Radionuclide Therapy Administration Procedure Note (Theranostics)

Date of Service: [Date of service]

Start Time / End Time: [Start time] / [End time]

Location: [Department/unit], [outpatient / inpatient]

Patient: [Name], [MRN]

Therapy Cycle: [Cycle X of Y] or [Dose X/Y]

Indication: [Diagnosis and therapeutic intent] (Keep to 2–4 sentences; include only details relevant to this administration.)

Ordering/Treating Service: [Service/clinic/team name]

Author: [Name and role]

Procedure Summary

• [Radiopharmaceutical name (generic and brand if applicable)]
• [Radionuclide]
• [Route of administration]
• [Administration date/time]
• [Premedications given]
• [Immediate outcome: tolerated without adverse events / adverse event summary] (Do not infer; if not documented, insert "REQUIRED DATA NOT CAPTURED".)

Prescribed Activity: [Activity in mCi and/or MBq] (Include acceptable range if applicable.)

Measured Activity (Pre-administration): [Activity in mCi and/or MBq] at [Assay time]

Residual Activity (Post-administration): [Activity in mCi and/or MBq] at [Assay time]

Net Administered Activity: [Calculated net activity]

Route / Access Site: [Route and access site]

Variance From Prescribed Activity: [None / Variance present: reason and authorizing clinician instruction] (If variance present and details not captured, insert "REQUIRED DATA NOT CAPTURED".)

Written Directive and Consent

Written Directive: [Present: yes / no], [Date/time signed], [Authorized user name]

Radiopharmaceutical / Radionuclide: [As per written directive]

Prescribed Activity and Route: [As per written directive]

Informed Consent: [Obtained: yes / no], [Date/time], [Obtained by: name/role]

Attestation: Administration was performed in accordance with the written directive. (If written directive or consent not documented, insert "REQUIRED DATA NOT CAPTURED" and route for correction.)

Pre-Administration Assessment

Baseline Vitals: [Vitals and time recorded]

Labs Reviewed: [Relevant labs and dates] (Include CBC, renal, hepatic as applicable to therapy.)

Performance Status / Clinical Stability: [Performance status and clinical stability statement]

Pregnancy Screening: [Verification method, result, date/time] or [Not applicable: reason] (Do not infer. If applicable but not documented, insert "REQUIRED DATA NOT CAPTURED".)

Lactation Status: [Status, counseling provided, written instructions given] or [Not applicable: reason]

Pre-Administration Verification

• Two patient identifiers verified (name + DOB or MRN): [verified / not verified]
• Radiopharmaceutical label matches written directive: [verified / not verified]
• Prescribed activity matches measured activity within acceptable variance: [verified / not verified]
• Route and IV access confirmed: [verified / not verified] (Note if dedicated line required.)
• Special precautions addressed: [yes / no / not applicable] (e.g., urinary incontinence plan, isolation needs)
• Team members participating: [Names and roles of authorized user, RN, technologist]

Attestation: [Time-out / Pre-administration verification] completed prior to administration.

Premedications and Protective Adjuncts

(Document each medication: name, dose, route, time, indication. Omit subsections not applicable to this therapy.)

• Antiemetics: [Medication, dose, route, time, indication]
• Amino acid infusion / renal protection: [Agent, concentration, rate, start/stop times] (Include only for PRRT.)
• Hydration protocol: [Fluids, rate/volume, start/stop times; voiding instructions given]
• Steroids/antihistamines: [Medication, dose, route, time, indication] (Include only if hypersensitivity prophylaxis used.)

Deviations/Adjustments: [Held medications, modified rates, intolerance with rationale and authorizing clinician] or [None] (Do not infer.)

Administration Details

Route / Technique: [IV infusion / IV slow push / oral]; [gravity / pump / syringe method]

IV Access: [Peripheral / central], [site], [gauge], patency confirmed, [pre/post flush performed], [dedicated line: yes / no / not required]

Radiopharmaceutical Start Time: [Time]

Radiopharmaceutical Stop Time: [Time]

Total Duration: [Duration]

Extravasation Surveillance: [Monitored during administration; no extravasation / suspected extravasation: time, site assessment, actions taken, radiation safety notified]

Monitoring and Tolerance

Vitals: [Time-stamped vitals at baseline and protocol intervals] (Format as brief table or inline.)

Patient Symptoms: [Symptoms reported during/after infusion] or [No immediate symptoms reported] (Do not infer.)

Adverse Events: [Time of onset, description, severity/CTCAE grade, interventions, outcome] or [No immediate complications] (Do not infer absence of complications.)

Radiation Safety and Disposition

• Radiation safety measures: [PPE and shielding used; room preparation; contamination controls; body fluid handling precautions; RSO involvement if incident occurred]
• Patient Release Status: [Released home / admitted / isolated] (If admitted, document reason.)
• Written Radiation Precautions Provided: [yes / no], provided to [patient / caregiver / both]; patient/caregiver verbalized understanding

Precautions Counseling Covered: [Distance/contact limits; sleeping arrangements; toileting and hygiene; hydration and voiding; sexual activity/contraception; breastfeeding] (Include only applicable items; confirm understanding.)

Clinical Discharge Instructions Provided: [Expected side effects, when to call, contact information, medication instructions, post-therapy imaging schedule]; patient acknowledged receipt and understanding

Follow-Up Plan

• Next cycle: [Target date/window; required labs by date; required clinic visit]
• Monitoring plan: [Labs, imaging, toxicity review as applicable]
• Patient-specific risks: [Risks requiring closer monitoring] or [None]
• Therapy course status: [Continuing / completed / discontinued] (If completed or discontinued, document reason.)

Variance Review

Variance From Written Directive: [yes / no]

(If yes:)

• Nature of variance: [Activity variance beyond threshold / partial dose / wrong route averted / extravasation / other]
• Medical event threshold: [Meets / does not meet] per institutional policy
• Actions taken: [Incident report, RSO notification, patient notification, corrective steps]

(If no variance: "No variance from written directive. Medical event screening: negative.")

Attestation

Authorized User/Attending Attestation: I attest that the administration was performed and documented accurately, including prescribed versus administered activity and route.

Author/Role: [Name, credentials/role]

Date/Time: [Date/time of attestation]