Planning Planning | ||||
---|---|---|---|---|
1 | Treatment time printed | 0 0 0 | ||
2 | Plan approved | 0 0 0 | ||
3 | Physics Check performed | 0 0 0 | ||
4 | Consents verified | 0 0 0 | ||
5 | Lengths entered | 0 0 0 | ||
6 | Number of Fx on Rx | 0 0 0 | ||
7 | Dose/Fx on Rx: | 0 0 0 | ||
8 | Dose/Fx on Plan: | 0 0 0 | ||
9 | Isodose plan printed | 0 0 0 |
Treatment Treatment | ||||
---|---|---|---|---|
1 | Fraction: | 0 0 0 | ||
2 | Date: | 0 0 0 | ||
3 | Time: | 0 0 0 | ||
4 | Patient survey before treatment | 0 0 0 |
Treatment Time out | ||||
---|---|---|---|---|
1 | Two forms of ID | 0 0 0 | ||
2 | On hand: survey meter, Lead Container, Tongs | 0 0 0 | ||
3 | Tx times compared with printout | 0 0 0 | ||
4 | Applicator imaging verified by: (MD initials) | 0 0 0 | ||
5 | Applicator connected by: (Initials) | 0 0 0 | ||
6 | Authorized user signature | 0 0 0 | ||
7 | Backup timer set (Minutes & seconds) | 0 0 0 |
Post Treatment Post treatment | ||||
---|---|---|---|---|
1 | Total accumulated dose (Gy) | 0 0 0 | ||
2 | Review post treatment record | 0 0 0 | ||
3 | Operator Initials | 0 0 0 | ||
4 | Dose per fraction | 0 0 0 | ||
5 | Authorized Medical Physicist (Initials) | 0 0 0 | ||
6 | Survey room & record | 0 0 0 |