HDR Brachytherapy Written Directive/Procedure Note

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Date/Time: [Encounter date and time]

Location: [Treatment location]

Note Type: HDR Brachytherapy Written Directive/Procedure Note

Fraction: [Current fraction] of [Total fractions]

Treatment Team:

Authorized User (AU): [Name, credentials]

Authorized Medical Physicist (AMP): [Name, credentials]

Radiation Therapist(s): [Name(s)]

Nursing: [Name(s) / N/A]

Anesthesia: [Name(s) / N/A]

Part A — Written Directive

Critical: Treatment must not proceed if any required field is incomplete or unsigned.

Clinical Context

[Brief clinical summary including primary diagnosis, treatment intent, treatment site with laterality, and device/approach category] (Keep to 2–3 sentences. Reference separate operative note for applicator placement if documented elsewhere.)

Prescription

Radionuclide: [Radionuclide, e.g., Ir-192] (If not documented, insert "[REQUIRED - must complete before treatment]")

Treatment Site: [Anatomic site with laterality if applicable] (If not documented, insert "[REQUIRED - must complete before treatment]")

Dose per Fraction: [Dose and units] (If not documented, insert "[REQUIRED - must complete before treatment]")

Number of Fractions: [Integer] (If not documented, insert "[REQUIRED - must complete before treatment]")

Total Dose: [Dose and units] (If not documented, insert "[REQUIRED - must complete before treatment]")

Prescription Method: [Point-based / Volume-based] to [Specification, e.g., Point A, HR-CTV D90, vaginal surface at depth] (If not documented, insert "[REQUIRED - must complete before treatment]")

Applicator Type: [Applicator type and size] (If not documented, insert "[REQUIRED - must complete before treatment]")

Special Instructions: [Bladder/rectal preparation, packing, imaging requirements, or other delivery-critical instructions / None]

Written Directive Authorization

AU Signature: [Signature]

Date/Time Signed: [Date and time] (Must be completed before treatment)

Revision to Prior Written Directive: [Revision description, effective starting fraction, new AU signature and date/time] (Include only if this revises a prior WD; otherwise omit this line)

Part B — Procedure/Treatment Delivery Record

Pre-Treatment Verification

• Consent confirmed: [Yes / No]
• Patient identity verified (two identifiers): [Yes / No] — [Identifiers used]
• Pregnancy screening: [Completed / N/A] — [Result if obtained]
• Treatment site and laterality confirmed: [Yes / No]
• Fraction number and prescription verified against WD: [Yes / No]
• Applicator type/size confirmed: [Yes / No] — [Type/size]
• Time-out performed: [Yes / No] — [Team members present]
• Applicator insertion this encounter: [Yes / No] (If Yes, note guidance method and any placement complications; if No, document "Applicator in situ from [date], no change.")

Final Time-Out Immediately Before Irradiation:

• Patient identity re-verified: [Yes / No]
• Correct plan selected at console: [Yes / No] — Plan ID: [Plan ID]
• Channel connections and transfer tube integrity verified: [Yes / No]
• Channel length/first dwell position verified: [Yes / No]
• Independent calculation check completed: [Yes / No] — [Performed by, date/time]

Treatment Planning Summary

Imaging Dataset: [Modality] — [Date]

Treatment Planning System: [TPS name/version] — Plan ID: [Plan ID]

Source Model/Library Version: [Model/library / N/A]

Plan Approval: AU: [Name, date/time] — AMP: [Name, date/time]

Planned Dose Metrics: [For point-based: Point A dose, rectal/bladder reference point doses. For volume-based: HR-CTV D90, OAR D2cc values as applicable]

Independent Check: [Completed by, date/time]

Treatment Delivery

Fraction Number: [Fraction number]

Treatment Date: [Date]

Treatment Start Time: [Time]

Treatment End Time: [Time]

Delivered Dose: [Dose and units]

Delivered Dose Matches WD: [Yes / No] (If No, describe difference and document deviation workflow)

AU Present at Initiation: [Yes / No]

AMP Present: [Yes / No]

Visual/Audio Monitoring Confirmed: [Yes / No]

Interruptions: [None / Description including reason, action taken, and dose completion status]

Patient Tolerance: [Brief statement with at least one objective finding, e.g., vital signs stable, no acute distress]

Radiation Safety Surveys

(Required prior to patient release. If details are missing, insert "[Survey details required - instrument, result, surveyor name]")

Patient Survey Performed: [Yes / No]

Afterloader Survey Performed: [Yes / No]

Survey Instrument: [Model/serial or asset tag]

Survey Result: [Quantitative reading and units / Returned to background]

Survey Date/Time: [Date/time]

Surveyor Name: [Name and role]

Room Survey: [Results, instrument, performer / N/A]

Post-Procedure Status

Applicator Removed: [Yes — date/time / No — plan for retention and safety precautions]

Hemostasis/Bleeding Status: [Status]

Complications: [None / List complications]

Disposition: [Home / Inpatient / PACU / Other]

Next Fraction/Follow-up: [Next scheduled fraction date or follow-up plan]

Deviations and Medical Event Screening

(Include detailed section only if a deviation occurred; otherwise use single line below)

No deviations or events requiring reporting.

• Description of deviation: [What occurred and when discovered]
• Immediate mitigation and patient impact: [Actions taken and clinical effect]
• Internal incident reporting threshold met: [Yes / No]
• Regulatory medical event determination: [Yes / No / Under review]
• Notifications made: [AU / RSO / Physics leadership / Patient] — [Names, date/time]
• Follow-up actions planned: [Plan]

Final Attestations

AU Attestation: I attest that the Written Directive is accurate and treatment was delivered as documented (or deviation described above).

AU Signature: [Signature]

Date/Time: [Date/time]

AMP Attestation: Plan and console verification steps completed; surveys documented per policy.

AMP Signature: [Signature]

Date/Time: [Date/time]