Radiopharmaceutical Therapy Dose Documentation Form

Radiopharmaceutical Therapy Dose Documentation Form
I-131 Sodium Iodide
A. WRITTEN DIRECTIVE:
1. Pt Name: 2. MR#: 3. Female Male
4. Radiopharmaceutical (Including Isotope): 5. Dose in mCi:
6. Date of Administration: 7. Time of Administration: 8. Route of Administration:
9. Clinical Research (Protocol Number: )
10. Indication: 11. Patient Meets Criteria for this Radiotherapy
12. Other therapy treatment within the past year NO YES (if yes, complete section F. Repeat Treatment)
13. Signature of Authorized MD 14. Date___________& Time_______ Signed
Verified by (initial): ____________
NOTE: Must NOT be the individual who signed the written directive.
MUST be Nuclear Pharmacist, Authorized User Physician, or Med Physicist.
B. PATIENT INFORMATION/EDUCATION VERIFICATION:
(NOTE: To be completed by the Authorized User)
Pt ID Verification (2 methods used; Name must be 1 of the 2)
Completed by (initial): ____________
Check: Name AND Birthdate MR#
Completed by (initial): ____________
Completed by (initial): ____________
Completed by (initial): ____________
Prescribing physician explained dose and treatment to administering clinician.
Negative pregnancy test or excluding clinical condition confirmed with reasonable
assurance
Patient is not currently breast feeding.
Completed by (initial): ____________
Completed by (initial): ____________
Informed consent obtained or verified
Written radiation safety instructions provided. If the patient will receive I-131, the
radiation safety checklist in the “Health Facts for You” has been reviewed with the
patient and the specific instructions identified.
C. PHARMACY COMPUTER ORDER ENTRY DOCUMENTATION:
Persons performing this task MUST be Pharmacy Technician Pharmacist Nuclear Medicine Technologist Physician
Completed by (initial): ____________
Verified by (initial): ______________
NOTE: Person verifying this task must NOT be the individual who did the pharmacy computer
order entry.
D. DOSE PREPARATION DOCUMENTATION:
Persons performing this task MUST be Pharmacy Technician Pharmacist Nuclear Medicine Technologist Physician
Completed by (initial): ____________
NOTE: Must NOT be the individual administering the product.
Dose Assay (mCi) = ______________ Assay Date _______________ & Time ___________ RX# ___________________
Verified by (initial): ______________
NOTE: Must NOT be the individual who did the preparation, NOR the one administering.
Dose Assay (mCi) = ______________ Assay Date _______________ & Time ___________ RX# ___________________
Side 1 of 2

E. I-131 THERAPY PATIENT RELEASE JUSTIFICATION RECORD for Exposure from the Patient
RADIATION DOSE TO AN INDIVIDUAL EXPOSED TO PATIENT MUST BE < 500 mrem
(Note: Complete either section 1, 2, 3, OR 4, as applicable.
1. Patient with Thyroid (Assumes 100% whole body retention, dose MUST BE < 33 mCi for patient release):
Estimated maximum dose to an individual exposed to patient.
___________ mrem
(15.15 x administered mCi) Using Appendix U, Table 14, WisReg 1556, Vol 9.
2. Hyperthyroid Thyroid Therapy (Thyroid uptake < 40% or lower (E*), dose MUST BE < 56 mCi for patient release):
* Assumes 0.125 Occupancy Factor (E), patient lives alone and few visits by family & friends for at least the first 2 days.
Estimated maximum dose to an individual exposed to patient.
___________ mrem
(8.84 x administered mCi) Using Appendix U, Equation B-5, WisReg 1556, Vol 9.
3. Patient Post-Thyroidectomy (dose MUST BE < 220 mCi for patient release):
___________ mrem
Estimated maximum dose to an individual exposed to patient.
(2.27 x administered mCi) Using Appendix U, Equation B-5, WisReg 1556, Vol 9.
4. Patient Specific Calculations (Calculations MUST BE APPROVED by Authorized Physician
___________ mrem
Estimated maximum dose to an individual exposed to patient. (Must be < 500 mrem for patient release)
Using patient specific calculations, Using Appendix U, Equation B-5, WisReg 1556, Vol 9.
(Attach spreadsheet used to aid in the calculation: J:/Nuclear/NuclearPharmacy/NRC & Safety & Dosimetry/I131
Exposure/I-131 Thyroid Cancer Exposure Calculation.xls)
F. Repeat Treatments (Refer to Section A. WRITTEN DIRECTIVE, Item No. 12)
Is this repeat therapy
treatment within a
year?
___________ mrem
NO (SKIP this section, if NO is checked)
YES (Estimated dose to an individual exposed to patient due to other treatment ____ mrem)
TOTAL Estimated dose to an individual exposed to patient from other therapy treatments. (The sum of mrems
from 1, 2, 3, or 4 to dose from other treatments within one year MUST be < 500 mrem for patient release)
G. ADMINISTRATION VERIFICATION (NOTE: To be completed at the time of treatment)
Persons performing this task MUST be Pharmacy Technician Pharmacist Nuclear Medicine Technologist Physician
Authorized User Physician
Clinician
#1
Initial
_______
Initial
_______
Initial
_______
Initial
_______
Initial
_______
Initial
_______
Initial
_______
Clinician
#2
Initial
_______
Clinician #1 is the Administering Clinician who is giving the dose.
Clinician #2 is NOT administering the dose.
Clinician #1 reads aloud the patient name, radiopharmaceutical and dose from the product label.
Clinician #2 reviews the written directive and verifies that the following match (check as done):
Patient Name Radiopharmaceutical Dose
Clinician #1 Clinician #2 assays the dose in the dose calibrator. NOTE: Must NOT be the individual
who did the preparation, NOR the one who verified the product.
Dose Assay (mCi) = ___________________ Date _________________ Time ______________
(also document assay, time, date, initials on the computer generated prescription)
Pt ID Verification (2 methods used; Name must be 1 of the 2) Check: Name AND Birthdate MR#
Negative pregnancy test or excluding clinical condition confirmed with reasonable assurance.
Patient is not currently breast feeding.
Dose administered to patient.
Patient released at the time of administration. YES NO
Clinician #1 Signature ______________________________________ Date________________ Time___________________
Side 2 of 2
Initials on file in Nuclear Medicine Procedure Manual Version date 11/11/08; Updated 12/14/09