2-C-2: Components of Patient Records Flashcards
How must a patient’s identity be confirmed?
A patient’s identity must be confirmed in two ways, such as the patient’s name and date of birth.
A face photo of the patient should be included in the patient’s chart for visual confirmation.
What is the best way to identify an inpatient?
The best way to ID an inpatient is with their wrist bracelet.
What should an outpatient carry for identification?
An outpatient should carry an identification card that will be checked by therapists treating the patient.
What must be included in patient chart documentation?
Entries on the patient’s chart must be dated and initialed or signed by the radiation therapists who treated the patient.
What is essential for the clarity of information in a patient’s chart?
Information written in a patient’s chart must be clear and legible.
What should be done if an error is made in the treatment chart?
If an error is made, draw a single line through the error and write the correct information, adding the initials of who corrected it along with the date.
Never use correction fluid (Wite-Out) or anything that completely covers the error.
What may necessitate a change in treatment?
Sometimes a change in treatment is necessary depending on the patient’s circumstances.
What must a therapist do if there is a change in treatment?
The therapist treating the patient must be aware of any changes and take the appropriate measures following any changes.
What is required if there is a change in field size?
Changes in field size will require imaging to validate changes.
How should a changed field be named?
If there is a change in the field, it will be renamed to show the change, using subscript letters, numbers, or prime marks (1,*).
What constitutes a medical event according to the NRC?
A medical event is when the total dose delivered to a patient is different from the prescription by 20 percent or more, or when the delivered dose for one fraction is different from the prescription by 50 percent or more.
What are other examples of medical events?
Examples include delivering radioactive materials to the wrong patient, via the wrong route, using the wrong materials, or leakage from the sealed source.
What is the reporting requirement for a medical event?
The medical event must be reported to the NRC by the next day after realization, and a written report must be submitted within 15 days.
What must be communicated to the patient and physician after a medical event?
The patient and the physician must be informed within 24 hours.
What must the report of a medical event include?
The report must include the licensed person’s name, the physician who prescribed the treatment, a description of what occurred, the effect on the patient, and the appropriate measures that will be taken after the event.
