Medical record – Ohio Admin. Code 3701-83-49

As a condition of licensure, each freestanding radiation therapy center must document in the patient medical record the following information:

• Confirmation of the presence of malignancy by histopathology, or a statement of benign condition, or other alternative evidence for diagnosis of all cases accepted for radiation;
• Documentation of services and radiographic images, including localization films, appropriate to the therapy provided;
• Report of the initial evaluation including a definition of the tumor location and the extent of each cancer as a basis for staging;
• The treatment plan including the selection of dose, selection of treatment modality, and selection of treatment technique;
• The dosimetry calculations;
• The patient’s progress and tolerance; and
• The completion of treatment with statement of follow-up plan.