Standards

For

Clinical Neurophysiology

Basic Level

Assessments


1. EEG


NEUROPHYSIOLOGY ASSESSMENT - EEG

EEG Assessment No.…………….

EEG No…………… Patient Age Provisional Diagnosis Patient condition as identified in range EEG performed in [delete as appropriate] Dedicated area Non-Dedicated environment


Section 1: Plan and Prepare for EEG recordings

Achieved

(tick) Not Achieved

(comment/reason required)

Question(tick)

Not applicable

(tick) 1.1 Ensure that all available data pertinent to the

investigation upon the patient is available, in accordance with recommended procedures, and checked for validity.

1.2 Evaluate the above data and plan the investigation.

1.3 Where the above data is insufficient to produce a valid plan, request further data, or refer the matter to senior staff.

1.4 Discuss, where appropriate, the location for the investigation, and any special needs of the patient.

1.5 Seek advice if the skills or knowledge required for the investigation is beyond that of the TP.

1.6 Ensure that any medication prescribed for the investigation is available


1.7 Make arrangements where necessary for the

transport of equipment and accessories outside the dedicated laboratory.

Performance evidence required

4 Assessments to include: -

Adult

Child under 5 years of age

Portable recording in a non-dedicated environment

Planned sleep or other non-routine investigation

Polygraphy *


Section 2: Prepare equipment for EEG recording

Achieved(tick)

Not Achieved (comment/reason

required)

Question (tick)

Not applicable

(tick) 2.1 Check that the equipment selected is in a safe

condition and operates correctly, including all relevant peripheral devices.

2.2 Assess printer function (if used) and check that adequate paper is available.

2.3 Ensure that there is adequate available storage media for the proposed investigation

2.4 Ensure that default settings, sampling rate, number of channels enabled etc. are appropriate.

2.5 Ensure that recording parameters e.g. sensitivity, low & high pass filters, notch filter etc. are checked and are appropriate.

2.6 Perform an auto calibration/amplifier integrity check.

2.7 Assess sensitivity using a square wave signal - all channels are tested over a range of settings.

2.8 Check the photic stimulator is functioning, and assess the accuracy of the photic marker.


2.9 Assess the display speed and check the accuracy of the time marker.

2.10 Identify equipment faults and either report or rectify as appropriate, in accordance with departmental policy.

2.11 Produce a formal record of machine performance (relating to 2.6-2.10)

2.12 Ensure that the necessary type (and quantity) of consumables are available for the planned investigation.

2.13 Ensure equipment and accessories are checked in the base department before transportation for off-site recordings.



Dedicated environment

Non-dedicated environment

Equipment log (machine function and faults)


Section 3: Prepare Patient for EEG recording

Achieved(tick)

Not Achieved (comment/reason

required)

Question (tick)

Not applicable (tick)

3.1 Confirm the patient’s identity matches that on the referral documents

3.2 Accurately enter/identify the patient’s information on the recording machine.

3.3 Establish effective communication with the patient/carers. Explain the test in a manner liable to ensure that their co-operation is enlisted.

3.4 Obtain a full, but concise history, relevant to the investigation and record this information accurately

3.5 Discuss and confirm the patient's current medication with the patient &/or carers, and record any recent variations.

3.6 Accurately assess the patient’s present condition based on all of the available information - including case notes, direct observation and questioning of patient and carers.

3.7 Following 3.4, consider any modifications to the planned procedures and refer to senior staff as required

3.8 Accurately mark electrode sites in accordance with the recommended placement system, ensuring appropriate accuracy with electrode distances (e.g. within +/- 0.5cm).


3.9 Attach electrodes and transducers correctly and securely ensuring appropriate accuracy (e.g. within +/- 0.5cm).

3.10 Ensure leads are appropriately and securely positioned and connections to the headbox are checked as correct.

3.11 Assist the patient into a position that is comfortable (as per local procedures) thereby optimising the quality of the recording.

3.12 Confirm that contact impedances are appropriate to electrode type and to the patient.

3.13 Perform preparation efficiently (e.g. co-operative adult 30 minutes approximately).*

3.14 Administer/organise for the administration of medication required for the investigation in accordance with local protocols and procedures.


In addition, when the patient is a child 3.15 Encourage parents/siblings/carers to participate.

3.16 Make the recording area suitable for children.

3.17 Fully inform parents/relatives/carers of the nature and purpose of the investigation

3.18 Adopt a suitable approach to the child to optimise co-operation.

3.19 Ensure arrangements are made for feeds and for comforters, where appropriate.

Section 3: Performance evidence required


Adult


Non-dedicated environment

Planned sleep or other non-routine investigation

Polygraphy


Section 4: Monitor and record EEG with appropriate polygraphy

Achieved

(tick) Not Achieved


Question(tick)


4.1 Employ a range of montages appropriate to the clinical problem and take recordings correctly. For digital recordings this includes referential data checks at the beginning and end of recording (as a minimum).

4.2 Continuously monitor the results of the investigation, reviewing for validity, accuracy and clinical significance. Interactively modifies the procedure (including encouragement of spontaneous sleep) to optimise the collection of clinically useful data.

4.3 Use appropriate control settings during the investigation to optimise the identification of clinically useful data.

4.4 Modify electrode positions, apply additional electrodes and transducers as appropriate and use non-standard montages according to the patient characteristics, clinical problem, and findings during the recording.

4.5 Identify and eliminate artefacts or minimise and annotate them.

4.6 Ensure that patients having seizures and other medical emergencies are correctly managed


4.7 Give the necessary support to patients in disturbed mental states and treat them in accordance with agreed guidelines.

4.8 Accurately and legibly annotate the EEG recording.

4.9 Record a single channel ECG.

4.10* Record Polygraphic variables, as indicated by the clinical condition of the patient, and ensuring machine settings are adjusted appropriately (filter settings etc.).

4.11 Accurately identify the need to modify or extend the current investigation and refer to a senior member of staff for advice, if necessary.



Using a range of montages; bipolar, common and average reference and non routine montages

Adult


Portable recording in a non-dedicated environment

Planned sleep

Polygraphy *

*Should a suitable opportunity not arise during one of the formal assessments a simulation could be used and assessed (evidence should be presented with the formal assessment).


Section 5: Implement and monitor activation procedures during the EEG: Hyperventilation. Achieved

(tick) Not Achieved


Question (tick)


5.1 Review the data obtained from the initial recording to assess the relevance of the proposed activation procedure.

5.2 Establish that the proposed activation procedure is not contraindicated and is performed to department guidelines.

5.3 Accurately identify any indications that activation should not proceed and refer to a senior member of staff for discussion, if appropriate.

5.4 Provide the patient with a clear and accurate explanation of the procedure and encouraged them to clarify any areas of concern.

5.5 Treat the patients in a manner which is likely to encourage co-operation and confidence and maintain their dignity.

5.6 Obtains consent to perform the procedure. 5.7 Make the immediate environment suitable for the

intended activation procedure.

5.8 Position the patient suitably to perform the activation procedure.

5.9 Implement the activation procedure correctly and safely in accordance with conventional protocol and encourage the patient to co-operate.

5.10 Annotate details relevant to the procedure (time, effort, eyes open etc)


5.11 Continuously monitor the activation procedure and accurately record changes in the condition of the patient.

5.12 Accurately identify and respond promptly to any indications that the activation procedure should be discontinued.


Section 5: Implement and monitor activation procedures during the EEG: Photic stimulation Achieved

(tick) Not Achieved


Question (tick)













5.11 Continuously monitor the activation procedure and

accurately record changes in the condition of the patient.


5.13 In the event of a photo-paroxysmal response being obtained, follow the correct local procedures.


Section 5: Implement and monitor activation procedures during the EEG: Sleep recording Achieved

(tick) Not Achieved


Question(tick)













5.11 Continuously monitor the activation procedure and accurately record changes in the condition of the patient.


Section 5: Performance evidence required


Hyperventilation

Intermittent Photic Stimulation

Sleep

Polygraphy

Adult



Section 6: Complete and report on EEG investigation Achieved

(tick) Not Achieved


Question(tick)


6.1 Completely remove electrodes and transducers and carefully clean the sites with minimum discomfort to the patient. *

6.2 Reassure the patient and give them sufficient time to recover from the investigation prior to leaving the department. *

6.3 Clearly and accurately inform the patient of the procedure for notification of the results from the investigation. *

6.4 Treat the patients in a manner which is likely to preserve their dignity, confidence and self esteem throughout the investigation. *

6.5 Ensure that any required transportation/portering services and escort are made available to coincide with the completion of the investigation and the readiness of the patient to leave. *

6.6 Clean equipment (and where appropriate sterilise it), in accordance with local policy, and leave it in a condition suitable for re-use. *

6.7 Dispose of consumable in a safe manner and place. * 6.8 Adhere to local infection control and hand hygiene

policies and procedures throughout the investigation.

6.9 Ensure that annotations made to recordings and other patient documentation are accurate, legible and complete.


6.10 Manipulate the data - to include: measuring frequency

and amplitude, re-montaging to enhance specific features etc. Demonstrate other skills, for example; editing a montage, searching for events, demonstrating the effect of changing machine parameters and setting up a new montage.

6.11 Promptly prepare a concise, accurate factual report- covering the procedures employed, together with the neurophysiological findings and clinical events, drawing the clinician’s attention to features considered to be of clinical importance.

6.12 Establish the degree of urgency for the clinical report and forward the factual report to the clinician within the required time.

6.13 Follow appropriate archiving procedures.


4 Assessments to include: - Adult


6 Assessments of reports on records, to include adult adolescent, child under 5 years of age, clinical events, abnormal recordings in epilepsy and abnormal recordings in other disorders.

NOTE: The candidate will need to include at least 3 additional reports in addition to those produced during the formal assessments in order to satisfy the above.

* 6.2-6.8 only needs 2 formal assessments e.g. sleep and child under 5years


EEG Assessment

Assessment Outcome:

Plan [if required] :

Comments:

Date of Assessment: Signature of Trainee Practitioner ........................................…………………………………………….

Signature of Assessor ........................................…………………………………………….

Name of Assessor [Block Capitals] ……………………………………………………………………….


Completion of all Performance Criteria during the training period In the eventuality of one of the performance criteria not being met over the 3 assessments carried out by the Work based Assessor - keep a record of when the TP had demonstrated competence in that particular aspect of the procedure over the training period. Evidence of this will need to be available to the National Assessors at the time of the final assessment.

Assessment Criteria not applicable during

all 3 assessments

EEG No./Date When AC covered

Assessor Comments


ASSESSMENT SUMMARY SHEET - EEG

Assessment No. Date Type of EEG:-(Adult/Child/Sleep/Portable)

Range covered Achieved Not Achieved Abandoned


2. Evoked Potentials


NEUROPHYSIOLOGY ASSESSMENT EVOKED POTENTIALS UNIT

Evoked Potential Assessment No……………………….

Evoked Potential No……………………. Evoked Potential Type [delete as appropriate] Pattern VEP Flash VEP Patient Age Provisional Diagnosis Patient condition as identified in range


Potentials Section 1: Prepare the environment and equipment for obtaining Visual Evoked

Achieved

(tick) Not Achieved

(comment/reason required) Question

(tick) Not applicable

(tick) 1.1 Check the equipment to be used for safe condition and

correct operation, including all relevant peripheral devices.

1.2 Identify any faults and report and/or rectify them (if possible) in accordance with departmental procedure.

1.3 Check that there is adequate storage volume for the investigation

1.4 Perform a basic machine check in all modalities to be used.

1.5 Make a formal record of machine performance (as described in 1.4).

1.6 Accurately identify and report and/or rectify equipment faults.

1.7 Ensure that environmental conditions are suitable for the investigation.


2 Assessments (the third assessment will be at the part 2 final exams)

Equipment log (machine function and faults) .


Section 2 : Plan recording of Visual Evoked potentials Achieved

(tick) Not Achieved



(tick) 2.1 Ensure that all available data pertinent to the

investigation upon the patient is available and checked for validity

2.2 Evaluate the above data and thus plan the investigation.

2.3 Seek advice if there is any requirement for skills or knowledge beyond that of the candidate (the candidate recognises their own limits)

2.4 Take appropriate action where the data is insufficient to produce a valid plan.

2.5 Discuss any special needs of the patient are discussed with the patient and/or their carers.

2.6 Select appropriate apparatus for the test.

2.7 Ensure that the required consumables are present for the test, in sufficient quantity.

2.8 Ensure that the recording environment is made suitable for the needs of the patient.


2 Assessments: pattern and flash, at least one of which must be flash VEP


Section 3: Prepare patients for recordings of Visual Evoked Potentials Achieved

(tick) Not Achieved



(tick) 3.1 Confirm the patient’s identity from the referral

documents

3.2 Correctly identify /enter the patient’s information on the recording system

3.3 Establish effective communication with the patient/carers. Explain the test in a manner liable to ensure that their co-operation is enlisted.

3.4 Obtain a full but concise history, relevant to the investigation and record the information accurately

3.5 The patient’s condition is accurately assessed, based on all the available information, including case notes, direct observation and questioning of patient and carers.

3.6 Following 3.4 and 3.5, consider any modifications to the planned procedures.

3.7 Seek advice if there is any requirement for skills or knowledge beyond that of the candidate (the candidate recognises their own limits)

3.8 Accurately assess visual acuity ensuring the required correction is used.


3.9 Accurately mark electrode sites in accordance with a

recommended placement system and the planned investigation.

3.10 Ensure that electrodes are correctly and securely sited and leads are correctly positioned.

3.11 Confirm that contact impedances are appropriate to the electrode type.

3.12 Assist the patient to reach a position that is comfortable and optimises the quality of the recording.

3.13 Ensure that stimulators are correctly and accurately positioned in accordance with recommended procedures and adjusted in accordance with the type of investigation.

3.14 Ensure that vision is corrected, as appropriate for the patient and the test.




Section 4 :Monitor and record visual evoked potentials Achieved

(tick) Not Achieved



(tick) 4.1 Provide the necessary level of support and reassurance

to the patient throughout the investigation.

4.2 Select appropriate recording programs according to standard protocol.

4.3 Confirm that machine settings (filters, stimulus parameters etc) are correct for the investigation

4.4 Modify machine controls, as necessary, to optimise the display and highlight salient features.

4.5 Mask/patch the eye not being tested adequately to ensure it receives no stimulus

4.6 Monitor the technical quality of raw data.

4.7 Identify, eliminate or minimise any artefacts.

4.8 Give the patient clear instructions for the procedure and monitor compliance/attention.

4.9 Perform the procedures in accordance with standard protocols.

4.10 Monitor the quality of the raw data during the signal averaging process


4.11 Ensure that sufficient samples are averaged to yield a waveform which is stable and contains minimal noise.

4.12 Check evoked potentials for reproducibility.

4.13 The recording is legibly annotated to show control settings, stimulus settings, clinical states and events.




Section 5: Complete and report the results of Visual Evoked Potentials Achieved

(tick) Not Achieved



(tick) 5.1 Completely remove electrodes and transducers,

cleaning the site carefully and with minimum discomfort to the patient.

5.2 Reassure the patient and give them sufficient time to recover from the investigation prior to leaving the department.

5.3 Accurately and clearly inform the patient of the results notification procedure.

5.4 Ensure that any required transportation and escort are made available to coincide with the completion of the investigation and the readiness of the patient to leave.

5.5 Clean equipment (sterilise as appropriate) leaving it in a condition suitable for re-use.

5.6 Dispose of consumables in a safe manner and place.

5.7 Adhere to local infection control and hand hygiene policies and procedures throughout the investigation.

5.8 Annotate recordings and other patient documentation, ensuring it is accurate, legible and complete.


5.9 Compare salient features of the evoked potential waveforms with local normative data

5.10 Prepare a concise, accurate factual report; covering the procedures employed, together with any relevant neurophysiological findings and clinical events. Comment upon how the numerical data obtained correlates with normative data and also give a brief interpretive comment (even though this may not appear in the final report issued by the department).

5.11 Establish the degree of urgency for the clinical report is and forward the factual report to the clinician within the locally required time scale.



Normal and Abnormal results in each of the following

Pattern and flash VEP

EXPLANATORY NOTE: At least one assessment must include flash and at least one must include pattern reversal stimulation. Additional waveforms / reports should be included (preferably, but not essentially, the candidate’s own work) to show both a normal and abnormal result for each test type.


Assessment Outcome Plan [if required]

Additional Comments Date of Assessment: Signature of Trainee Practitioner ........................................………………… Signature of Assessor .......................................…………………. Name of Assessor [Block capitals] ……………………………………………


Completion of all performance criteria during the training period In the eventuality of one of the performance criteria not being met over the assessments carried out by the Work based Assessor, keep a record of when the TP had demonstrated competence in that particular aspect of the procedure over the training period. Enter the details in the reference table below. ( Evidence of this will need to be in the TP’s portfolio and cross-referenced).

Assessment Criteria not applicable to this assessment

Test No. Type & Date

When AC covered

Assessor Comments


ASSESSMENT SUMMARY SHEET – Evoked Potentials Unit

Assessment No.

Date Type (VEP):- (flash / pattern reversal)



3. Nerve Conduction Studies


NEUROPHYSIOLOGY ASSESSMENT PERIPHERAL NEUROHYSIOLOGY UNIT

Peripheral Neurophysiology Assessment No:

EMG/Nerve Conduction No: Patient Age: Provisional Diagnosis: Other Medical History /medication: Ranges met in this assessment:


NCS Assessment package

Section 1: Prepare equipment for investigating the peripheral nervous system. Achieved

(tick) Not Achieved



(tick) 1.1 Check the equipment is in a safe condition to use

1.2 Identify faults and rectify and/or report them properly

1.3 Identify the amount of storage space required by the test and check there is sufficient storage space on the equipment

1.4 Perform a basic machine check on the machine (in all modalities to be used)

1.5 Produce a formal record of the machine performance

1.6 Identify faults relating to machine performance and rectify (if possible) or report them properly

Performance evidence required 4 Assessments in CTS Equipment log (machine function and faults).


Section 2: Plan and prepare for recording NCS (in CTS) Achieved

(tick) Not Achieved



(tick) 2.1 Assemble and check all pertinent data concerning the

patient, establishing that the nature of the requested investigation is valid.

2.2 Plan the investigation following evaluation of the information concerning the patient and the clinical problem.

2.3 Seek advice if the planned investigation is beyond the scope or current skills of the trainee.

2.4 Select and correctly prepare appropriate electrodes and stimulators.

2.5 Ensure that all consumables likely to be required are available

2.6 Ensure that all equipment required is prepared in line with local infection control guidelines

Performance evidence required 4 Assessments


Section 3: Prepare patients for investigations of the peripheral nervous system Achieved

(tick) Not Achieved



(tick) 3.1 Ensure that the patient's identity is confirmed as correct.

3.2 Ensure that the patient’s data is accurately transferred to the recording system.

3.3 Ensure that effective communication with the patient is established and patients and carers are told what the investigation entails and their co-operation enlisted.

3.4 Obtain a full and concise history relevant to the investigation

3.5 Consider any modifications to the planned procedure which may be required in light of the history obtained.

3.6 Ensure the environment is suitable for the investigation, taking into account any special needs of the patient.

3.7 Measure and record the patient's skin temperature. Modify this if required and ensure that it is maintained at a suitable level.

Performance evidence required 4 Assessments in CTS


Section 4: Perform NCS in patients with CTS. Achieved

(tick) Not Achieved



(tick) 4.1 Ensure that correct programs are selected for

performing sensory NCS and that the default settings (filters, time base etc) are correct.

4.2 Correctly and securely position recording electrodes for a median sensory study

4.3 Correctly and securely position recording electrodes for a second (comparative) sensory nerve.

4.4 Correctly and securely position electrodes for a ‘sensitive’ sensory test

4.5 Correctly position stimulators for sensory nerve tests, paying particular attention to polarity.

4.6 Deliver supramaximal stimuli so as to obtain optimum sensory responses..

4.7 Identify artefacts and eliminate or minimise during sensory NCS

4.8 Accurately measure and document distances between stimulation and recording electrodes


4.9 Accurately and correctly mark SNAPs for latency and amplitude

4.10 Calculate sensory conduction velocities.

4.11 Continuously review the data obtained and, if required, modifies the procedure accordingly.

4.12 Select correct programs for motor studies and ensure that default settings are confirmed to be correct.

4.13 Correctly and securely position recording electrodes for motor NCS –median nerve.

4.14 Correctly position stimulator for motor NCS- distal (including polarity)

4.15 Correctly position stimulator for motor NCS- proximal (including polarity)

4.16 Deliver supramaximal stimuli in order to achieve optimal motor responses

4.17 Identify artefacts and eliminate or minimise during motor NCS

4.18 Accurately measure and document distances between stimulation and recording electrodes


4.19 Calculate motor conduction velocity

4.20 Continuously review the data and, if required, modify the procedure accordingly.

4.21 Review data from the complete investigation is and seek advice if additional investigations appear to be required

Performance evidence required 4 Assessments (must include at least 1 abnormal)


Section 5: Report NCS in patients with CTS Achieved

(tick) Not Achieved



(tick) 5.1 Accurately and legibly prepare the waveforms

obtained in the investigation, with clearly presented numerical data.

5.2 Prepare a brief written factual report, to include an assessment of the numerical data (comparing to normative data) and also basic interpretational comments (NOTE: This data/comments need not be included in the report issued to the referring clinician

5.3 Submit the report to the reporting Neurophysiologist (or reporting clinician), taking account of the urgency of the referral.

Performance evidence required 4Assessments (must include at least 1 abnormal)


Section 6: Complete investigations of the PNS Achieved

(tick) Not Achieved



(tick) 6.1 Remove electrodes and clean sites in accordance with

local infection control policies

6.2 Dispose of consumables promptly and appropriately

6.3 Tell the patient the procedure by which they get the results of the test

6.4 Allow the patient adequate time to recover from the procedure and give any assistance required for their transport.

6.5 Clean and disinfect the equipment in accordance with local policy, leaving it in a fit condition for re-use.

6.6 Adhere to local infection control and hand hygiene policy throughout the procedure.

Performance evidence required 4Assessments


Assessment Outcome Plan [if required]

Additional Comments Date of Assessment: Signature of Trainee Practitioner ........................................………………… Signature of Assessor .......................................…………………. Name of Assessor [Block capitals] ……………………………………………


Completion of all performance criteria during the training period In the eventuality of one of the performance criteria not being met over the assessments carried out by the Work based Assessor, keep a record of when the TP had demonstrated competence in that particular aspect of the procedure over the training period. Enter the details in the reference table below. (Evidence of this will need to be in the TP’s portfolio and cross-referenced).

Assessment Criteria not applicable to this assessment

Test No. Type & Date

When AC covered

Assessor Comments


ASSESSMENT SUMMARY SHEET - Peripheral Neurophysiology

Assessment No.

Date Type (NCS):-



Documents

National Standards For Clinical Neurophysiology