Table 1

Number of omissions for each criterion; and number corrected subsequently out of 2597 patients
Number of omissions Number corrected subsequently
Departmental or hospital clinical record
1 History recorded 23 9
2 Examination recorded 3 1
3 Primary tumour site correctly documented 0 0
4 Histology correctly documented and report filed 45 29
5 Relevant imaging of treated site correctly documented and reports filed 105 48
6 Tumour stage correctly documented 5 2
7 Rationale for radiotherapy documented 0 0
8 Treatment intent documented 0 0
9 Discussion of treatment risks and consent recorded 0 0
10 Letter or notes copied to referring doctor 8 8
Treatment prescription
11 Legible patient name is present on all prescriptions 0 0
12 Treatment site specified and correct 0 0
13 Laterality (i.e. ‘left’ or ‘right’) for treated site correctly documented 1 1
14 Radiation modality and energy for all phases 0 0
15 Total dose specified for all phases 0 0
16 Dose per fraction specified for all phases 0 0
17 RT dose point specified for all phases 3 3
18 Number of fractions/day specified for all phases 0 0
19 Number of fractions per week for all phases 0 0
20 Treatment prescriptions are signed/approved and dated 0 0
Simulation and planning
21 Isodoses/treatment plan signed/approved and dated by doctor 0 0
22 Legible and correct patient name on all simulation/VP film/electronic images 0 0
23 Simulation image is signed or approved and dated by doctor 0 0
Performance criteria
24 Indication for treatment 0 0
25 Treatment intent (radical vs. palliative) 0 0
26 Target volume coverage 0 0
27 Critical structure doses 0 0
28 Prescribed total dose for each volume 0 0
29 Fractionation schedule 0 0
30 Clinical protocol or practice guideline followed 0 0
31 Research or Study followed 0 0
(*for 6 patients the actual omission was unclearly documented). 6 0
Total 199 101

Taghavi Bayat et al.

Taghavi Bayat et al. BMC Health Services Research 2013 13:148   doi:10.1186/1472-6963-13-148

Open Data