TNA Clinical IOM Program Daily Eval Form

TNA Clinical IOM Program Daily Eval Fom

Clinical Hours are a combination of the following activities (observation and hands on), patient interview, pre op/post op evaluation, actual OR time shadowing/hands on, observing/shadowing/running IOM cases from start to finish.

Student's Name
MM slash DD slash YYYY
Type of cases
The time the student arrives at the facility.
The time the student leaves the facility.
What role did the student play?(Required)


Please only grade the student on what they performed.
Prepared with research of expected case
Student on time
Appropriate number of electrodes prepared
Predocumentation prior to pt in the room
Program turned on and any changes made prior to pt in the room
Reader online and documented prior to the pt in the room
Patient consent obtained if applicable
Anesthesia regimen confirmed
MD orders confirmation of levels, modalities and documented
Communication with surgeon with regards to contraindications for MEPs
Patient in room documented
Correct electrode placement with EMGs
Correct head electrode placement
Timing – held up surgery?
Electrodes accurately plugged into equipment
Pre-incision SSEP baseline quality
Pre-incision MEP baseline quality
Baseline communication with surgeon & documented
Case log comments every 15 – 20 minutes
Understood anesthesia's effect in IOM signals
MEPs ran and documented- per MD preference
Ability to evaluate MEPs
SSEPs run consistently throughout the case
Ability to evaluate SSEPs
Communication with surgeon & documented
Communication with anesthesia & documented
Changes reported timely & appropriately & documented
Pedicle screw/nerve stim
IOM complete comment documented
Surgeon informed of closing data & documented
Pulled out electrodes appropriately & cleaned patient
Cares for and disinfects equipment properly
Please take into account their enthusiasm, professionalism, motivation to learn and take correction.
Preceptor's Name