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TNA Clinical IOM Program Weekly Form

TNA Clinical IOM Program Weekly Eval Fom

This form is to assess the student’s performance over the course of the work week.

Student's Name
MM slash DD slash YYYY

Understanding anatomy (5 highest, 1 lowest)(Required)
1. Knowledge of anatomy and physiology 2. Knowledge of muscle groups, nerve roots associated with muscle groups
Understanding types of modalities (5 highest, 1 lowest)(Required)
SSEPs, MEPs, EMG, T-EMG, S-EMG, TOF, EEG
Spinal Procedures (5 highest, 1 lowest)
1. Understanding types of cervical, thoracic, and lumbar cases as well as the modality guidelines associated with each case 2. Understanding anesthesia protocols for each type of case/and modalities selected
ENT, Cardiovascular, Neurosurgical Procedures (5 highest, 1 lowest)
1. Understanding the types of cases and modality guidelines associated with each type of case. 2. Understanding anesthesia protocols for each type of cases and modalities selected.
Prepping (5 highest, 1 lowest)(Required)
1. Pre patient set up 2. Patient interview and patient consent 3. Patient in room documented
Patient set up, needle placement, & bed hook up (5 highest, 1 lowest)
1. Ability to apply different types of electrodes to a patient’s anatomy with precision & speed in preparation of monitoring a surgical procedure 2. Prepares patients for testing by attaching monitoring devices & explaining test procedures
Clinical correlations (5 highest, 1 lowest)
1. Ability to understand various electronic and neurophysiological waveforms. 2. Understands the clinical correlations between abnormal responses and various disease states.
Communication (5 highest, 1 lowest)
1. Case logging/note taking 2. Communication with surgeon, anesthesia, reader
Post case (5 highest, 1 lowest)
1. Proper disposal of needles, clean up 2. Communication with the surgical team 3. Interpersonal and communication skills necessary to interact with MDs, medical staff, patients, visitors, other hospital employees, and company personnel. 3. Reporting baselines, surgical events, and closing data to the surgeon.
Preceptor's Name