1.2 Electronic Medical Record (EMR)

hospital informaiton system

track and store information on patients (incl hardware, software, telecommunications, datastoreage)

what type of hospital information system do RTs use?

oncology information system (OIS) — and we put pt’s info into electronic medical record (EMR) (may incl records of diagnosis, surgery, chemo, radiation therapy)

electronic medical record

electronic medical record (EMR) (may incl records of diagnosis, surgery, chemo, radiation therapy + pt charts

what components of pts radiation therapy chart

• Components 

  • Diagnosis 

  • Radiation prescription 

  • Consent and waivers 

  • CT sim requisition 

  • Set up notes 

  • Treatment planning report 

  • IGRT protocols 

  • Treatment notes 

  • Patient care management 

how many pt identifications is needed

minimum 2 (eg. DOB, full name spelling, ID, phone number)

day 1 teaching

‘training/information sess’ for pt before their treatment, prepping them of what to expect

• What to expect from the room and during the treatment, side effects and management, answer questions 

• must be recorded upon completion  

CBCT

cone beam CT image

types of CTs done before treatment (for positioning + planning)

• MV images (portal image) (capture image of radiation delivered)  

• kV images – single or orthogonal pair (2 images that are 90 deg to one another) 

• Cone beam CT image (CBCT) – 3D representation/CT snapshot of treatment area

how many people perform QA

** best to have 2 people to preform QA (1 person completing a step, and 2nd person (not in treatment for this pt) to QA and overlook, picking up on errors) 

is RT chart legally binding

yes. only facial and true info should be included and no changes should be made to pt treatment once it has been delivered

what is the system we use for OIS

aria