Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET The Neurodiagnostic Society

The Guidelines for Qualifications of Neurodiagnostic Personnel (QNP) document has been created through the collaboration of the American Clinical Neurophysiology Society (ACNS), the American Society of Neurophysiological Monitoring (ASNM), the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), and ASET The Neurodiagnostic Society (ASET). The quality of patient care is optimized when neurophysiological procedures are performed and interpreted by appropriately trained and qualified practitioners at every level. These societies recognize that neurodiagnostics is a large field with practitioners who have entered the field through a variety of training paths. This document suggests job titles, associated job responsibilities, and the recommended levels of education, certification, experience, and ongoing education appropriate for each job. This is important because of the growth and development of standardized training programs, board certifications, and continuing education in recent years. This document matches training, education, and credentials to the various tasks required for performing and interpreting neurodiagnostic procedures. This document does not intend to restrict the practice of those already working in neurodiagnostics. It represents recommendations of these societies with the understanding that federal, state, and local regulations, as well as individual hospital bylaws, supersede these recommendations. Because neurodiagnostics is a growing and dynamic field, the authors fully intend this document to change over time.

Competency assessments 5 including, but not limited to, recognition of clinical seizures and other clinical paroxysmal events, ictal testing procedures, measures to reduce risk of fall, and seizure first aid. Supervision (Table 3).
General technical supervision by an ND Technologist III or above.
Ongoing education/maintenance of competency Should attend relevant educational offerings and be required to demonstrate ongoing competence.
1.2 | Neurodiagnostic Technologist I (Grandfather clause*: Any ND technologist practicing in the ND field before December 31, 2021, shall be considered grandfathered in ND education, and therefore shall be deemed that the existing ND education requirement as outlined in Section 3 has been met ( Table 2)) Job responsibilities. This is a transitional position, and a new hire is expected to obtain credentials within 5 years.
Performs routine testing under supervision; writes a descriptive technical analysis for QA purposes only. 6 Has hospital training to alert supervisor and/or activate hospital systems, such as rapid response, cardiac arrest, etc., per established protocols when encountering patient clinical issues. Has hospital training to alert supervisor and/or activate hospital systems, such as rapid response, cardiac arrest, etc., per established protocols when encountering patient clinical issues. Education/certification.
Associate degree or higher is preferred, or graduate of a CAAHEP-accredited ND program. 7,8 Experience.
Twelve or more months of experience working in a patient care environment with supervised experience in performing primary testing modality.
Competencies should at minimum include those specified by ASET's National Competency Skill Standards 5 and/or AA-NEM's skill standards for NCS, 10 as appropriate.
General technical supervision. Reports to ND Technologist III or above.
Works under supervision of interpreting provider who can be immediately present either electronically or in person. For NCS, works under direct physician supervision. 9 Regular quality assessments of technical skills must be performed and documented at least yearly.
Ongoing education/maintenance of competency.
A minimum of 15 credits should be obtained every 3 years, covering all modalities performed by the technologist.
Performs routine, as well as more advanced testing (per program guidelines); recognizes clinically significant events and patterns; T A B L E 3 Supervision Levels in Neurodiagnostics.

Direct technical supervision
Credentialed technologist or physician approved to perform all technical aspects of the procedure must be physically present at all times during the procedure.

Indirect technical supervision
Credentialed technologist or physician approved to perform all technical aspects of the procedure must be immediately available at all times to provide assistance and direction throughout the procedure.

General technical supervision
Performed under technical supervision as detailed in the facility policy and procedures. Requires ongoing evaluation of quality but not the necessity of immediate availability.

Level Description
Personal supervision The physician must be in attendance in the room during the performance of the service or procedure.

Direct supervision
The physician must present in the office suite and be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean the physician must be present in the room when the procedure is performed.

General supervision
The procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. follows policy and procedures regarding critical test results; communicates with team members; writes a technical descriptive analysis. 6 Has hospital training to alert supervisor and/or activate hospital systems, such as rapid response, cardiac arrest, etc., per established protocols when encountering patient clinical issues.
• R. EEG T. 18 dPerforms clinical EEG in the adult, pediatric, and neonatal populations. Also performs studies in ICUs.
• R. EP T. 17 dDemonstrates proficiency in the acquisition and recognition of basic EP waveforms relevant to EP modality being tested.
• R.NCS.T. or CNCT 11,19 dPerforms NCS; recognizes clinically significant events and follows facility policy and procedures regarding critical test results.
• CAP 14 dPerforms basic and advanced ANS testing proce-dures independently with a high degree of technical proficiency; recognizes physiologic and nonphysiologic artifacts and takes appropriate steps to eliminate them; and describes normal and abnormal clinical manifestations observed during the testing.
Associate degree or higher is preferred, or graduate of a CAAHEP-accredited ND program. 7,8 Experience.
Meets qualifications and requirements of Technologist II, is credentialed, and meets all education requirements set forth by ABRET, AAET, or ABEM.
Works under general technical supervision as specified in departmental policy and procedure manual.
Regular quality assessments of technical skills must be performed and documented at least yearly.
Works under supervision of interpreting provider who can be immediately present either electronically or in person. For NCS, works under direct physician supervision. 9 Ongoing education/maintenance of competency.
A minimum of 30 credits should be obtained every 5 years covering all modalities performed by the technologist. This is a minimum requirement and is superseded by individual credential requirements as set forth by ABRET, AAET, and ABEM.

| IONM Neurodiagnostic Technologist I
Job responsibilities. This is a trainee-level position and is considered transitional. It is expected that new hires will obtain CNIM certification within 5 years.
Helps set up monitoring equipment while assuring patient safety.
Communicates effectively with team members.
Has hospital training to alert supervisor and/or activate hospital systems, such as rapid response, cardiac arrest, etc., per established protocols when encountering patient clinical issues. Education/certification.
R. EEG T. or R. EP T. or a bachelor's degree. Experience.
Six or more months of experience working in a patient care environment. For individuals entering the field with a bachelor's degree, patient experience requirements will be determined by their employer.
Requires direct technical supervision.
Works under supervision of interpreting provider who can be immediately present either electronically or in person.
Regular quality assessments of technical skills must be performed and documented at least yearly.
Ongoing education/maintenance of competency.
A minimum of 30 credits should be obtained every 5 years. This is a minimum requirement and is superseded by individual credential requirements. Regular quality assessments of technical skills must be performed and documented at least yearly.
Ongoing education/maintenance of competency.
A minimum of 30 credits should be obtained every 5 years.
This is a minimum requirement and will be superseded by individual credential requirements and/or maintenance of certification requirements.
• Three or more years of experience in the ND field that includes 1 year of experience in LTM for epilepsy.

Specific job responsibilities
• Recognizes and reports critical values to the appropriate medical personnel, significant clinical events, and EEG patterns.
• Prepares, organizes, and summarizes data for physician review.
• Three or more years of experience in the ND field that includes 1 year of experience in ICU/cEEG monitoring.

Specific job responsibilities
• Recognizes significant clinical events and EEG patterns; provides alerts as detailed in departmental policy and pro-cedure manual.
• Prepares, organizes, and summarizes data for physician review.

Specific job responsibilities
• Able to apply electrodes and obtain high-quality waveforms independently.
• Able to recognize changes and communicate such with team as specified in the departmental policy and procedure manual.
• Able to troubleshoot common problems in IONM recordings. • Three or more years of experience in the field of ND, which includes at least 6 months of supervised clinical and hands-on experience in an active MEG center.
• Experience of 75 MEGs for epilepsy; know the 10 to 20 International System of Electrode Placement.
• Twenty-five MEG evoked potentials including three or more of the five EP scans: auditory, language evoked, motor evoked, sensory evoked, and visually evoked.
• Experience to trouble shoot the system, including filling liquid Experience.
Minimum of 5 years of experience, of which 3 years are postcredential.
• NCS specialist II requires a minimum of 5 years as a CNCT or R.
NCS.T., with 6 years of experience, including ICU experience. 9 Advanced modality requirements for experience and qualifications are listed below in Sections 7a-7e.
Works under general technical supervision as specified in departmental policy and procedure manual.
Works under supervision of interpreting provider who can be immediately present either electronically or in person. For NCS, works under direct physician supervision. 9 Ongoing education/maintenance of competency.
A minimum of 30 credits should be obtained every 5 years. This is a minimum requirement and may be superseded by the requirements of credentialing boards. • Bachelor's degree required.  Table 2)) and may have ICU experience. 9 Specific job responsibilities • Assists in development of and monitoring of adherence to policies and procedures for NCS.
• Demonstrated ability to train others in the principles and practice of NCS, including technologists, residents, and fellows.
• Three or more years of experience in the ND field, specifically EEG, and 2 years of experience in MEG.

Specific job responsibilities
• Performs digitization for co-registration to MRI, performs initial MEG spontaneous recording with concurrent EEG recording, understands placement and recording of evoked field trials (SEF, VEF, MEF, AEF, and LEF), implements nontraditional activation procedures as required (or ordered by attending physician), performs initial filtering and review of MEG/EEG data, performs preprocessing and localization of interictal activity, review of initial localization with physician, localization of evoked field data (for review by physician), and archiving and retrieval of MEG data.
Writes detailed description of EEG patterns, seizure semiology, ictal and interictal abnormalities, and selection of representative EEG samples.
Acts as a physician extender in collaboration with the supervising physician and other health care staff.
If the NeuroAnalyst is working in an EMU, they must be able to perform the following duties: • All duties and responsibilities for typical and special consid-eration for routine and advanced EEG/ECoG.
• Extensive knowledge in neuroanesthesia and its application to neuromonitoring.
• All aspects of invasive implants preoperatively, intraopera-tively, and postoperatively, including, but not limited to, electrode setup, montage creation/verification, troubleshoot-ing, hook-up and discontinuation, and stimulation for cortical mapping. Education/certification.
Associate degree or graduate of a CAAHEP-accredited ND program, 7,8 bachelor's degree is preferred. Experience.
Minimum of 5 years of experience in LTM in the ambulatory setting, EMU, and/or critical care postcertification in LTM.
Works under general supervision of the neurodiagnostic technical lab supervisor or the neurodiagnostic lab director and the interpreting physician.
Ongoing education/maintenance of competency.
A minimum of 30 credits should be obtained every 5 years. This is a minimum requirement and is superseded by individual credential requirements.
Each laboratory requires technical supervision. These qualifications refer only to the issues specifically related to supervision of technical activities. The laboratory supervisor may take on additional responsibilities as dictated by hospital administrative policies and organization.
Job responsibilities.
Provides direct supervision and education to other technologist levels; oversees day-to-day operations; responsible for maintaining policies and procedures; and QA program development and implementation in conjunction with the medical and technical laboratory directors. Education/certification.
Must have a minimum of one credential in ND technology, two or more preferred, in the area supervised.
Associate degree or graduate of a CAAHEP-accredited ND program, 7,8 bachelor's degree is preferred. Experience.
Minimum of 5 years of experience in ND.
Works under the neurodiagnostic technical lab director and with the medical director.
For clinical studies, works under supervision of interpreting provider who can be immediately present either electronically or in person.
Ongoing education/maintenance of competency.
A minimum of 30 credits should be obtained every 5 years. This is a minimum requirement and is superseded by individual credential requirements.
Functions in the role of educator, facilitator, change agent, consultant, and leader for professional development.
Job responsibilities.
Designs and implements competency and educational activities for ND personnel, including annual competency programs, orientation, continuing education, and professional development within a collaborative practice framework.
Develops new employees to meet job requirements.
Assists those who are not credentialed for board examination.
Coordinates continuing education and competency activities for staff.

Education/certification.
Graduate of an accredited Baccalaureate program, preferably in ND 7,8 or higher education.
Must have a minimum of one ND-related credential, two or more preferred. Credential should be specific to the modality for which education is being provided. Experience.
Minimum of 5 years of experience in ND with previous teaching experience preferred.
Works under the neurodiagnostic technical lab director.
Ongoing education/maintenance of competency.
A minimum of 30 credits should be obtained every 5 years. This is a minimum requirement and is superseded by individual credential requirements.
This position can be held either by a ND professional with additional management training or experience, or by non-ND manager, typically with experience in other diagnostic services. Experience.
Minimum of 5 years of minimum experience; 3 years of previous supervisory experience is recommended.
Works with hospital administration and Medical Director.
If job description includes performing clinical ND studies, works under general supervision of interpreting provider who can be immediately present either electronically or in person.
Ongoing education/maintenance of competency.
A minimum of 30 credits should be obtained every 5 years. This is a minimum requirement and is superseded by other individual credential requirements.
2 | NONPHYSICIAN NEUROPHYSIOLOGIST POSITIONS 2.1 | (All abbreviations and corresponding definitions are found in Table 1) NOTE: As may pertain to all higher levels of practitioners, please note that there are individuals who perform, and in some cases interpret, testing under the supervision of a licensed and qualified physician.
These individuals do not have a medical or osteopathic doctorate and are referred to as "Advanced Practi-tioners" or other "Qualified Health Care Providers." This document recommends privilege-based licensure, as well as skills, knowledge, and abilities, gained through training, experience, and accredited programs. [24][25][26][27][28][29] These are demon-strated by passing board examinations and maintained through continuing education. [30][31][32][33][34] This document does not supersede applicable state law.
These practitioners work within their state's regulatory and/ or statutory scope of practice guidelines and within institutional credentialing. The scope of practice may differ across states, institutions, and insurance carriers.

| Audiologist (Lab)
Job responsibilities 35. Audiological and vestibular testing and BAEPs including both the technical and the interpretative components related to the assessment of the function of the eighth cranial nerve and peripheral hearing apparatus. Education/certification.
All audiologists must be an AuD or hold current board certification. Experience.
Has performed and interpreted the number of studies required by federal, state, institutional, and/or certifying organization regulations.
The minimum number should be sufficient for the practitioner to have gained mastery of all aspects of testing.
May work independently or under supervision as specified by federal, state, and hospital regulations.
To supervise technologists performing audiological testing within the ND laboratory, the audiologist must have a minimum of 3 years of experience in clinical practice in addition to the AuD.
Ongoing education/maintenance of competency.
Minimum of 50 CEUs spanning 5 or more years, as required for maintenance of certification. This is a minimum requirement and is superseded by other individual credential requirements.

| Nonphysician (PhD, AuD 35 , FMG) Neurophysiologist Performing IONM
Job responsibilities This may include: • Management of personnel and instrumentation that support IONM.
• Technical performance of IONM.
• Real-time interpretation of IONM under the supervision of a licensed physician who is immediately available, either in person or online, if needed, e.g., for rendering of medical opinion, decisions, and recommendations during surgery. 36 This physician must be a clinical neurophysiologist trained, qualified, and experienced in IONM as referenced under Section 18.
Evidence of continuous experience in IONM including case logs that document a minimum of 300 cases monitored with the primary responsibility for the clinical tasks in which the provider will participate.
Supervision (Table 3). May perform any of the job responsibilities described for the nonphysician neurophysiologist (Section 13) as described above. Available for teaching less experienced providers.
The specific responsibilities assigned to each practitioner should be documented by the employer. Education/certification.
All requirements are the same as for the nonphysician neurophysiologist performing IONM except: • The DABNM credential is required. Experience.
All requirements are the same as for the nonphysician neurophysiologist except that: • At least 7 years of clinical activity in IONM is required.
The requirements are the same as the nonphysician neurophysiologist (Section 13).
Ongoing education/maintenance of competency.
The requirements are the same as the nonphysician neurophysiologist (Section 13). Interprets CNP studies under supervision as discussed below.

| PHYSICIAN POSITIONS (ALL ABBREVIATIONS AND CORRESPONDING DEFINITIONS ARE FOUND IN
Education/certification.
Valid state license to practice medicine in the state in which the study is performed.
Completion of an ACGME-accredited residency.
If practicing in a hospital setting, must satisfy the hospital's requirements for medical staff privileges in their specialty area. If the hospital has separate criteria for performing and interpret-ing neurophysiologic tests, the practitioner must meet those requirements for the particular test performed.  Completion of an ACGME-accredited fellowship in CNP or equivalent training before the establishment of accredited training programs as recognized by board certification as specified below.  (Table 3).
Supervises studies performed by other providers with less experience or training.
Ongoing education/maintenance of competency.
Must maintain medical staff privileges in CNP as applicable.
Must have ongoing education in the area practiced with an average of 15 CME credits annually in the area(s) of CNP practiced, averaged over 3 years.
Must participate in ongoing QA and quality improvement activities.
Supervises and interprets general and complex CNP studies in the areas of expertise.
Involved in planning QA and quality improvement activities in the ND department.
Available for consultation with other staff on complex or difficult cases.
Involved in ongoing training and education of physicians and technologists. Education/certification.
Valid state license to practice medicine in the state in which the study is performed.
Completion of an ACGME-accredited fellowship in CNP or equivalent training before the establishment of accredited training programs as recognized by board certification as specified below. Board certification by ABPN-CN, 32 ABCN, 30 or ABEM. 31 Completion of an ACGME-accredited residency in physical medicine and rehabilitation or neurology. Supervision (Table 3).
Supervises studies performed by other providers with less experience or training.
Available for teaching and supervision of less experienced practitioners.
Ongoing education/maintenance of competency.
Must maintain medical staff privileges/subspecialty privileges in CNP as applicable.
Must have ongoing education in the area practiced with an average of 15 CME credits annually in the area(s) of CNP practiced, averaged over 3 years.
Must participate in ongoing QA and quality improvement activities.
Development and implementation of policies and procedures for ND laboratory.
Supervision and assessment of competency of ND laboratory staff at all levels.
Assures that there is ongoing teaching and educational activities within the department.
Supervises quality improvement activities.
Works with technical director/manager in planning for the laboratory, staff, equipment, and budget. Education/certification.
Valid medical license to practice in the state where supervising studies.
Case experience equal to or greater than that required for subspecialty neurologist or physiatrist (Section 18).
Board certified by ABPN or ABPMR.
Board certified in at least one area of CNP (ABPN-CN, ABCN, or ABEM).
For AANEM medical director for EDX laboratories or EDX laboratory accreditation, 23 the qualifications of a medical labo-ratory director shall meet AANEM medical lab director qualifi-cations and AANEM CME requirements: • 1. Completed ACGME or RCPSC neurology or PMR residency.
• 2. Completed primary board certification in ACGME or RCPSC neurology or PMR.
3. Completed 3 months of training in EDX medicine during neurology or PMR ACGME or RCPSC residency or fellowship. Experience.
At least 5 years of professional practice in neurophysiology.
Department Chair/Vice Chair, Chief Medical Officer, or Section Chief as governed by the department or medical facility.
Ongoing education/maintenance of competency.
Must maintain medical staff privileges in neurology or PMR, and CNP.
Should have ongoing education in the area practiced with an average of 15 CME credits annually in the area(s) of CNP practiced, averaged over 3 years.
Should be involved in managing ongoing QA and quality improvement activities.