Graduate Medical Dosimetry Certificate

Indiana University School of Medicine

IU Department of Radiation Oncology
RAON D704
Clinical Practicum IV Assessment Challenges in Medical Dosimetry
Assessment #1
Complex 2D (CT based) or Basic 3D Treatment Planning
Plan Assigned:

Whole Brain

Spine

Other ___________________

Date Assigned: _________________

Date Completed: ___________________

Student Name: ____________________________

Physician: _________________________

Performance Assessment
Excellent

The student exhibits skills and qualities much like an experienced dosimetrist,
communicating knowledgeably and professionally, making suggestions and
decisions as appropriate and completing the work accurately.

Above Average

The student professionally completes required elements of the assignment

accurately and independently.

Minimum Standards

The student completes the required elements of the assignment at the level
of a novice planner, with some occasional supervision from the CMD.

Performance 1 Initialization of Planning Process

Excellent

Above Average
5
4

Minimum Standards
3

to be completed by physician

A. Establishes Professional Communication with the Physician.

B. Acquires Images and Completes Contouring as Directed.

owing specific request.

Performance 2 Treatment Planning

Excellent

Above Average

Minimum Standards
3

to be completed by CMD

A. Creates the Treatment Plan including Reference Points

and Establishes the Plan Normalization Techniques.

B. Generates the Beam Arrangement.

C. Determines Appropriate Type and Use of

Beam Modification Devices

D. Performs the Dose Calculation Appropriately

Performance 3 Plan Evaluations / Approvals

Excellent

Above Average Minimum Standards

5
4
3

to be completed by physician

A. Performs the Initial Plan Evaluation with the Physician.

The treatment plan requires additional planning

due to: ___________________________.
Any requested plan revisions are made as directed.
B. Final Evaluation and Plan Approval Completed. Date: _______________

Performance 4 Chart Documentation (EMR)

Excellent

Above Average Minimum Standards

5
4
3

to be completed by CMD or by ABR certified physicist.

A. Verifies the Monitor Unit Calculation.

B. Completion of RT Chart, Patient Manager

& Paper Documentation

C. Billing Procedures Completed Correctly

Signatures and Comments:

_____________________________
CMD signature / date

___________________________________________________
___________________________________________________

_____________________________
ABR physicist signature/date

___________________________________________________
___________________________________________________

_____________________________
Physician signature / date

___________________________________________________
___________________________________________________

_____________________________
Student signature / date

___________________________________________________
___________________________________________________

___________________________________
Marvene M. Ewing, CMD Clinical Instructor

Scoring:
Must Repeat Test-Out:

____________________
Score

45 50 points (A)
40 44 points (B)
< 40 points

Graduate Medical Dosimetry Certificate

Indiana University School of Medicine
IU Department of Radiation Oncology
RAON D704
Clinical Practicum IV Assessment Challenges in Medical Dosimetry
Assessment #2
3D Conformal Treatment Planning
Plan Assigned: Lung Esophagus Pelvis

Other ___________________

Date Assigned: _________________

Date Completed: ___________________

Student Name: ____________________________

Physician: _________________________

Performance Assessment
Excellent

The student exhibits skills and qualities much like an experienced dosimetrist,
communicating knowledgeably and professionally, making suggestions and
decisions as appropriate and completing the work accurately.

Above Average

The student professionally completes required elements of the assignment

accurately and independently.

Minimum Standards

The student completes the required elements of the assignment at the level
of a novice planner, with some occasional supervision from the CMD.

Performance 1 Initialization of Planning Process

Excellent

Above Average
5
4

Minimum Standards
3

to be completed by physician

A. Establishes Professional Communication with the Physician.

B. Acquires Images and Completes Contouring as Directed.

owing specific request.

Performance 2 Treatment Planning

Excellent

Above Average
5
4

Minimum Standards
3

to be completed by CMD

A. Creates the Treatment Plan including Reference Points

and Establishes the Plan Normalization Techniques.

B. Generates the Beam Arrangement.

C. Determines Appropriate Types and Use of

Beam Modification Devices

D. Performs the Dose Calculation Appropriately

E. Demonstrates Time Management Skills

Performance 3 Plan Evaluations / Approvals

Excellent

Above Average Minimum Standards

5
4
3

to be completed by physician or CMD

A. Performs the Initial Plan Evaluation with the Physician.

The treatment plan requires additional planning

due to: ___________________________.
Any requested plan revisions are made as directed.

B. Verifies the Dose Constraints by DVH.

C. Final Evaluation and Plan Approval Completed. Date: _______________

Performance 4 Chart Documentation (EMR)

Excellent

Above Average
5
4

Minimum Standards
3

to be completed by CMD or by ABR certified physicist.

A. Verifies the Monitor Unit Calculation.

B. Completion of RT Chart, Patient Manager

& Paper Documentation

C. Billing Procedures Completed Correctly

Signatures and Comments:

_____________________________
CMD signature / date

___________________________________________________
___________________________________________________

_____________________________
ABR physicist signature/date

___________________________________________________
___________________________________________________

_____________________________
Physician signature / date

___________________________________________________
___________________________________________________

_____________________________
Student signature / date

___________________________________________________
___________________________________________________

___________________________________
Marvene M. Ewing, CMD Clinical Instructor

Scoring:
Must Repeat Test Out:

____________________
Score

55 60 points (A)
50 54 points (B)
< 50 points

Graduate Medical Dosimetry Certificate

Indiana University School of Medicine
IU Department of Radiation Oncology
RAON D704
Clinical Practicum IV Assessment Challenges in Medical Dosimetry
Assessment #3
Intensity Modulated Radiotherapy with Stationary Fields
Plan Assigned: Prostate Head/Neck
Date Assigned: _________________

Date Completed: ___________________

Student Name: ____________________________

Physician: _________________________

Performance Assessment
Excellent

The student exhibits skills and qualities much like an experienced dosimetrist,
communicating knowledgeably and professionally, making suggestions and
decisions as appropriate and completing the work accurately.

Above Average

The student professionally completes required elements of the assignment

accurately and independently.

Minimum Standards

The student completes the required elements of the assignment at the level
of a novice planner, with some occasional supervision from the CMD.

Performance 1 Initialization of Planning Process

Excellent

Above Average
5
4

Minimum Standards
3

to be completed by physician

A. Establishes Professional Communication with the Physician.

B. Acquires Images and Completes Contouring as Directed.

est.

Performance 2 Treatment Planning

Excellent

Above Average
5
4

Minimum Standards
3

to be completed by CMD

A. Creates the Treatment Plan including Reference Points

and Establishes the Plan Normalization Techniques.

B. Generates Appropriate Beam Arrangement.

C. Performs the Plan Optimization, Determines Dose

Constraints, Optimization Limits and Priorities.

D. Performs the Dose Calculation Appropriately

E. Demonstrates Time Management Skills

Performance 3 Plan Evaluations / Approvals

Excellent
5

Above Average
4

Minimum Standards
3

to be completed by physician

A. Performs the Initial Plan Evaluation with the Physician.

The treatment plan requires additional planning

due to: ___________________________.

Any requested plan revisions are made as directed.

B. Verifies the Dose Constraints by DVH.

C. Final Evaluation and Plan Approval Completed. Date: __________________

Performance 4 Chart Documentation (EMR)

Excellent

Above Average Minimum Standards

5
4
3

to be completed by ABR certified physicist.

A. Verifies the Monitor Unit Calculation.

B. Completion of RT Chart, Patient Manager

& Paper Documentation

C. Billing Procedures Completed Correctly

Performance 5 Quality Assurance

Excellent

Above Average Minimum Standards

5
4
3

to be completed by ABR certified physicist.

A. Creates the QA Plan for Quality Assurance Procedures.

B. Performs QA Measurements and Evaluation with the

ABR certified physicist.

Signatures and Comments:

_______________________
Physician signature / date

___________________________________________________
___________________________________________________

_____________________________
Student signature / date

___________________________________________________
___________________________________________________

_____________________________
CMD signature / date

___________________________________________________
___________________________________________________

_____________________________
ABR physicist signature/date

___________________________________________________
___________________________________________________
___________________________________________________

___________________________________
Marvene M. Ewing, CMD Clinical Instructor

Scoring:

64 70 points (A)
58 63 points (B)
Must Repeat Test Out:

____________________
Score

< 58 points

Graduate Medical Dosimetry Certificate

Indiana University School of Medicine
IU Department of Radiation Oncology
RAON D704
Clinical Practicum IV Assessment Challenges in Medical Dosimetry
Assessment #4
Stereotactic Body Radiation Therapy Treatment Planning
Plan Assigned: IU Health - University

IU Health - Methodist

Date Assigned: _________________

Date Completed: ___________________

Student Name: ____________________________

Physician: _________________________

Performance Assessment
Excellent

The student exhibits skills and qualities much like an experienced dosimetrist,
communicating knowledgeably and professionally, making suggestions and
decisions as appropriate and completing the work accurately.

Above Average

The student professionally completes required elements of the assignment

accurately and independently.

Minimum Standards

The student completes the required elements of the assignment at the level
of a novice planner, with supervision from the CMD or ABR physicist.

Performance 1 Initialization of Planning Process

Excellent

Above Average
5
4

Minimum Standards
3

to be completed by physician

A. Establishes Professional Communication with the Physician.

B. Acquires Images and Completes Contouring as Directed.

owing specific request.

Performance 2 Treatment Planning

Excellent

Above Average
5
4

Minimum Standards
3

to be completed by CMD

A. Creates the Treatment Plan including Reference Points

and follows SBRT Plan Normalization requirements.

B. Generates Appropriate Beam Arrangement

Beam template checked by physics: _____

C. Uses Available Tools to Perfect the Dose Distribution
Field in Field versus Inverse Planning: _____
E. Demonstrates Time Management Skills

Performance 3 Plan Evaluations / Approvals

Excellent

Above Average
5

Minimum Standards
4
3

to be completed by physician

A. Performs the Initial Plan Evaluation with the Physician.

The treatment plan requires additional planning

due to: ___________________________.
Any requested plan revisions are made as directed.
B. Verifies the Normal Tissue Dose Constraints by DVH.
a) Constraints from Protocol __________
b) Constraints from Timmerman ____ fx
c) Constraints (other) _______________

C. Final Evaluation and Plan Approval Completed. Date: ____________________

Performance 4 Chart Documentation (EMR)

Excellent

Above Average
5
4

Minimum Standards
3

to be completed by ABR certified physicist.

A. Verifies the Monitor Unit Calculation.

B. Completion of RT Chart, Patient Manager

& Paper Documentation

C. Billing Procedures Completed Correctly

Performance 5 Treatment Delivery QA

Excellent

Above Average Minimum Standards

5
4
3

to be completed by ABR certified physicist.

A. Verifies patient setup and beam delivery for

Fraction #1 of treatment.

Signatures and Comments:

_____________________________
CMD signature / date

___________________________________________________
___________________________________________________

_____________________________
ABR physicist signature/date

___________________________________________________
___________________________________________________

_____________________________
Physician signature / date

___________________________________________________
___________________________________________________

_____________________________
Student signature / date

___________________________________________________
___________________________________________________

___________________________________
Marvene M. Ewing, CMD Clinical Instructor

Scoring:

____________________
Score

55 60 points (A)

50 54 points (B)
Must Repeat Test Out:

< 50 points

Graduate Medical Dosimetry Certificate

Indiana University School of Medicine
IU Department of Radiation Oncology
RAON D704
Clinical Practicum IV Assessment Challenges in Medical Dosimetry
Assessment #5
HDR Brachytherapy Treatment Planning
Plan Assigned: HDR: GYN
Date Assigned: _________________

Date Completed: ____________________

Student Name: ____________________________

Physician: __________________________

Performance Assessment
Excellent

The student exhibits skills and qualities much like an experienced dosimetrist,
communicating knowledgeably and professionally, making suggestions and
decisions as appropriate and completing the work accurately.

Above Average

The student professionally completes required elements of the assignment

accurately and independently.

Minimum Standards

The student completes the required elements of the assignment at the level
of a novice planner, with supervision from the CMD or ABR physicist.

Performance 1 Initialization of Planning Process

Excellent

Above Average
5
4

Minimum Standards
3

to be completed by physicist

A. Establishes Professional Communication with the Physician.

B. Evaluates the Imaging for Localization of Sources

owing specific request.

Performance 2 Treatment Planning

Excellent

Above Average
5
4

Minimum Standards
3

To be completed by ABR physicist

A. Understands the Written Directive

B. Inputs Imaging Data and Isotope Data into the TPS

C. Locates and Places Classic Calculation Points for GYN

D. Locates and Places Points for OAR

E. Generates the Treatment Plan with Isodose Curves &

Point Calculations

Performance 3 Plan Evaluations / Approvals

Excellent

Above Average
5
4

Minimum Standards
3

to be completed by physician

A. Performs the Initial Plan Evaluation with the Physician.

The treatment plan requires additional planning

due to: ___________________________.
Any requested plan revisions are made as directed.

10

B. Final Evaluation and Plan Approval Completed

Performance 4 Chart Documentation (EMR)

Excellent

Above Average
Minimum Standards
5
4
3

to be completed by ABR certified physicist

A. Uses manual calculation to verify doses to all

calculation points on the plan.

B. Patient manager documentation complete.

Understands correct billing processes.

Performance 6 Treatment Quality Assurance & Delivery

Excellent

Above Average
Minimum Standards
5
4
3

to be completed by ABR certified physicist.

A. Assists with Quality Assurance procedures prior to

treatment.

B. Is present for patient set up and treatment delivery.

a) Assists with any preparations at treatment console.
b) Observes and assists patient treatment.

Signatures & Comment :

_____________________________
CMD signature / date

___________________________________________________
___________________________________________________

_____________________________
ABR physicist signature/date

___________________________________________________
___________________________________________________

_____________________________
Physician signature / date

___________________________________________________
___________________________________________________

_____________________________
Student signature / date

___________________________________________________
___________________________________________________

___________________________________
Marvene M. Ewing, CMD Clinical Instructor

Scoring:
Must Repeat Test Out:

____________________
Score

59 65 points (A)
52 58 points (B)
< 52 points

11

Graduate Medical Dosimetry Certificate

Indiana University School of Medicine
IU Department of Radiation Oncology
RAON D704
Clinical Practicum IV Assessment Challenges in Medical Dosimetry
Assessment #6
Intensity Modulated V-Mat (Rapid Arc)
Plan Assigned: Prostate Head/Neck

Pelvis & Groin

Date Assigned: _________________

Date Completed: ___________________

Student Name: ____________________________

Physician: _________________________

Performance Assessment
Excellent

The student exhibits skills and qualities much like an experienced dosimetrist,
communicating knowledgeably and professionally, making suggestions and
decisions as appropriate and completing the work accurately.

Above Average

The student professionally completes required elements of the assignment

accurately and independently.

Minimum Standards

The student completes the required elements of the assignment at the level
of a novice planner, with some occasional supervision from the CMD.

Performance 1 Initialization of Planning Process

Excellent

Above Average
5
4

Minimum Standards
3

to be completed by physician

A. Establishes Professional Communication with the Physician.

B. Acquires Images and Completes Contouring as Directed.

All overlapping contours are cropped for optimization.

est.

Performance 2 Treatment Planning

Excellent

Above Average
5
4

Minimum Standards
3

to be completed by CMD

A. Creates the Treatment Plan including Reference Points

and Establishes the Plan Normalization Techniques.

B. Creates Appropriate Beam & Arc angles.

C. Performs the V-Mat Optimization, Determines Dose

Constraints, Optimization Limits and Priorities.

D. Performs the Dose Calculation Appropriately

E. Demonstrates Time Management Skills

Performance 3 Plan Evaluations / Approvals

Excellent
5

Above Average
4

Minimum Standards
3

to be completed by physician

A. Performs the Initial Plan Evaluation with the Physician.

The treatment plan requires additional planning

due to: ___________________________.

12

Any requested plan revisions are made as directed.

B. Verifies the Dose Constraints by DVH.

C. Final Evaluation and Plan Approval Completed. Date: __________________

Performance 4 Chart Documentation (EMR)

Excellent

Above Average Minimum Standards

5
4
3

to be completed by ABR certified physicist.

A. Verifies the Monitor Unit Calculation.

B. Completion of RT Chart, Patient Manager

& Paper Documentation

C. Billing Procedures Completed Correctly

Performance 5 Quality Assurance

Excellent

Above Average Minimum Standards

5
4
3

to be completed by ABR certified physicist.

A. Creates the QA Plan for Quality Assurance Procedures.

B. Performs QA Measurements and Evaluation with the

ABR certified physicist.

Signatures and Comments:

_____________________________
CMD signature / date

___________________________________________________
___________________________________________________

_____________________________
ABR physicist signature/date

___________________________________________________
___________________________________________________

_____________________________
Physician signature / date

___________________________________________________
___________________________________________________

_____________________________
Student signature / date

___________________________________________________
___________________________________________________

___________________________________
Marvene M. Ewing, CMD Clinical Instructor

Scoring:

64 70 points (A)
58 63 points (B)
Must Repeat Test Out:

____________________
Score

< 58 points

13

RAON D704 Summer Session I

Clinical Practicum IV Competencies 2016
Competency

Points Available

#1

CT based Complex 2D or Conventional 3D Planning

50 points

#2

3DCRT Conformal Radiotherapy

60 points

#3

IMRT Stationary Fields

70 points

#4

SBRT Stereotactic Body Radiotherapy

60 points

#5

Brachytherapy GYN

65 points

#6

VMAT dynamic arc therapy

70 points

Total Points Possible:

350 375
340 349
330 339
310 329
300 309

Points Earned

375 points

A
AB+
B
B-

14