Radiation Therapy Peer Review Note (Contour/Plan Review)

Radiation Therapy Peer Review

Patient: [name]

DOB: [date of birth]

MRN: [medical record number]

Review Date: [date and time]

Review Type: [Contour only / Plan only / Combined / Re-review]

Workflow Stage: [Pre-planning / Post-contouring / Post-planning / On-treatment]

Plan/Structure Set: [plan name, version, structure set ID] (If version identifiers are unavailable, note "version not available".)

Peer Reviewer(s): [name(s) and role(s)]

Attending Physician: [name]

Documented By: [name and role]

Clinical Context

[Diagnosis with site/histology, stage, treatment intent, target region and laterality. Include safety-critical context only: prior radiation, concurrent systemic therapy, special populations if relevant to planning decisions.] (If staging or intent is pending, note as conditional review and specify what is pending.)

Materials Reviewed

Imaging: [CT simulation date/technique, fusions performed] (State explicitly if not directly visualized in TPS.)

Planning Directive: [finalized / draft / not available]

Contouring Reference: [protocol/guideline name and version, or "not specified"]

Key Materials Unavailable: [list any missing items, or "none"] (State explicitly rather than inferring acceptability.)

Review Findings

Contours: [Assessment of target volumes—GTV, CTV, ITV, PTV as applicable—with margin rationale; OAR completeness and any intentional omissions with reason; auto-segmentation use and validation status] (Include only if contours were reviewed.)

Plan: [Technique/modality, prescription (total dose, fractions, dose per fraction, normalization), key target and OAR DVH metrics driving approval] (Include only if plan was reviewed.)

Constraint Deviations: [Which constraint not met, clinical rationale for deviation, agreed mitigation strategy] (Omit if all constraints met.)

Issues and Changes: [For each issue: brief description, classification as Major (patient-impacting, requires re-review) or Minor (quality improvement, no re-review), specific change required, owner, and timeframe if treatment start is imminent] (If no issues, state "No issues identified.")

Outcome and Disposition

Changes: [No change / Minor only / Major]

Summary: [Brief description of changes requested, or "None"]

Re-review Required: [Yes—specify trigger / No]

Final Status: [Approved / Approved pending minor edits / Not approved—replan required / Deferred—specify missing information / Hold treatment—specify concern and who notified]

Changes Completed During Session: [Yes—describe verification / No / N/A]

Dissenting Opinion: [Differing view, resolution pathway, and final decision rationale] (Include only if meaningful disagreement occurred; use neutral, action-focused language.)

Peer Reviewer Signature: [name, credentials, date/time]

Attending Physician Signature: [name, credentials, date/time]