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