Documentation Standards Flashcards

A daily cone-beam CT shows a 4 mm shift that is applied before treatment. What should the therapist document?

Answer: The shift values in each direction, the approval, and that the correction was applied

Recording shift magnitudes and actions lets the team spot systematic errors and confirms the corrections are traceable.

Which correctly documents a dose per fraction according to safe-documentation standards?

Answer: 2 Gy

Trailing zeros are on the Joint Commission 'Do Not Use' list because '2.0' could be misread as '20'.

What is the purpose of documenting a 'time-out' before a special procedure such as HDR brachytherapy?

Answer: To confirm the correct patient, procedure, and site before starting

The Universal Protocol time-out is a final documented check that the team agrees on patient, procedure, and site.

For a female patient of childbearing age, what should be documented before simulation and treatment?

Answer: Pregnancy status

Fetal radiation exposure is a serious risk, so pregnancy status must be checked and recorded before imaging or treatment.

A near miss is caught before treatment, so no radiation reaches the patient. How should it be handled?

Answer: Report it through the department's incident learning system

Reporting near misses, for example to RO-ILS, helps find system weaknesses before harm occurs.

When should bolus use be documented in the treatment record?

Answer: Every fraction in which bolus is used, as specified in the plan

Bolus changes the surface dose, so whether it was applied should be recorded each session to confirm the plan was followed.

Who is responsible for obtaining and documenting the patient's informed consent for radiation therapy?

Answer: The radiation oncologist

The treating physician must explain risks, benefits, and alternatives and document informed consent before treatment.