Radiation Therapy CT Simulation Procedure Note

Procedure Summary

• Patient Name: [patient name]
• MRN: [MRN]
• Date/Time of Simulation: [date and time]
• Location: [CT simulation suite/department]
• Ordering Radiation Oncologist: [physician name]
• Performing Staff: [RTTs, RN if contrast/sedation, physicist if applicable]

[Concise 1–3 sentence summary of the simulation performed, including site with explicit laterality, immobilization type, special features (contrast yes/no, motion management type if used), and patient tolerance.] (Do not infer laterality from diagnosis alone. If laterality cannot be confirmed, state that simulation was paused pending clarification.)

Clinical Indication

• Primary diagnosis: [diagnosis or condition requiring radiation therapy]
• Treatment intent: [curative / adjuvant / definitive / palliative / prophylactic]
• Treatment site and laterality: [explicit site with laterality] (If laterality cannot be confirmed, document status and action plan; do not infer.)
• Target description: [key anatomic target] (Include only if explicitly stated.)
• Stage/histology: [staging and histology if known] (Omit if unknown.)

Pre-Procedure Verification

(For safety-critical items, document status explicitly: Done, Not done with reason, Not applicable, or Unknown with action plan. Do not leave blank or infer.)

• Patient identity verified (two identifiers): [Done / Not done—reason / Unknown—action plan]
• Site and laterality verified against order/consent: [Done / Not done—reason / Unknown—simulation paused pending clarification]
• Time-out performed: [Yes / No—reason]
• Radiation therapy consent: [Obtained previously / Obtained today / Pending—action plan]
• Tattoo authorization (if tattoos placed): [Completed / Not applicable / Declined—alternative method documented]
• Pregnancy screening (if applicable per policy): [Negative test with date / Patient-reported not pregnant per policy / Not of pregnancy potential—rationale / Unknown—simulation paused]
• Implanted devices relevant to imaging/planning: [None / Present—type, location, and planning considerations]
• Contrast allergy history (if contrast planned): [No known allergy / Known—details and premedication plan]

Simulation Order

(Capture ordered elements so deviations are explicit.)

• Treatment site/extent with laterality and scan coverage: [ordered site/extent and required landmarks]
• Position/orientation: [supine / prone / decubitus], [head-first / feet-first], [head/neck position], [arm position], [leg position]
• Immobilization: [ordered devices]
• Imaging technique: [standard 3D CT / 4DCT / breath-hold], [contrast: none / IV / oral], [slice thickness or protocol if specified]
• Motion management: [none / ITV-motion encompassing / DIBH / respiratory gating / abdominal compression]
• Special instructions: [additional order details if any]

Simulation Performed

Positioning and Immobilization

(Document with sufficient specificity to reproduce daily setup.)

• Orientation: [head-first / feet-first]
• Position: [supine / prone / decubitus], head/neck [neutral / flexed / extended]
• Upper extremities: [arm position and supports], [hand grips if used]
• Lower extremities: [knee support, footstock, leg position]
• Immobilization devices and indexing: [baseplate/board name, index bar slot numbers, board angle settings, mask type and attachments if applicable, vacuum bag/cushion label and fill status, additional supports]
• Patient-specific considerations: [comfort limitations and accommodations] (Omit if none.)

Reference Marks and Setup Instructions

• Marks placed: [none / temporary skin marks / tattoos]
• Tattoo details (if placed): [count, type, locations]
• Reference coordinate strategy: [CT reference marks for initial setup with final isocenter in planning / isocenter tattoos placed at simulation]
• If tattoos not placed: [reason] and [alternative reproducibility method]
• Photo documentation: [obtained / not obtained]

Motion Management

(Include only if motion management was used.)

• Technique and devices: [4DCT / DIBH / respiratory gating / abdominal compression], [devices used]
• Coaching quality: [adequate / variable / poor], [reproducibility notes]
• Breath-hold details (if applicable): [method, target level and hold duration, reproducibility assessment, fallback plan]
• 4DCT details (if applicable): [phases reconstructed, Average/MIP series created, irregular breathing issues]
• Deviation from order: [none / deviation and reason]

Contrast Administration

(Include only if contrast was given or ordered but not given.)

• Contrast type and route: [IV iodinated / oral / other]
• IV site (if IV): [location and gauge]
• Administered as ordered: [Yes / No—reason and decision maker]
• Adverse reaction/extravasation: [none / event and actions taken]

CT Acquisition

• Scan range: [superior landmark] to [inferior landmark]
• Protocol: [slice thickness and/or protocol name]
• Additional series: [none / non-contrast and contrast / breath-hold / 4DCT phases / repeat scans with reason]
• Artifacts: [none / artifact type and mitigation]
• Fiducial visibility: [adequate / limited—notes] (Include only if fiducials present.)

Image Registration Requests

(Include only if fusion work is requested.)

• Datasets to register: [MRI / PET-CT / prior CT]
• Intended use: [target delineation / OAR delineation / dose summation]
• Known limitations: [different positioning / surgical changes / anatomic change]

Variances and Issues

(Include only if non-routine events occurred.)

[Problem, impact on reproducibility/planning, and mitigation/plan] (Omit section if none.)

Complications

[No complications. / Complication type, interventions performed, and patient disposition.] (Safety-critical; do not leave blank.)

Daily Setup Instructions

(Always include actionable reproducibility instructions for the treatment team.)

• Alignment method: [tattoos / temporary skin marks / surface guidance], [primary setup strategy]
• Immobilization required daily: [all devices with index slot numbers, board angle, mask type, vacuum bag label as applicable]
• Bolus: [none / thickness and placement location, frequency]
• Motion management at treatment: [DIBH coaching cues and thresholds / gating parameters / compression settings, fallback plan] (Include only if applicable.)
• Image guidance: [daily CBCT / kV-MV / schedule], [match target: soft tissue / fiducials / bony anatomy], [shift thresholds for MD notification]
• Additional setup notes: [other critical reproducibility instructions] (Omit if none.)

Attestation

Radiation Oncologist: [name, credentials] — [signature/authentication] — [date/time]

(If physician review is pending, label as "Pending MD Review" and do not treat as final until signed.)