Quality Control Feedback Form for Sleep Study

Quality Control Feedback Form

Recording Tech: _______________________ Scoring Tech: ________________________

Scorer’s Feedback:

Adequate acquisition baseline/treatment Yes No

Instrument calibrations completed Yes No

Bio-Calibrations completed Yes No

Artifact recognition/ intervention Yes No

Adequate CPAP titration Yes No

Patient paperwork completed Yes No

Scoring Tech Comments:_____________________________________________________

Interpreting Physician’s Feedback:

EEG Recording Quality Satisfactory Yes No

Other channel recording quality Satisfactory Yes No

Adequate treatment titration N/A Yes No

Overall quality of recording Excellent Satisfactory Marginal Poor

Scoring quality satisfactory Yes No

EKG recording/scoring satisfactory Yes No

Notes:____________

Physician signature________________ Date:___________

Board-certified sleep M.D. physicians, scientists, editors and writers for ASA.