SRS/SBRT Treatment Delivery Note

Patient name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Date of service: [Service date]

Session start time: [Start time]

Session end time: [End time]

Treatment facility: [Facility name]

Treatment unit/machine: [Unit/machine name]

Course ID: [Course ID] (If not determined from dictation, use placeholder: "REQUIRES RESOLUTION BEFORE FINALIZING")

Plan ID: [Plan ID] (If not determined from dictation, use placeholder: "REQUIRES RESOLUTION BEFORE FINALIZING")

Treatment site and laterality: [Anatomic site and laterality when applicable]

Technique: [Linac-based SRS / SBRT / Other stereotactic technique]

Fraction number: Fx [X] of [Y]

Team and Supervision

Team members present:

• Radiation therapist(s): [Names]
• Qualified medical physicist: [Name]
• Radiation oncologist: [Name]
• Other participants: [Names and roles] (Only include if present; e.g., anesthesia, neurosurgery, nursing)

First stereotactic treatment of this course? [Yes / No]

QMP personal supervision provided today? [Yes / No]

[If QMP personal supervision was required but not provided, document rationale and how safety was maintained] (Omit if QMP supervision was provided)

Pre-Treatment Verification and Time-Out

Pre-treatment verification completed:

• Two patient identifiers verified: [Completed / Not completed]
• Correct procedure confirmed (SRS vs SBRT): [Confirmed / Not confirmed]
• Correct treatment site and laterality: [Confirmed / Not confirmed]
• Correct plan in R&V matching Plan ID: [Confirmed / Not confirmed]
• Prescription verified (dose per fraction and total fractions): [Verified / Not verified]
• Correct immobilization device available: [Available / Not available]
• Required imaging/localization method available: [Available / Not available]
• Motion management requirements reviewed: [Reviewed / Not applicable]

Stereotactic time-out:

• Participants: [Names and roles]
• Timestamp: [Time]
• Proceed decision: [Proceed / Do not proceed]

(Time-out documentation is required for every fraction)

Setup and Immobilization

Patient position and orientation: [Supine / Prone], [Head-first / Feet-first], [Arms position], [Supports used]

Immobilization devices used today: [List devices used; e.g., frame, mask, bite-block, headrest, vacuum cushion, body cradle, abdominal compression, SBRT board]

Immobilization fit acceptable? [Yes / No]

[If immobilization differed from planned setup or fit was not acceptable, document modifications and cross-reference in Deviations section] (Omit if fit was acceptable and setup matched plan)

Localization / IGRT

IGRT method used: [kV orthogonal / CBCT / CT-on-rails / MR-guidance / Surface guidance / Fiducial imaging / Spine tracking / Other]

Matching method/alignment basis: [Bony anatomy / Soft tissue / Fiducials / Combined]

Initial registration result: [Summary of initial offsets]

Corrections applied:

• Translational shifts: LAT [±value] mm, LNG [±value] mm, VRT [±value] mm
• Rotational corrections (if 6D): Pitch [±value]°, Roll [±value]°, Yaw [±value]°

Final residual error after correction: [Translational residuals in mm; rotational residuals in degrees]

Tolerance thresholds used today: Translational [value] mm; Rotational [value]°

Alignment within tolerance? [Yes / No]

[If not within tolerance: document re-setup performed, repeat imaging count, who approved proceeding (physician/QMP name and role), and rationale] (Omit if alignment was within tolerance)

Image review/approval: [Reviewer name and role], [Approval timestamp] (If approval deferred per site policy, state expected review timeframe and responsible reviewer)

Motion Management

(Include this section only if motion management was part of the treatment plan or used today; otherwise omit entirely)

Strategy: [Free breathing with ITV / Abdominal compression / Respiratory gating / Breath hold / Real-time tracking / Other]

Operational parameters: Gating window or threshold: [Value]; Monitoring modality: [SGRT / RPM / Fiducial tracking / MR cine / Other]; Baseline established and acceptable: [Yes / No]

Intra-fraction verification: Intra-fraction imaging performed: [Yes / No] ([Type and count]); Pauses or repositions due to motion: [Yes / No] ([Description if yes]); Motion tolerance met throughout: [Yes / No]

Treatment Delivery

Prescription for this session: [Dose per fraction in cGy or Gy]; [Total prescribed fractions]

Delivery status: Fraction delivered as planned? [Yes / Partially / No]

Dose delivered today: [Dose in cGy or Gy]

Cumulative dose delivered to date: [Cumulative dose in cGy or Gy]

Delivery technique summary: Modality: [Photons / Stereotactic linac]; Technique: [VMAT / IMRT / Arcs / Cones] [Coplanar / Non-coplanar]; Energy: [e.g., 6X FFF]

Targets treated today: (Include only for multi-target treatments)

• [Target name]: [Dose allocation this fraction]
• [Additional targets as needed]

Treatment interruptions: Interlocks or faults: [Yes / No]; Pauses: [Yes / No] ([Reason and duration if yes]); Partial arc/field delivery: [Yes / No] ([Specify what was completed if yes])

(Reference R&V system as authoritative source for detailed machine parameters)

Patient Tolerance

Tolerance during treatment: [No issues / Mild discomfort / Moderate discomfort / Severe discomfort] [Observations or patient comments]

Interventions required: [None / Coaching / Repositioning / Medication / Other]

Sedation: [Agent, dose, and route] (Include only if sedation was used)

Immediate post-treatment events: [None / Description of adverse events]

Disposition: [Stable, discharged from department / Escalated care: description]

Deviations and Corrective Actions

(This section is required even if there were no deviations)

Deviation present? [No / Yes-clinical / Yes-technical / Yes-workflow / Yes-patient-related]

[If No: "No deviations occurred during this treatment session." End section here.]

[If Yes, complete all fields below:]

• What happened: [Plain-language description]
• When detected: [Pre-IGRT / After IGRT / During delivery / After delivery]
• Magnitude of deviation: [Quantify or characterize]
• Immediate actions: [Re-setup / Repeat imaging / Physician consult / QMP consult / Plan review / Abort / Other]
• Outcome: [Delivered as planned / Delivered with modification / Partial delivery with dose accounting / Aborted with dose accounting]
• Preventive steps for next session: [Description if applicable]
• Notifications: Physician notified: [Yes / No] at [Time]; QMP notified: [Yes / No] at [Time]
• Approval to proceed despite deviation: [Approver name/role and rationale] (Include only if treatment proceeded despite deviation)
• Internal incident report: [Created / Not required]

Attestations

Therapist attestation: [Name, credentials], [Timestamp] — Confirms patient identity verification, setup performed per plan, imaging performed as documented, and delivery status as recorded.

Physicist attestation: [Name, credentials], [Timestamp] — [For first fraction: attests to personal supervision including time-out participation, immobilization assessment, imaging adequacy, motion management accuracy if applicable, and consultation on shifts. For subsequent fractions: attests when required by protocol or when exceptions occurred.]

Physician attestation: [Name, credentials], [Timestamp] — Confirms oversight of stereotactic session and review/approval of IGRT.

(If any required attestation cannot be obtained, note must remain pending with reason documented)