Radiation Therapy Treatment Prescription

Radiation Therapy Treatment Prescription

Header

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Encounter/Episode ID: [Episode identifier]

Prescribing Physician: [Physician name and credentials]

Date/Time Authored: [Date and time]

Status: [Draft / Final]

NOT VALID FOR TREATMENT (Include only if Status = Draft; display prominently)

Course/Plan Name: [Plan or course name as in planning system] (If Draft, may state "Pending plan build")

Clinical Context / Indication

• [Diagnosis and histology]
• [Treatment intent: curative/definitive / adjuvant / neoadjuvant / salvage / palliative]
• [Laterality: left / right / bilateral / midline] (Must be explicit when anatomically applicable; never infer from diagnosis)
• [Prior RT history with date, site, and dose if known] (Include only for re-irradiation cases)
• [Concurrent systemic therapy: Yes with regimen name / No] (Omit if not addressed)
• Prior RT history incomplete—confirm before first fraction (Include only if prior RT suspected but details unavailable)

Prescription Overview

Canonical summary: [Treatment site/target] – [Modality/technique] – [Dose per fraction] Gy × [Number of fractions] = [Total dose] Gy – [Frequency]

(Display total dose as auto-calculated; require clinician validation)

(Include summary table only for multiple targets or phases; omit for single-target, single-phase prescriptions)

Phase/Target	Dose/fx (Gy)	Fractions	Total Dose (Gy)	Schedule	Notes
[Phase or target identifier]	[Dose per fraction]	[Number]	[Auto-calculated total]	[Fractions per week or pattern]	[SIB, boost, cone-down details]

(Add rows as needed for additional phases or targets)

Targets / Sites to Treat

(For Final prescriptions, target nomenclature must match planning system object names exactly)

Target 1: [Target name with explicit laterality]

• Anatomic site: [Site description with laterality]
• Target volume name(s): [GTV, CTV, ITV, PTV identifiers as in planning system]
• Treatment extent: [Whole organ only / organ plus regional nodes / post-op bed only / other specification]

(Repeat Target block for each additional target)

Modality / Technique

• Radiation Type: [photons / electrons / protons / brachytherapy] (Select one for Final prescriptions)
• Technique: [3D-CRT / IMRT / VMAT / SBRT / SRS / other] (No either/or language for Final prescriptions)
• Energy: [Energy specification] (Required for electrons; optional for photons per institutional policy)

Dose Prescription Details

• Dose per fraction: [Dose] Gy
• Total fractions: [Number]
• Total dose: [Auto-calculated total] Gy (Clinician must validate)
• Schedule: [Fractions per week or explicit pattern] (If BID, specify minimum interfraction interval)

Prescription Definition: [Point-based / Volume-based / Isodose line-based]

• Point specification: [Point type and label] (Include if point-based)
• Volume specification: [Structure name and metric, e.g., PTV D95% = Rx dose] (Include if volume-based; structure name must match planning system)
• Isodose specification: [Prescription isodose percentage and normalization method] (Include if isodose line-based)
• Coverage goals reference: [Planning Directive or Protocol name and version] (Include only if referencing separate document)

Image Guidance (IGRT) Requirements

• Imaging Modality: [kV/kV orthogonal / CBCT / SGRT / MV portal / fiducial tracking / other]
• Frequency: [every fraction / first 3 then weekly / daily / other criteria]
• Match Target: [bony anatomy / soft tissue / fiducials / surgical clips / other]
• Tolerances: Translation ±[value] mm; Rotation ±[value]°
• Correction Strategy: [3D couch shifts / 6D couch shifts / gating adjustments / replan if threshold exceeded]
• Approval Workflow: [Therapist-led per protocol / Physician review required] (Specify criteria for escalation)

IGRT Order Summary: [Single-line summary of modality, match target, tolerance, correction strategy, and review criteria]

Motion Management

(Include only when motion management is clinically indicated; omit entirely if not applicable)

• Motion assessment method: [4DCT / fluoroscopy / cine MRI / other]
• Chosen strategy: [ITV / gating / DIBH / abdominal compression / tracking]
• Operational parameters: [Gating window, breath-hold instructions, phase selection, thresholds]
• IGRT verification: [How setup imaging confirms motion management each fraction]

Special Instructions

(Include only when applicable; omit section if none)

• [Setup position and immobilization devices]
• [Bolus: thickness and treatment schedule]
• [Patient preparation: bladder filling, rectum prep, fasting, medications]
• [Device considerations: pacemaker/ICD parameters, shielding requirements]
• [Protocol reference with name and version] (Do not use "per protocol" without specific identification)

Approval / Signature

Prescribing Physician Signature: [Electronic signature with date and time]

After signing, the following fields are locked and require formal revision to change: treatment site(s), dose per fraction, number of fractions, total dose, technique, and IGRT requirements.

Revision Log

(Complete for any mid-course changes; clinical changes require re-signing)

• Revision date/time: [Date and time of revision]
• Author: [Name and credentials]
• What changed: [Specific field(s) modified]
• Reason: [Clinical rationale / Administrative correction]
• Effective from: [Fraction number or date]