Radiation Therapy Plan Approval Note (DVH/Isodose Summary)

Patient: [Patient name, MRN, DOB per institutional policy]

Diagnosis/Site: [Diagnosis and treatment site including laterality]

Course/Intent: [definitive / adjuvant / palliative]; [primary / boost / replan-adaptive]

Plan ID/Version: [Plan name]; [Version]; [Revision date-time]

Treatment Planning System: [TPS name and version]

Treatment Unit: [Machine ID] (Only include if assigned)

Re-irradiation Considerations: [Prior RT course reference]; Cumulative dose assessment: [yes / no]; [Summary of cumulative dose to key OARs] (Only include for re-irradiation cases)

Prescription Summary

• Total Dose/Fractionation: [Total dose in Gy] in [Number of fractions] fractions; [Dose per fraction in Gy]
• Prescription Method/Normalization: [e.g., PTV D95% = Rx dose / Rx to isodose line (%) / other method]
• Technique: [3D-CRT / IMRT / VMAT / SBRT / SRS / Protons / Electrons / Mixed]
• Targets and Prescribed Doses:
  • [Target name]: [Rx dose in Gy] in [# fx]; [Normalization specification]
  • (Repeat for each target/dose level, including SIB targets)
• Key Planning Trade-offs: [Description of explicit prioritizations or trade-offs accepted] (Only include if applicable)

DVH and Isodose Review

(Use standardized DVH nomenclature per TG-263; report units with all metrics. Document intentional undercoverage with anatomic rationale. Include conformity/homogeneity indices for stereotactic plans if used locally.)

Target Coverage

Structure	Metric	Goal	Achieved	Status	Comments
[Target name]	[D95% / V100% / D98%]	[Goal with units]	[Achieved with units]	[Pass / Deviation]	[Anatomic rationale if intentional undercoverage]
(Add rows for each target and metric)

Hotspots

• Global maximum dose: [Value in Gy] ([% of Rx])
• Location: [Within PTV / Outside target]; [Anatomic location and proximity to critical structures]
• Clinical acceptability: [Acceptable / Not acceptable]; [Brief justification]

Organs at Risk

Structure	Metric	Goal	Achieved	Status	Comments
[OAR name]	[Dmax / D0.03cc / V20Gy / Dmean]	[Threshold with units]	[Achieved with units]	[Pass / Deviation]	[If deviation: magnitude, rationale, mitigation]
(Add rows for each OAR and constraint)

[Narrative interpretation of deviations] (Only include if deviations require additional explanation beyond table comments)

Isodose Distribution Confirmation

[Statement confirming prescription isodose coverage verified on representative imaging planes and dose spillage/fall-off appropriate for technique]

Composite Dose Evaluation

(Only include this section if composite/accumulated dose applies: boost, sequential plans, adaptive replanning, or prior RT)

• Composite includes: [Plans included in composite evaluation]
• DVH basis: [Per-plan evaluation / Composite DVH evaluation]
• Dose accumulation method: [Registration/deformation method and known limitations]
• Composite OAR summary: [Key composite doses relative to cumulative constraints]

Image Guidance and Setup

• Patient positioning and immobilization: [Setup position and immobilization devices]
• Imaging modality and frequency: [Daily CBCT / kV pairs / MV portal / Surface guidance]; [Frequency]
• Matching strategy: [Bone / Soft tissue / Fiducials / Target]; [Priority ROIs for alignment]
• Action thresholds: [Translational/rotational tolerances] (Only include if defined locally)
• Motion management: [DIBH / Gating / Tracking / Abdominal compression]; [Verification method] (Only include if applicable)
• Adaptive triggers: [Criteria prompting re-simulation or replanning] (Only include if applicable)

Attestation

(If plan identifiers, prescription, or target DVH metrics cannot be verified, set Plan Status to "Not approved" and document missing elements below. Do not generate approval attestation with incomplete data.)

I have reviewed the DVH metrics and isodose distributions directly within the treatment planning system. [The plan satisfies the prescription and documented constraints / Exceptions to constraints are documented above]. The plan can be accurately delivered with the documented IGRT strategy.

Plan Status: [Approved / Approved with documented deviations / Conditional / Not approved]

Pending items or reasons: [Outstanding items or reasons preventing full approval] (Only include if status is Conditional or Not approved)

Supersession notice: If this plan is subsequently modified (re-optimization, normalization change, or structure revision), this approval is superseded and a new approval note is required.

Treating Radiation Oncologist: [Name, credentials]

Signature: [Signature per institutional policy]

Date/Time: [Date and time of attestation]