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

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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.

Current as of June 2015