UNC Hospitals Patient Survey Form

UNC-HOSPITALS INTERNAL RADIOTHERAPY PATIENT SURVEY REPORT
PATIENT DATA
Patient Name:_____________________________Unit No.:_______________Room No.:____________
Date
Time
Radiotherapist:____________________________ Treatment Start: ____________ ___________
Chemical/Physical Form:____________________ Estimated Removal: ____________ ___________
No. of Sources_____________________________Total Treatment Time:
____________ ___________
Nuclide:______________mg. Ra eq.________________________ mCi___________________________
RADIATION SAFETY DATA – use “RECORD OF RELEASE” if Outpatient
Surveyor:________________Survey Date:__________Time:_________Notification Time:___________
Instrument Type (circle one): G.M., ion chamber, NaI
Make & Model: _________________________ S/N & Calibration Due: ____________/______________
LOCATION UNSHIELDED SHIELDED LOCATION UNSHIELDED
(mrem/hr, max.) (mrem/hr, max) (mrem/hr, max.)
0.5 meters 5.0 centimeters (P-32)
1.0 meters Doorway (open/closed) /
2.0 meters Hallway
Foot of bed
Room above
Visitor area
Room below
Adjacent areas/rooms
ROOM LAYOUT
CHECKLIST
Check Once Completed Room Chart
Nuclide & Activity
Number of Sources
Date, Time Loaded
Survey Time, Surveyor Name
Exposure Rate at 1 Meter
Nursing Instructions
Radiation Signs
Housekeeping Signs
Written instruction provided for prostate
patients (patient AND PACU nursing staff)?
All I-125 seeds accounted for? (prostate)
Comments, unusual circumstances, seed count, etc:__________________________________
______________________________________________________________________________
______________________________________________________________________________
DAILY SURVEYS AND DOSE RATE VERIFICATION
DATE 1 METER (mrem/hr) RESULTS SURVEYOR INITIALS
RECORD OF RELEASE
Surveyor:___________________Date:____________Time:____________
Instrument Type (circle one): G.M., ion chamber, NaI
EXPOSURE RATES:
Make & Model:___________________________ PATIENT, 1 meter (mrem/hr):______________
S/N & Calibration Due:_____________/_____________ ROOM (mrem/hr):______________
Revised: November 19, 2012

STAY TIMES AND GUIDELINES
VISITOR TIME GUIDELINES AT 2.0 METERS
Source Loading (mg. Ra. Eq.)
Time Limit (hours/day)
< 30 4
30-40 3
40-70 2
>70 1
Eye Plaque Patients (2 meter dose rate – mrem/hr)
Time Limit (hours/day)
0.8 6 (consult with HP)
NURSING STAFF TIME GUIDELINES
TIME LIMIT (HOURS/NURSE/DAY)
Source Loading (mg. Ra.Eq.) 0.5 meters 1.0 meter 2.0 meters
< 30 3/4 2 1/4 3 3/4
30-40 3/4 1 3/4 2 3/4
40-50 1/2 1 1/4 2 1/4
50-60 1/4 1 1/4 2
60-70 1/4 1 1 1/2
70-80 1/4 3/4 1 1/4
> 80 1/4 3/4 1
EXPECTED DOSE RATE AT 0.5 AND 1.0 METER DISTANCE
Source Loading (mg. Ra. eq.) 0.5 meters (mrem/hr) 1.0 meters (mrem/hr)
30 40-58 10-14
40 52-77 13-19
50 66-96 16-24
60 80-115 19-29
70 92-134 22-34
80 106-154 26-38
CONVERSION FACTORS FROM mg. Ra eq to mCi
(mg. Ra. eq of Cs-137) X 2.5 = mCi of Cs-137 (G.C. = 0.33 mrem/hr mCi at 1 meter)
(mg. Ra. eq of Ir-192) X 1.72 = mCi of Ir-192 (G.C. = 0.48 mrem/hr mCi at 1 meter)
ND= “NOT DONE” - Refers to the following adjacent area surveys:
4701 and 4702 Anderson Pavilion, January 17, 1986
6W18, 6W19, 6W20, 6W21 Women’s Hospital, April 4, 2000
IMPORTANT NUMBERS
NCMH OPERATOR 6-4131
NCMH SECURITY 6-3686
BED CONTROL 6-1795/2041
ENVIRONMENTAL SERVICES 6-5611
ENVIRONMENTAL HEALTH & SAFETY
Main Number: 6-0749
LINEN SERVICES 6-4663
NUCLEAR MEDICINE 3-2936
VASCULAR RADIOLOGY 6-4645
PATIENT EQUIPMENT 6-5252
RADIATION ONCOLOGY 6-1101
ANDERSON 4 NORTH 6-1943
4 WEST 6-5406
Hospital Assoc RSO 216-4564
Hospital Safety Officer Pager 216-4563
RSO Pager 216-2311
Revised: November 19, 2012