AAPM TG103 Report

CHART REVIEW CHECKLIST

DATE:

Facility Name:	Physicist name:

Patient number:

Description	1	2	3	4	5
Prescription: The chart contains a signed and dated prescription, including:

Treatment site

Planned total dose and fractionation

Modality and energy

Normalization (e.g. % isodose, depth)	Yes No

Yes No

Yes No

Yes No

Yes No

Treatment plan: If a graphic dose distribution plan was generated, the plan matches the prescription (modality/energy/dose/site) and has been signed by the physician and physicist.	Yes No

N/A

Yes No

N/A

Yes No

N/A

Yes No

N/A

Yes No

N/A

Meter setting: The monitor unit calculation is clearly documented, and checked by another person or another method before the 3rd fraction or 10% of the total dose.	Yes No

Yes No

Yes No

Yes No

Yes No

Set-up: The setup information is clearly and comprehensively documented (e.g., setup distance, field parameters, positioning equipment, diagrams / photos).	Yes No

Yes No

Yes No

Yes No

Yes No

Dose delivery: The prescribed and delivered dose agree, and accumulated dose to relevant critical structures is documented. There is documentation of a weekly chart check by the physicist or a designee, and a final check by the physicist at completion of treatment.	Yes No

Yes No

Yes No

Yes No

Yes No

Brachytherapy: If the treatment included brachytherapy, there is documentation of:

A written directive prior to treatment

Independent source strength verification (in chart or log book)

Adequate localization of source(s)

Post-implant dosimetry (prostate seeds)	Yes No

N/A

Yes No

N/A

Yes No

N/A

Yes No

N/A

Yes No

N/A

Comments:

Privileged and Confidential Peer Review

AAPM PICR - TG103 Report

Mechanisms for Peer Review in Clinical Radiation Oncology Physics

Peer review, professional

Per H Halvorsen

2005-03-17

Ravi Rao