Table 1 Number of omissions for each criterion; and number corrected subsequently out of 2597 patients
From: Ten-year results of quality assurance in radiotherapy chart round
| Â | Number of omissions | Number corrected subsequently | |
|---|---|---|---|
Departmental or hospital clinical record | |||
1 | History recorded | 23 | 9 |
2 | Examination recorded | 3 | 1 |
3 | Primary tumour site correctly documented | 0 | 0 |
4 | Histology correctly documented and report filed | 45 | 29 |
5 | Relevant imaging of treated site correctly documented and reports filed | 105 | 48 |
6 | Tumour stage correctly documented | 5 | 2 |
7 | Rationale for radiotherapy documented | 0 | 0 |
8 | Treatment intent documented | 0 | 0 |
9 | Discussion of treatment risks and consent recorded | 0 | 0 |
10 | Letter or notes copied to referring doctor | 8 | 8 |
Treatment prescription | |||
11 | Legible patient name is present on all prescriptions | 0 | 0 |
12 | Treatment site specified and correct | 0 | 0 |
13 | Laterality (i.e. ‘left’ or ‘right’) for treated site correctly documented | 1 | 1 |
14 | Radiation modality and energy for all phases | 0 | 0 |
15 | Total dose specified for all phases | 0 | 0 |
16 | Dose per fraction specified for all phases | 0 | 0 |
17 | RT dose point specified for all phases | 3 | 3 |
18 | Number of fractions/day specified for all phases | 0 | 0 |
19 | Number of fractions per week for all phases | 0 | 0 |
20 | Treatment prescriptions are signed/approved and dated | 0 | 0 |
Simulation and planning | |||
21 | Isodoses/treatment plan signed/approved and dated by doctor | 0 | 0 |
22 | Legible and correct patient name on all simulation/VP film/electronic images | 0 | 0 |
23 | Simulation image is signed or approved and dated by doctor | 0 | 0 |
Performance criteria | |||
24 | Indication for treatment | 0 | 0 |
25 | Treatment intent (radical vs. palliative) | 0 | 0 |
26 | Target volume coverage | 0 | 0 |
27 | Critical structure doses | 0 | 0 |
28 | Prescribed total dose for each volume | 0 | 0 |
29 | Fractionation schedule | 0 | 0 |
30 | Clinical protocol or practice guideline followed | 0 | 0 |
31 | Research or Study followed | 0 | 0 |
| Â | (*for 6 patients the actual omission was unclearly documented). | 6 | 0 |
Total | 199 | 101 | |