3701-84-73 Medical record.

In addition to the requirements of rule 3701-84-11 of the Administrative Code, each radiation therapy service and/or stereotactic radiosurgery service shall maintain documentation of the following in the patient's medical record:

(A) Confirmation of the presence of malignancy by histopathology, 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 or target type, 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 a follow-up plan.

R.C. 119.032 review dates: 05/11/2012 and 05/01/2017
Promulgated Under: 119.03
Statutory Authority: 3702.11, 3702.13
Rule Amplifies: 3702.11, 3702.12, 3702.13, 3702.14, 3702.141, 3702.15, 3702.16, 3702.18, 3702.19, 3702.20
Prior Effective Dates: 3/1/1997, 3/24/03, 5/15/08