IMPLEMENTATION OF THE QUALITY CONTROL PROCESS OF THE RECORDS OF PATIENTS UNDERGOING RADIOTHERAPY TREATMENT

The patient record contains information about the prescription, fractionation and execution of the entire treatment. Some accidental occurrences may occur due to the absence of prescribing protocols in the treatment plan as well as in the absence of relevant information in the data sheet. In order to consider some procedures to prevent mistakes in radiotherapy and to follow the standard of CNEN NN 6.10 that aims to ensure the quality control of therapeutic treatments, the Quality Control Process of Medical Records (Technical Data Sheet) was implemented. In this process, a multidisciplinary team (Physician, Physicist-Doctor and Dosimetrist) reviews the technical file for the third time. This study aims to highlight the need to implement quality assurance programs and demonstrate that with the implementation of the Quality Control Process of medical records improved the standardization of protocols of the institution, minimizing possible adverse events in radiotherapy. Data were collected from 2016 December to 2018 December. Serious divergences: Incorrect dose and fractionation; Out-of-protocol contours; Informed Consent with incomplete completion; Description of Treatment Laterality incorrect. Media divergences: Faceless photo management and positioning system; No signatures; Documents without foreseen by the physical physician; No Printed Restrictions. Slight divergences: Notes on the Plan in the Management system; Checklist not completed by Radiotherapy Technicians. From 2016 December to 2018 December, the study analyzed 4,267 medical records and in 94 occurrences, the planning had to be redone. The implementation of the quality control process of medical records in radiotherapy services is another barrier to prevent accidents.