Radiation Therapy Treatment Completion Summary

Patient: [Patient name] | DOB: [Date of birth] | MRN: [Medical record number] | Course ID/Name: [Course identifier/name] | Treating Facility: [Facility name] | Diagnosis: [Primary cancer with laterality] | Attending Physician: [Attending radiation oncologist] | Note Date: [Note date]

Care Team/Copies to: [Referring clinician]; [Medical oncologist]; [Surgeon]; [Primary care clinician] (List as applicable; if any identifier is unavailable, insert bracketed placeholder indicating reconciliation needed before finalizing.)

Indication / Diagnosis / Intent

[Primary diagnosis and histology relevant to the RT course]. [Disease site(s), laterality, and involved regions]. [Stage or risk group if documented; if unknown, state: "Stage: Not documented in radiation record."]. [Disease status at RT start: definitive / postoperative / recurrent / oligometastatic / palliative]. [Treatment intent: curative / adjuvant / neoadjuvant / palliative / bridging]. [Goal statement tied to indication]. (3–6 sentence narrative. Do not infer staging or details not present in the record.)

Radiation Treatment Delivered

Course dates: [Start date] to [End date] | Elapsed days: [Number] | Fractions: [Planned] / [Delivered] | Status: [Completed as prescribed / Completed with modification / Discontinued early — reason]

Sites / Dose Levels

Anatomic Site/Target (with laterality)	Target Volume(s)	Modality	Technique	Dose/Fx	Fx Planned/Delivered	Total Dose Planned/Delivered	Dates	Schedule	Notes
[Site/target (laterality)]	[Target volume(s)]	[Photon / Electron / Proton / Brachytherapy]	[3D-CRT / IMRT / VMAT / SBRT / SRS / Adaptive]	[Dose per fraction]	[Planned] / [Delivered]	[Planned] / [Delivered]	[Start – End]	[Daily M–F / BID / Weekly]	[IGRT, motion management, or replan notes if clinically significant]

(Add rows for each dose level/phase/target. Use consistent units [Gy or cGy] throughout. If delivered dose data are missing, flag for reconciliation from OIS before signing; do not substitute planned values. For brachytherapy, include total brachytherapy dose and combined EBRT + brachytherapy dose if applicable.)

Treatment Interruptions / Deviations

[None / Interruptions occurred as follows:]

• [Date range]: [Reason — toxicity / machine downtime / hospitalization / nonadherence / other]; [Compensatory changes if any]; [Clinical impact]

(Include bullet list only if interruptions occurred; otherwise state "Treatment interruptions: None.")

Concurrent / Sequential Therapy

• [Agent/regimen]: [Start date] to [End date relative to RT]; [Held or modified due to toxicity: details if applicable]
• (If managed externally) Concurrent systemic therapy managed externally; regimen details not available in radiation record.

(Include this section only if systemic therapy or major supportive interventions occurred during RT; omit entirely if none.)

Tolerance / Acute Toxicities

[Global tolerance statement, e.g., "Patient completed treatment with expected grade 1–2 acute toxicities" or "Treatment complicated by..."]. Grading scale: [CTCAE v5.0 / CTCAE v6.0 / Institutional scale].

• Dermatitis/Skin: [Grade], [Time course], [Management], [Status at end of treatment]
• Mucositis: [Grade], [Time course], [Management], [Status]
• GI: [Grade], [Time course], [Management], [Status]
• GU: [Grade], [Time course], [Management], [Status]
• Fatigue: [Grade], [Time course], [Management], [Status]
• Pain: [Grade], [Time course], [Management], [Status]
• Hematologic: [Grade], [Time course], [Management], [Status]
• Neurologic: [Grade], [Time course], [Management], [Status]
• Pulmonary: [Grade], [Time course], [Management], [Status]

(Include only domains relevant to the treated site. If no significant toxicities: "Acute toxicities: None beyond expected grade 0–1 effects." Note limitations if on-treatment visit data are incomplete.)

Response / Status at End of RT

• Clinical/symptom response: [Description, especially for palliative courses]
• Radiographic response: [Findings if imaging performed during RT]
• Performance status: [Scale and score if tracked]

(If not yet assessable: "Tumor response not yet assessable; evaluation planned at follow-up imaging." Include this section only when response is evaluable or symptom assessment is relevant.)

Follow-Up Plan

• Radiation oncology follow-up: [Timing and purpose]
• Imaging plan: [Modality, timing, indication]
• Medical oncology: [Follow-up timing]
• Surgical oncology: [Follow-up if applicable]
• Supportive care referrals: [Nutrition / Speech-swallow / Wound care / Pain-palliative / PT-OT / Dental as applicable]
• Late effects counseling: [Expected toxicity trajectory and monitoring]
• Return precautions: [Urgent symptoms warranting earlier contact or ED evaluation]

(If follow-up will occur outside institution, document handoff expectations. Use bracketed placeholder if timing undecided.)

Copies / Communication

Summary sent to: [Referring physician, PCP, medical oncology, others as applicable].

Electronically signed by: [Attending physician name, credentials]
Date/Time: [Date and time]
(If scribe-assisted, clinician signature indicates review and verification.)