Radiation Therapy Re-Simulation/Re-Planning Note

Date/Time: [date and time of note]

Author: [author name, role; supervising attending if applicable]

Patient: [patient name or identifier]

Diagnosis: [diagnosis]

Course: [course name/number, treatment site, laterality]

Technique: [modality/energy]

Machine: [treatment machine]

Current Plan: [active plan name]

New Plan: [new plan name / N/A]

(This note documents offline adaptive re-simulation/re-planning decisions and rationale. Omit sections that do not apply. For missing information, state what is unavailable rather than leaving blank. Reference supporting documents by date rather than duplicating content.)

Active Treatment Summary

[Concise summary of active course at time of issue identification] (2–3 sentences including treatment site, total prescribed dose and fractionation, fractions delivered to date, current fraction date, and cumulative dose delivered to the primary target. If multiple dose levels exist, note the primary target dose level.)

Indication for Re-Simulation/Re-Planning

• Primary reason(s): [anatomic change / setup or immobilization inadequacy / dosimetric concern / prescription or course modification] (List specific reasons in decreasing order of clinical importance.)
• Supporting evidence: [objective findings supporting indication] (Include relevant weight trends, IGRT observations, imaging findings, and dosimetric assessment as applicable. If dosimetric impact has not been formally evaluated, explicitly state this rather than inferring compromise.)

Summary of Changes

• Anatomy: [anatomic changes identified or "Unchanged"]
• Setup/Immobilization: [setup or immobilization changes or "Unchanged"]
• Technique: [technique changes or "Unchanged"]

(Explicitly state key unchanged elements to prevent silent assumptions.)

New Plan Summary

Prescription Status: [Unchanged / Changed] (If changed, document prior prescription, new prescription, rationale, and the fraction at which the change takes effect.)

Plan Versioning: [old plan name and status; new plan name; start fraction for new plan]

Plan Acceptance: [decision-relevant dosimetric findings] (Summarize target coverage metrics, OAR constraints near-limit or exceeded, and any intentional deviations with clinical rationale. If cumulative dose was formally evaluated, summarize conclusion; otherwise state per-plan evaluation and clinical judgment were used. Reference location of full DVH/plan report.)

Dose Accounting & Implementation

Dose Accounting:

• Fractions delivered under prior plan(s): [number]
• Dose delivered to date: [dose to primary target]
• Remaining fractions: [number]
• Timeline: [plan-to-fraction mapping]
• Treatment breaks: [dates and reason; compensatory plan if decided / None]

Treatment Status: [Continuing on current plan pending replan / Treatment hold required] (State reason if hold required.)

Implementation:

• Target date for new plan completion: [date / Pending]
• Physics QA status: [Completed / Pending / Not Required]
• Expected first fraction on new plan: [date or fraction number / Pending]
• In-room workflow updates: [changes to alignment, action levels, bolus, other / None / Pending]

Safety Attestations:

• Physician plan review/approval: [Completed / Pending]
• Physics plan check: [Completed / Pending / Not Required]
• Patient-specific QA: [Completed / Pending / Not Required]
• Therapist notification of setup changes: [Completed / Pending / Not Required]

Patient Communication: [Informed / Pending / Not Required] (Summarize key points discussed. If prescription or risk changes affect consent, document discussion and whether new consent was obtained per institutional policy.)

References

• [CT simulation note: date]
• [TPS plan report: plan name and date]
• [Physics QA documentation: date]
• [Other relevant documents as applicable]