1 Task Group 315: Medical Physics Practice Guideline (MPPG) For Plan and Chart Review in

2 External Beam Radiotherapy and Brachytherapy

3 Ping Xia1, Cynthia Chuang2, Valdir C. Colussi3, Yeh-Chi Lo4, Deborah Schofield5, Benjamin J.
4 Sintay6, Michelle Wells7, and Sumin Zhou8
5 1
Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
6 2
Department of Radiation Oncology, University of California- San Francisco, CA
7 3
Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
8 4
Department of Radiation Oncology, Mount Sinai Hospital- New York, New York, NY
9 5
Department of Radiation Oncology, Florida Hospital South, Orlando, FL
10 6
Department of Radiation Oncology, Cone Health, Greensboro, NC
11 7
Department of Radiation Oncology, Piedmont Healthcare, Atlanta, GA
12 8
Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE

13

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15 Contents
16 I. Introduction ................................................................................................................................................ 3
17 1. Scope.................................................................................................................................................. 4
18 2. The charges of this MPPG .................................................................................................................. 5
19 II. Definition ................................................................................................................................................... 6
20 III. Expectations and Responsibilities............................................................................................................. 9
21 1. External Beam Radiation Therapy ..................................................................................................... 9
22 (a) Initial plan/chart check ...................................................................................................................12
23 (b) Weekly chart check ........................................................................................................................13
24 (c) Final chart check .............................................................................................................................14
25 2. Brachytherapy ......................................................................................................................................14
26 IV. Essential Content of a Treatment Plan Document .................................................................................15
27 1. External Beam Plan Document ........................................................................................................16
28 2. Brachytherapy Plan Document ........................................................................................................17
29 V: Recommended Checklist During Plan and Chart Review ........................................................................17
30 1. External Beam Plans and Charts ......................................................................................................17
31 a. Checklist for Planners ..................................................................................................................17
32 b. Initial Plan/Chart Checklist for Physicists....................................................................................18
33 c. Initial Plan/Chart Checklist for Therapists ...................................................................................20
34 d. Weekly Chart Review Checklist ...................................................................................................20
35 e. Final Chart Review Checklist ........................................................................................................20
36 2. Brachytherapy Plans/ Charts ...........................................................................................................21
37 a. Initial Plan/Chart Checklist for Physicists ...................................................................................21
38 b. Initial Plan/Chart Checklist for Therapists .................................................................................21
39 c. Weekly Chart Review Checklist ..................................................................................................22
40 f. Final Chart Review Checklist ......................................................................................................22
41 VI: Computer-aided Plan/Check and Automation .......................................................................................22
42 VII: Discussion ..............................................................................................................................................24
43 VIII: Summary ...............................................................................................................................................26
44 References: ..................................................................................................................................................28
45

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46 I. Introduction
47

48 Task group (TG) 40 report [1], published in 1994, established the foundation of comprehensive

49 quality assurance (QA) for radiation therapy. Most current medical physics practices in radiation

50 therapy stem from this report. With the advancement of radiation therapy in the past two

51 decades, several additional QA reports have been published [2-4], each addressing one specific

52 aspect of QA topics covered in TG 40. A recently published TG 275 [5] provided evidence-

53 based recommendations on physics plan and chart review for radiation therapy based on a survey

54 of AAPM members and failure mode and effect analyses (FMEA). In parallel with TG 275, the

55 purpose of this report is to provide specific checklist during plan/chart review for dosimetrists,

56 medical physicists, and therapists based on minimum practice standards. Since radiation therapy

57 is a coordinated team effort, this report also clarifies the responsibilities of each team member

58 (radiation oncologists, medical physicists, dosimetrists, and therapists). The differences between

59 this MPPG and TG 275 are elaborated the last section of this report.

60

61 A patient chart typically consists of many types of documents, including diagnostic reports,

62 consultation reports, simulation documents, treatment plan reports, daily treatment records, and

63 on-treatment visit reports. With the advent of electronic medical records (EMR), many clinical

64 reports reside in a general hospital EMR system, while other radiation-related technical reports

65 may reside in a radiation specific EMR system. One integrated EMR system is ideal; but

66 currently not feasible because hospital EMR systems are generally incapable of sending radiation

67 treatment plans to the treatment equipment and recording radiation treatment parameters

68 automatically, both of which are critical for radiation therapy. The purpose of having a patient

69 chart reviewed by different team members at multiple time points throughout the course of

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70 treatment (e.g. prior to treatment (initial), during treatment (weekly), and at the end-of-treatment

71 (final) is to ensure accurate and precise radiation treatment planning and delivery. To

72 accomplish these tasks, one of the most important documents of a radiation therapy-related

73 patient chart is the treatment plan report, along with other supporting documents for treatment

74 delivery.

75

76 Treatment plans for radiation oncology consist of two major components: a clinical element and

77 a technical element. The clinical component of a treatment plan includes the intent of radiation

78 treatment (definitive, adjuvant, or salvage), radiation dosage, fractionation scheme, and anatomic

79 contours that are delineated either to receive the prescribed treatment doses or to be protected

80 from a specific tolerance dose. The technical component of a treatment plan includes the details

81 of patient positioning along with the immobilization devices, placement of radiation beams, and

82 the aperture shapes of radiation beams (designed either manually or by computer optimization)

83 to achieve highly conformal radiation dose distributions to the treatment target volumes while

84 protecting the critical organs.

85 1. Scope
86

87 This MPPG report is focused on the technical component of a treatment plan, referred to as the

88 treatment plan in subsequent sections. The goal of this MPPG is to provide essential checklist

89 items for medical physicists who conduct plan/chart reviews according to the minimum

90 acceptable safe standards.

91

92 The purpose of a new (initial) plan/chart review is to ensure compliance with the prescription,

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93 no clinically significant deviations are present, and that all information necessary for the

94 therapists to deliver the treatment has been provided. Significant deviations in the plan/chart

95 include errors, inconsistencies, or ambiguities, which may cause confusion for the team and

96 potentially resulting in treatment errors. A recent publication [6] from the Radiation Oncology

97 Incident Learning System (RO-ILS) reported that 33% of reported events occur during the

98 processes of treatment planning and pretreatment review/verification. Mitigation of these

99 hazards is best accomplished by catching errors as far upstream as possible and including

100 multiple layers of plan check/review. The possibility of an error propagating through to the

101 patient can further be minimized by using a standardized treatment plan document, a consistency

102 check from the planners, and a pretreatment check by radiation therapists.

103

104 The purpose of weekly on-treatment (weekly) chart review is to verify that the prescription is

105 being fulfilled. If for clinical reasons, the prescription is altered, medical physicists are

106 responsible for ensuring that the modified prescription is followed accordingly. At the end-of-

107 treatment (final) chart check, medical physicists are responsible for ensuring that all technical

108 documents for that patient are signed/approved and that the treatment course is completed. If for

109 clinical reasons or patients’ decisions, the treatment course is not completed, a radiation

110 oncologist should document the specific reason in the chart. This MPPG provides essential

111 checklists for medical physicists to utilize while carrying out the responsibilities of initial,

112 weekly, and final chart review.

113 2. The charges of this MPPG

114

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115 (1) To define roles of a dosimetrist, therapists, a physicist in training, and a qualified

116 medical physicist as they pertain to the treatment plan/chart review process for external

117 beam radiotherapy (EBRT) and brachytherapy.

118 (2) To define essential checklist items for initial, weekly and final plan/chart review.

119 (3) To make recommendations on the timing of the initial, weekly, and final

120 plan/chart review, especially for special procedures (e.g. TBI, stereotactic body

121 radiotherapy, and brachytherapy).

122

123 This MPPG considers typical treatment plans in radiotherapy, including the most frequently used

124 external beam radiotherapy (C-arm linear accelerators) using photons and electrons (excluding

125 proton plans) and the most frequently practiced brachytherapy procedures, such as high dose rate

126 (HDR) brachytherapy for gynecological treatments. It is not feasible for this MPPG to cover

127 every procedure or situation, and as such, the medical physicist should collaborate with other

128 members of the department to establish and document appropriate procedures for those falling

129 outside of this work. Working with radiation oncologists, medical physicists are responsible for

130 confirming a patient-specific high-quality plan is developed; however, the quality of a treatment

131 plan is ultimately the radiation oncologist’s responsibility. This MPPG does not expound on the

132 aspect of plan quality metrics.

133

134 II. Definition

135

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136 The following terms will be used throughout this report. Their definitions are generally

137 understood by the radiation oncology community. For others who are not familiar with these

138 terms, the definitions are provided below.

139 QMP: For the purpose of providing radiation oncology therapy clinical professional services, a

140 Qualified Medical Physicist is an individual who is competent to practice independently in the

141 subfield of therapeutic medical physics. The ACR strongly recommends that the individual be

142 board certified. Individual who is not board certified but is licensed by the state, or documented

143 by home institution as passing the institution's competency requirement are also considered as

144 QMP. This definition is more aligned with the ACR definition [7] to be more encompassing

145 than the AAPM definition of QMP [8].

146 AU: Authorized Users are radiation oncologists who are authorized to utilize a high dose rate

147 (HDR) brachytherapy unit and are required by the Nuclear Regulatory Commission (NRC) and

148 agreement states to be present at the treatment console during high dose rate (HDR)

149 brachytherapy treatments.

150 AMP: Authorized Medical Physicists are individuals who are listed on the HDR license of

151 brachytherapy and are required by the NRC and the agreement States to be present at the

152 treatment console during brachytherapy treatments. For States that require a license to practice

153 medical physics, licensed medical physicists are AMP.

154 Prescription: Following the guideline of American Society of Radiation Oncology (ASTRO) on

155 the prescription [9], a Radiation Oncologist should provide the following minimum information

156 in the written prescription for external beam radiation: anatomic site, delivery technique

157 including photon/electron, energy, total dose, number of fractions, and the percent isodose line

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158 that is used for normalization to a specific point or to a specific volume. If IGRT is applicable,

159 the prescription should specify the alignment method (e.g. bone or soft tissue) and the frequency

160 of IGRT applications.

161 Written directive: Used for brachytherapy plans, similar to the prescription in EBRT plans

162 defined above, a Radiation Oncologist should provide the following minimum information in the

163 written prescription: anatomic site, isotope, activities, total dose, number of fractions, and the

164 percent isodose line that is used for normalization to a specific point or to a specific volume.

165 Clinical Plan: A radiation oncologist should provide the following in a clinical component of a

166 treatment plan: instructions to the planners on how to create the planning target volume (PTV), if

167 desired, total dose, fractionation scheme, and dose limits to the organs at risk (OARs), if they are

168 different from the institutional established standard tolerances, as indicated in ACR guidelines

169 [10, 11].

170 Chart: All of the documents that accompany a patient-specific radiation treatment, including:

171 treatment prescription, treatment plan (clinical and technical plans), treatment delivery

172 parameters, recorded treatment deliveries, and image guided radiotherapy (IGRT) images.

173 Plan: The technical component of a treatment plan, consists of the total dose, fractionation

174 scheme, energy, treatment method, treatment parameters, and the isodose line that is used for

175 normalization and dose statistics.

176 EBRT: External Beam Radiation Therapy

177 CT: Computed Tomography, which is acquired during simulation and used for treatment

178 planning.

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179 IGRT: Image-Guided Radiation Therapy, utilizing imaging, including Cone Beam CT (CBCT),

180 kilo-voltage (KV) or mega-voltage (MV) image pairs, for accurate patient alignment during

181 radiation treatments.

182 4D-CT: Multiple sets of CT scans obtained during regular respiration cycles, to obtain image

183 datasets that can be used to determine tumor/normal organ motions, and to create a better

184 representation of the tumor/normal organs by creating an internal target volume (ITV) or an

185 average CT for treatment planning purposes.

186 Initial Plan/Chart Check: The same as the new plan/chart check, applied to any plan that is

187 either a new or has significant dosimetric changes.

188 Weekly Chart Review: The same as the on-treatment chart check.

189 Final Chart Review: The same as the end-of-treatment chart check.

190

191 III. Expectations and Responsibilities

192

193 1. External Beam Radiation Therapy

194

195 In compliance with the American College of Radiology (ACR) practice guideline [10], radiation

196 oncologists are responsible for the delineation of the tumor volumes, including the gross tumor

197 volume (GTV) and clinical target volume (CTV). For the internal target volume (ITV) and

198 planning target volume (PTV), radiation oncologists can either create these target volumes, or

199 provide a written instruction to the planners on how to create ITV and PTV volumes from the

200 contoured GTV and CTV volumes. Radiation oncologists are responsible for reviewing and

201 approving contours of all target volumes and OARs. Any OARs that are not clearly discernible

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202 on the planning images should be delineated by radiation oncologists. Upon approval of all

203 targeted volumes and OARs, radiation oncologists should provide detailed written instructions to

204 the planner about the desired dose-volume coverage to the targeted volumes and dose limits to

205 clinically relevant OARs (sometimes referred to as dose constraints) [8, 9]. The primary

206 responsibility of a planner is to create a treatment plan in accordance to these dose constraints

207 provided by a radiation oncologist.

208

209 In the event that the prescription must be changed during planning, the radiation oncologist

210 should document the change in writing [12]. Some institutions may require a physicist to check

211 the plan quality (which, as mentioned previously, is not in the scope of this MPPG) before the

212 radiation oncologist’s approval. Before plan approval, some institutions may have a physicist

213 check important planning parameters such as the removal of the CT couch (or insertion of a

214 couch model), isocenter coordinates, normalization methods, and calculation point placements,

215 in an attempt to catch errors early in the planning process. Other institutions use a quality

216 checklist for the planner to perform a self-check or use a computer program to perform a plan

217 consistency check to eliminate obvious errors, which will be further discussed in Section V.

218 Ultimately, the treatment plan must be approved by a radiation oncologist.

219

220 After plan approval, a planner will assemble all necessary information pertinent to the delivery

221 of the plan, such as the creation of digitally reconstructed radiographs (DRRs), setup beams,

222 source to skin surface distance (SSD) parameters, and the key treatment table parameters, when

223 appropriate. Furthermore, a comprehensive treatment plan report is generated. This plan report

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224 is the basis for all levels of plan review by both physicists and therapists. This report can also be

225 used for peer review, billing purposes, and even for patients, who may request this document

226 when transferring care or for re-treatment considerations. The recommended documentation for

227 this plan report is detailed in Section IV. In addition to the plan report, a planner is responsible

228 for transferring the treatment delivery parameters to a Record and Verify (R&V) system, if the

229 R&V system has a separate database from the treatment planning system. The information that is

230 transferred may include additional shifts from the initial isocenter (or reference point) set during

231 simulation, modification of patient external contours (e.g. add bolus on specific region), all

232 essential treatment parameters for each field, and images (DRRs, reference images) associated

233 with the treatment isocenter. This information is essential for radiation therapists to perform

234 accurate treatment delivery for each patient.

235 Therapists are responsible for positioning the patient for treatment, according to the simulation

236 report, setup instruction, and treatment plan document. To ensure precise patient positioning,

237 radiation therapists must confirm all essential information is available, approved, and consistent.

238 Prior to each treatment, therapists must set up patients with patient-specific devices or patient-

239 specific settings of a reusable immobilization device. A recommended checklist for therapists is

240 discussed in Section V. 1c and listed in Table 5.

241

242 Plan/chart review consists of reviewing the treatment plan and/or report, relevant documentation

243 such as setup instructions, and daily treatment records to ensure accuracy, consistency, and

244 clarity. Reviews should occur at multiple time points during the treatment process: initially,

245 weekly, and at the conclusion of treatment (final) during the course of treatments.

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246
247 (a) Initial Plan/Chart Check
248

249 A QMP is responsible for an initial plan/chart check. It is a good practice to perform the initial

250 check prior to the first treatment. The essential checklist for the initial check is discussed in

251 Section V.1b and listed in Table 4. The majority of the DICOM data are transferred via network;

252 however, some information may need to be entered manually. During the initial check, it is

253 important to focus on these elements due to the higher risk of human error. Certain treatment

254 parameters may be automatically checked (see Section VI). We recommend all radiation dose

255 relevant components and critical verification imaging parameters in treatment fields be approved

256 and locked after the initial check to avoid any accidental alterations during the treatment course.

257 Treatments should not be allowed to proceed if the approval status is revoked.

258

259 If the initial check is completed by a QMP-designated physicist, then a QMP must complete an

260 initial check prior to the delivery of 10% of the prescribed dose or prior to the third treatment,

261 whichever comes first. The QMP-designated physicists must be someone who is a trained

262 medical physics resident, or other physicist who is supervised by a QMP. The QMP must

263 document the competency the designated physicists on plan and chart review of each specific

264 EBRT treatment modality (i.e. conventional EBRT, SBRT, and SRS). For emergency treatments

265 occurring after hours, an on-call QMP may be contacted to review the treatment plan remotely.

266 For institutions that do not have an on-call QMP, a radiation oncologist may conduct the

267 secondary initial check and a QMP shall check the plan on the next business day, or prior to the

268 treatment on the next business day if additional fractions are prescribed.

269

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270 (b) Weekly Chart Review
271

272 The purpose of weekly chart review is to conduct a systematic review of recorded treatment

273 delivery data, including any overrides, incomplete treatments, any unusual isocenter shifts after

274 the initial image verification, the status of verification image approval, and documentation of

275 SSDs. If daily image guidance is indicated in the prescription, weekly chart reviews should

276 check whether the frequency of image guidance is followed and that the shifts after IGRT are

277 within a reasonable range. A specific weekly chart checklist is discussed in Section V. 1d and

278 listed in Table 8. Any dosimetric changes in a treatment plan should be considered as a new

279 plan, and a new report of the modified plan should be created. For example, a change in daily

280 fraction dose requires a new report to document on the changes of monitor units (MUs). The

281 modified plan should undergo an initial plan/chart check. Weekly chart reviews should be

282 completed within a window of every five treatment fractions. If a treatment course is five

283 fractions or less, the institution should consider developing a process to ensure at least one

284 weekly chart review is conducted during the course of treatment, ideally near the beginning of

285 the course. For single fraction treatment, a weekly chart check can be omitted, but the chart

286 should be reviewed by a QMP within one business day of treatment completion.

287

288 Weekly chart reviews should be completed by a QMP or their trained designees, which may

289 include dosimetrists, medical physics residents, and other physicists. When a designee completes

290 the weekly chart review, the QMP must co-sign the document, indicating that the designees are

291 under the supervision of the QMP. It is recommended, when possible, that QMPs and/or their

292 designees conduct the weekly chart reviews on an alternating basis, so that the same person does

293 not check the chart for the entire treatment course.
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294
295 (c) Final Chart Review
296

297 The purpose of final chart review is to review all treatment delivery parameters and documents

298 to ensure that the treatment prescriptions have been fulfilled accurately and all pertinent

299 technical documents are signed and approved. The final chart review should be completed by a

300 QMP within five business days of the patient’s last delivered fraction [7]. For single fraction

301 treatment course, we recommend completing the final chart review on the same day of the

302 treatment or no later than the next business day, if the weekly chart review is omitted.

303
304 2. Brachytherapy - HDR
305

306 There is a broad scope of procedures encompassed within the brachytherapy realm. As an

307 example, this MPPG examines a common high dose rate (HDR) brachytherapy for gynecology

308 cancer. The plan/chart check procedure developed for this procedure may be extended to other

309 more complicated brachytherapy treatments or procedures.

310

311 The initial check for HDR should be performed by an AMP. In situations where an AMP is in a

312 solo practice, an AMP designated team member (either a therapist, a dosimetrit, or an AU) who

313 is trained for the HDR procedure may complete the initial plan/chart check if the HDR plan was

314 created by the solo AMP.

315

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316 This MPPG suggests an essential brachytherapy checklist for a new plan/chart checks in Section

317 V.2. In practice, some institutions generate a new plan for every fraction. The new plan is

318 checked again, which can be considered as the weekly chart review. In institutions where the

319 same brachytherapy plan is delivered over multiple fractions, the AMP should complete a

320 weekly chart review within a window of every 5 fractions, similar to those conducted for EBRT.

321 If an institution decides not complete weekly chart reviews on a brachytherapy procedure

322 because a new plan is created each fraction, a QMP should review a treatment procedure

323 document after each treatment to ensure the treatment record, pre- and post-radiation surveys,

324 and documentation of the presence of appropriate clinical personnel (an AU) is completed.

325

326 The final chart review should be performed at the end of the treatment course. The guidelines

327 are the same as for EBRT. The AMP should check the accuracy of all treatment delivery

328 parameters and documents to ensure the AUs’ directives have been fulfilled accurately and that

329 all pertinent technical documents are signed and approved. It is recommended the final chart

330 review be completed by an AMP at the day of final treatment, or no later than the next business

331 day.

332

333 IV. Essential Content of a Treatment Plan Document

334

335 A treatment plan report should be generated after the radiation oncologist (or AMP)’s review and

336 approval of the treatment plan. This report allows careful preservation of the treatment plan

337 stored in a central location, either in the hospital EMR system or radiation oncology specific

338 medical record system (Record and Verify System) along with other treatment-related

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339 documents. For purpose of patient care, the treatment plan report can be easily readable by all

340 caretakers as well as the patients themselves, who are not familiar with (or do not have access to)

341 the treatment planning system or a DICOM program.

342

343 1. External Beam Plan Document

344

345 The treatment plan report is often in a file format, such as PDF, where modification is restricted.

346 A treatment plan report should display information in a consistent manner from patient to patient

347 by standardizing the components, order, and the specific displays (i.e. isodose lines appearing at

348 standard levels and colors). For the prescription, it is recommended to include the anatomic site

349 name and laterality, total dose, number of fraction, and the percent isodose line that is used for

350 normalizing to a specific point or to a specific volume (see Table 3) according to the prescription

351 guideline from American Society of Radiation Oncology (ASTRO) [9]. Nomenclature such as

352 beam names should be standardized and designed to reduce confusion and improve safety. For

353 organ names and tumor volume names, it is recommended to use the established nomenclature

354 standard described by TG 263 [13]. We recommend including at least one isodose image for

355 each of the three orthogonal planes at isocenter or in the middle of the target(s) with isodose

356 lines shown in absolute dose and including the prescription dose level(s).

357

358 The second column in Table 1 shows the various components of a treatment plan report for

359 external beam and brachytherapy plans. Optional elements should be considered depending on

360 specific institutional workflow, clinical practice, or billing requirements. The components of the

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361 treatment plan report should be reconsidered when implementing new technology, e.g. proton

362 therapy. A treatment plan report must demonstrate that the prescription is being fulfilled. The

363 documentation should clearly convey how the plan fulfills the specific radiation oncologist

364 intent. Setup information including documentation of immobilization devices is important for

365 reproducible treatments. If setup information is not documented elsewhere, it should be included

366 in the treatment plan report.

367 2. Brachytherapy (HDR) Plan Document

368

369 A brachytherapy (HDR) plan document should follow the same order as the EBRT plan

370 document. The Third column in Table 1 shows the various components of a HDR plan report.

371 Optional elements should be considered depending on specific institutional workflow, clinical

372 practice, or billing requirements. The major differences in documents between EBRT and

373 brachytherapy plans are on the sections of plan summary and beam eye views. For

374 brachytherapy plans, it is of utmost importance to examine the reconstruction view of each

375 catheter and/or source position(s), including orientation (for example, tip verses catheter end). It

376 should be noted that the verification of the reconstruction may not be fully possible with a

377 printout alone but likely requires a review with the TPS.

378

379 V: Recommended Checklist items During Plan and Chart Review

380

381 1. External Beam Plans and Charts

382

383 a. Checklist for Planners

384

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385 As mentioned in Section III, the primary responsibility of a planner is to create a treatment

386 plan in accordance with the treatment prescription and other written instructions provided by

387 a radiation oncologist. In addition, a planner must assemble necessary information for the

388 therapists to deliver the plan, including isocenter shifts, IGRT reference images, and cross-

389 verification parameters (e.g. SSDs, table positions, etc.). To assist a planner, it is

390 recommended that a planer conducts a self-check during planning or after the plan is

391 completed. The self-check items are listed in Table 2. Once the plan is approved by a

392 radiation oncologist, it is recommended that a planner creates a plan report following a

393 standard format established by each local institution. The recommended components of a

394 treatment plan report are listed in Table 1. The final section in Table 2 lists checklist items

395 that are essential for therapists to deliver the plan. The optional items listed in Table 2 can be

396 added to the planner’s checklist, depending on the preference of the local institution and

397 practice.

398

399 b. Initial Plan/Chart Checklist for Physicists

400

401 A treatment prescription (and/or written directive) from a radiation oncologist is the

402 foundation for any new treatment, and thus it is recommended that the treatment prescription

403 be standardized, clear and concise, and follows the prescription guideline from American

404 Society of Radiation Oncology (ASTRO) [7]. The essential items to be included in the

405 prescription are listed in Table 3. During new plan/chart review, a QMP should ensure that

406 these items are documented in the prescription and are consistent with the corresponding

407 treatment plan report. Upon reviewing the plan report, it is recommended that a QMP

408 follows checklist in Table 4. In the treatment plan, the isocenter or the initial reference point
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409 that was marked during CT simulation must agree with the skin marks on the patient since

410 this is the starting point of treatment plan and delivery including any additional shifts

411 required during the planning process. A recent publication [5] from Radiation Oncology

412 Incident Learning System (RO-ILS) reported that a potential systematic error in 15% of

413 reported events was a wrong isocenter, which could have originated from the initial isocenter

414 marked on the patient skin mismatching the isocenter that was sent for treatment planning.

415 Therefore, this MPPG recommended that a photo documenting the initial alignment point

416 marked on the patient skin be added in the R&V system, which can assist therapists to

417 identify the alignment point ( sometimes, it referred to as the laser alignment point).

418 Furthermore, this MPPG also recommend documenting the agreement between the

419 coordinates or location of the initial isocenter sent to the treatment planning system and the

420 initial alignment on the patient skin markers. For example, for institutions that implement the

421 virtual simulation (identify the iso-center after completion of planning CT acquisition) one

422 can acquire an additional single slice axial CT scan after acquisition of the planning CT. This

423 single slice image should contain three radio-opaque markers that are placed on the skin

424 where three laser points intersected. A planner should then verify the initial isocenter (or

425 reference point) matched with points marked on the patient skin.

426

427 Optional items included in Table 4 can be added to the checklist depending on the specific

428 practice of each institution. A QMP should ensure that essential information from the

429 treatment plan report are correctly transferred into the R&V system and approved by

430 assigned responsible teams. The last section in Table 4 lists the essential checklist items. The

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431 optional items in this section of Table 4 can be added to the checklist depending on the

432 specific practice of each institution.

433

434 c. Initial Plan/Chart Checklist for Therapists

435

436 Prior to any new treatment, therapists should conduct a new plan/chart review to confirm all

437 essential information is available, approved, and consistent. The importance of therapists

438 conducting an initial check is well demonstrated [14]. A recommended checklist for

439 therapists is listed in Table 5. Optional items in Table 5 can be added to the checklist

440 depending on the specific practice of each institution.

441

442 d. Weekly Chart Review Checklist

443

444 A recommended checklist for weekly chart check is listed in Table 8. The optional items

445 listed in Table 8 can be added to the checklist depending on the specific practice of each

446 institution. After completion of the weekly chart review, we recommend that a formal report

447 to be generated to document the date of the weekly chart review, the treatment site,

448 accumulated dose, number of fractions delivered to date, and other checklist items listed in

449 Table 8. For a new plan or a modified plan that has dosimetric impact, the first on-treatment

450 chart check should also include a quick check on plan quality, which serves as another level

451 of assessment to ensure that there are no gross errors in the plan.

452

453 e. Final Chart Review Checklist

454

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455 A QMP should conduct a final chart checks to ensure the treatment prescriptions and/or

456 written directive have been fulfilled accurately and all pertinent documents are signed and

457 approved. A recommended checklist for final review is listed in Table 9. It is recommended

458 to generate a formal document to report the date of the final chart check, the treatment site,

459 total dose, and total number of fractions delivered in accordance to the prescription. This

460 recommendation is compliant with ACR practice guideline[7]. If the prescribed treatment

461 course was not completed, a comment should be added in the existing prescription, or a

462 separate note or document. This document and the existing prescription should be stated on

463 the final dictation by the radiation oncologist.

464

465 2. Brachytherapy Plans/ Charts

466

467

468 a. Initial Plan/Chart Checklist for Physicists

469 As discussed in Section III 2, during HDR planning, the accuracy of image co-

470 registration, applicator specification and placement, catheter reconstruction, and catheter

471 channel parameters (such as indexing/ length and the appropriate identification of the first

472 dwell positions) are important parameters to verify before transferring the treatment data

473 to the treatment console. We recommend each new plan be checked by an AMP listed on

474 the HDR license, using the checklist provided in Table 6.

475

476 b. Initial Plan/Chart Checklist for Therapists

477 Prior to each treatment, we recommend that therapists (or an AMP if a therapist is not

478 involved in the procedure) conduct a pre-treatment check following Table 7. The

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479 checklist can serve as a part of the treatment procedure document and be signed by an

480 AMP and an authorized radiation oncologist, who are present during the treatment.

481

482 c. Weekly Chart Review Checklist

483 Weekly chart review for brachytherapy plans is only required when the same

484 brachytherapy plan is delivered over multiple fractions. The applicable items are listed in

485 the second column in Table 8.

486 d. Final Chart Review Checklist

487 Similar to external beam, an AMP should conduct the final chart reviews to ensure the

488 treatment prescriptions and/or written directive have been fulfilled accurately and all

489 pertinent documents are signed and approved. A recommended checklist for final review

490 for brachytherapy plans is the same as the EBRT plans as listed in Table 9. If the

491 prescribed treatment course was not completed, a comment (or a note) should be added in

492 the prescription and approved by the radiation oncologist.

493

494 VI: Computer-aided Plan/Check and Automation

495

496 Some vendors and individual institutions have developed computer programs to

497 automatically check various parts of a patient plan or chart [15-20]. These programs are

498 effective in checking simple logistic requirements and numerical consistency. For example, a

499 computer program can check whether prescriptions or portal images are approved by radiation

500 oncologists[21], and whether radiation treatment parameters are in agreement with the planned

501 parameters [20] . A comprehensive literature review about computer-aided plan/chart check can

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502 be found in TG275 [5]. Due to significant variations in workflows among different clinical

503 practices, these programs cannot completely replace the function of a physicist in the process of

504 the plan and chart review. Computer programs, however, can assist in certain areas of plan/chart

505 review. For example, vendor-provided programs [22, 23] can assist with checking whether plan

506 DVHs meet clinical requirements, but these programs cannot substitute careful examinations of

507 three dimensional dose distributions on planning images.

508 With automation, plan document components recommended in Table 1 can be easily

509 standardized and implemented. Most items listed in Table 2 can be checked automatically to

510 avoid errors in the upstream during treatment planning, but items such as whether bolus is

511 applied appropriately and whether contours of normal/critical structures are completed and

512 accurate will still rely on human judgment and experiences. Some items in Table 3 can be

513 extracted from treatment plan documents, but items such as CBCT frequency, IGRT alignment

514 structures, and special motion management techniques vary from patient to patient, requiring

515 human judgment and discretion. While a majority of the items listed in Table 4 can be checked

516 by computer programs, items such as whether the isocenter of a plan (if no isocenter shift)

517 matches with isocenter markers on the patient’s skin, beam clearance, and anatomy structure

518 density override, still need human attention. Computer-aided programs can provide an alert list

519 for initial and weekly plan/chart review, calling for special attention to certain missing or

520 mismatched items, therefore can help streamline the whole process.

521 Before implementing computer-aided check programs, it is the responsibility of a QMP to

522 rigorously validate them to avoid potential systematic errors. With increasing use of artificial

523 intelligence and sophisticated statistical machine learning tools in the medical physics field,

524 more commercial computer-aided plan/chart review programs are expected to be available

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525 clinically in the near future. The combination of computer-aided and human plan/chart review

526 will significantly improve the effectiveness of this vital process while improving safety and

527 quality of our patient care.

528

529 VII: Discussion

530

531 The primary goal of this MPPG is to provide essential checklist items for medical physicists who

532 conduct plan/chart reviews according to the minimum practice standards. The plan/chart review

533 process, particularly the initial plan review process, is critical to prevent errors and to ensure

534 smooth patient care. Thus this process should have multiple layers and take collective efforts of

535 the entire department, in addition to the physics check/review. This MPPG, therefore, also

536 recommends therapists conduct the initial plan/chart check prior to any new treatment. The

537 initial plan/chart checklist for the therapists overlapped with the checklist of initial plan/chart

538 check for the physicists on the important items, such as the prescriptions and location of the iso-

539 center. In addition to act as an additional layer of the safety check, another purpose of checklist

540 for therapists is to ensure the presence of important documents and the associated authorizations

541 and approval, according to the rules of ACR and other regulatory agencies, thus preventing

542 potential interruptions of patient care. This MPPG invited American Society of Radiologic

543 Technologists to review the report and obtained the endorsement from the society.

544

545 To catch errors upstream, this MPPG recommends a self-consistent checklist for planners and the

546 use of standard documentation of a plan. Since the planners are often dosimetrists, this MPPG

547 also reach out to the American Association of Medical Dosimetrists (AAMD) for their input and

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548 endorsement of self-consistent checklist and standard documentation. There are some debates

549 about whether a standard documentation is necessary if everyone has an access to the treatment

550 planning system to review the plan comprehensively. Given the complexity of a treatment

551 planning system, a planner typically accesses numerous treatment planning parameters through

552 many sub-windows and panels, therefore, we believe that not everyone has the skill and

553 confidence level as a planner in the use of a treatment planning system. A standard plan

554 document displays all key information of a plan in a consistent order and straightforward format,

555 facilitating those who are not familiar with the treatment planning system to grasp the content of

556 a plan, including patients themselves.

557

558 From the perspective of minimum practice standards, this MPPG is different from TG 275 [5]

559 although the underlining principles are the same. Within this task group, we included two

560 members from TG 275, who provided a valuable link between TG 275 and this MPPG. Based

561 on TG 275 and practice experiences of the task group members, which included academic and

562 community practices using different Record & Verify systems and treatment planning systems,

563 the recommended initial plan/chart checklist for physicists has about 50% - accordance of the

564 example checklist (Table 1c from TG 275). Some items in the example checklist of TG 275,

565 such as physician directives for simulation procedures, treatment prescriptions with respect to the

566 standard of care/clinical guideline, are not included in the recommended checklist of this MPPG

567 because we believe these items are beyond the training and responsibility of a medical physicist.

568 This view is supported by ACR guideline for 3D external beam radiation planning and conformal

569 therapy[10]. Furthermore, the accuracy of contours of tumor volumes and normal tissue volumes

570 is predominant in 3D and IMRT planning and is the responsibilities of radiation oncologists per

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571 ACR guideline[10]. To improve patient care workflow, it is a good practice for each planner to

572 conduct a sanity check of all contours to avoid replanning. This sanity check (included in Table 2

573 of planner checklist) is to detect gross errors such as skip slides, miss labels of contours, an

574 illogical relationship among GTV, CTV, ITV and PTV, stray voxels, to name a few. According

575 to the guideline of ATSRO [9], this MPPG recommends each local institution establishes its own

576 standard format of a treatment prescription for both EBRT and brachytherapy. Medical

577 physicists can provide supports to radiation oncologists to adhere to the ASTRO guideline. The

578 accuracy and completeness of a prescription are again beyond the clinical training and

579 responsibility of a medical physicist. Some items in the checklist of this MPPG are not in the

580 checklist of TG 275, including items such as the patient name and medical record numbers, and

581 item such as all beams associated with the same iso-center ( for single iso-center plans). The

582 weekly and final chart review checklists from this MPPG are mostly in agreement of

583 recommendation of TG 275. For institutions that desire to conduct more comprehensive and

584 thorough plan/chart review and have the required resources, they are encouraged to develop their

585 own checklists that combines checklists from TG 275 and this MPPG and more.

586 The scope of this MPPG is limited to most frequently used external beam radiotherapy (C-arm

587 linear accelerators) and most frequently used brachytherapy (for gynecological treatments). The

588 recommended checklists can be extended to other external beam modalities such as proton beam

589 radiotherapy, Cyberknife, and Tomotherapy while taking account for unique applications of

590 these modalities.

591 VIII: Summary

592

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593 This MPPG provides lists of the essential checklist items, according to the minimum practice

594 standards, for medical physicists, dosimetrists, and therapists to follow when conducting

595 plan/chart reviews. The report also provides essential components to include in a treatment plan

596 report, provides minimum personnel qualifications for those completing plan/chart review, and

597 provides appropriate timelines for when to complete plan / chart reviews.

598

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