3701-83-49 Medical record.

In addition to the requirements of rule 3701-83-11 of the Administrative Code, each freestanding radiation therapy center shall maintain documentation of the following in the patient’s medical record:

(A) Confirmation of the presence of malignancy by histopathology, or a statement of benign condition, or other alternative evidence for diagnosis of all cases accepted for radiation;

(B) Documentation of services and radiographic images, including localization films, appropriate to the therapy provided;

(C) Report of the initial evaluation including a definition of the tumor location, and the extent of each cancer as a basis for staging;

(D) The treatment plan including the selection of dose, selection of treatment modality, and selection of treatment technique;

(E) The dosimetry calculations;

(F) The patient’s progress and tolerance; and

(G) The completion of treatment with statement of follow-up plan.

R.C. 119.032 review dates: 02/10/2011 and 02/10/2016

Promulgated Under: 119.03

Statutory Authority: 3702.12

Rule Amplifies: 3702.30

Prior Effective Dates: 1/13/1996