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Ohio Administrative Code (Last Updated: January 12, 2021) |
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3701 Department of Health - Administration and Director |
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Chapter3701-84. Quality Standards for Providers of Health Care Service (HCS) |
3701-84-73. Medical record - radiation therapy and radiostatic surgery service
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In addition to the requirements of rule 3701-84-11 of the Administrative Code, each radiation therapy service and/or stereotactic radiosurgery service shall maintain documentation of the following in each patient's medical record:
(A) Confirmation of the presence of malignancy by histopathology, a statement of benign condition, or other alternative evidence for diagnosis of all cases accepted for radiation;
(B) Documentation of services and radiographic images, including localization films, appropriate to the therapy provided;
(C) Report of the initial evaluation including a definition of the tumor or target type, location, and the extent of each cancer as a basis for staging;
(D) The treatment plan including the selection of dose, selection of treatment modality, and selection of treatment technique;
(E) The dosimetry calculations;
(F) The patient's progress and tolerance; and
(G) The completion of treatment with statement of a follow-up plan.