Name (Block Letters) (In Chinese) (HKID No.)

Transcription

1 Undertaking in respect of Patient Management in Name (Block Letters) (In Chinese) (HKID No.) 1. I have read the Protocol for Patient Management in ( Protocol ) and Guidelines of management of patient with radioactive implant at HKSH ( Guidelines ). 2. I agree to abide by the Protocol as stipulated in particular to the following: i. All consent forms shall be explained and signed by the clinical oncologist together with the patient. ii. All treatment plans must be approved, signed and dated by the clinical oncologist with the dose prescription clearly written on the treatment record. If the approval or prescription is sent to the by fax or , the original must be received by the within 24 hours. iii. All radiation doses from previous radiotherapy treatment (if any) shall be documented and reviewed before treatment. iv. All planning simulator films/images must be signed and dated by the clinical oncologist before treatment. v. All treatment verification films/images of first treatment shall be signed and dated by the clinical oncologist within the first week of treatment. 3. I agree, as the referring doctor, to abide by the Guidelines as stipulated in particular to the following: i. The referring doctor should provide full details of radioactive implant. ii. Patient can only be admitted to radiation isolation ward. iii. The referring doctor is responsible for taking out the radioactive Implant from the deceased body in case the patient dies at HKSH. iv. The Consent for Admission of Patient with Radioactive Implant form must be signed by the referring doctor, the patient and the patient relative before admission. Signature : Date : Page 1 of 1 MAN.108.H/E Undertaking in respect of Patient Management in 香港跑馬地山村道二號 2 Village Road, Happy Valley, Hong Kong Tel: Fax: Website :

2 Hong Kong Sanatorium & Hospital Protocol for Patient Management in Patient Appointment 1. All appointment requests received before 18:30 (Mon-Fri) or 13:00 (Sat) will be processed on the same business day. 2. All appointment date and time shall be assigned by our department. No guarantee of requested date and time. Specific date and time requested may be considered on a case by case basis. 3. "Radiotherapy Request & Payment Estimation Form" (appendix 1) and "RT CT Planning Request Form (No Film & Report)" (appendix 2) must be completed before appointment could be assigned. Patient Consent 1. The "Consent for Radiotherapy" form (appendix 3) shall be signed and received prior to any treatment planning procedures. If the consent form is sent to us by fax or , the original must be received by us within 24 hours. 2. If there is any specific consent (appendix 4) needed after reviewing the computer plan, patient must sign the relevant specific consent before treatment. 3. All consent forms shall be explained and signed by the clinical oncologist together with the patient and a witness. i. Doctors are strongly advised to sign the consent form in the presence of the patient and the witness (if any) at the same time before the procedure, as required by the Code of Professional Conduct set out by the Medical Council. II. A witness to the process of signing consent can be a staff member of the Hospital/ the Doctor's clinic or a third party such as the patient's next-of-kin. iii. It is a good practice to have a witness to the process of signing informed consent in major or high risk procedures, when the patient has underlying disease(s) which may increase the procedural risk, as well as when patients cannot sign and his/her thumbprints are taken to indicate his/her consent. IV. If a witness is present, the witness has no legal responsibility for the content of the information given. 4. Treatment program would not be initiated if the consent form is not available or incomplete. Protocol for Patient Management in Page 1 of 2 Approved by HMC: 09/2018

3 Radiotherapv Treatment Plan and Prescription 1. All treatment plans must be approved, Signed and dated by the clinical oncologist with the dose prescription clearly written on the treatment record. If the approval or prescription is sent to us by fax or , the original must be received by us within 24 hours. 2. All radiation doses from previous radiotherapy treatment (if any) shall be documented and reviewed before treatment. 3. Treatment cannot start if any treatment plan or prescription or previous radiotherapy treatment record is missing or incomplete. Radiotherapy Treatment Verification 1. All planning simulator films/images must be signed and dated by the clinical oncologist before treatment. 2. If the approvals for planning simulator films/images are sent to us by fax or , the original film/images must be signed and dated within 24 hours of the approval. 3. All treatment verification films/images of the first fraction shall be signed and dated by the clinical oncologist within the first week of treatment. Dr. TSAO Yen Chow Chairman, HKSH Management Committee Protocol for Patient Management in Page 2 of 2 Approved by HMC: 09/2018

4 日期 Consultation Date: 診斷 Diagnosis: 治療位置 1 Treatment Site 1: 治療位置 2 Treatment Site 2: 治療位置 3 Treatment Site 3: 通知及收費評估表 Radiotherapy Request & Payment Estimation Form 組織報告 : Histology Report: 是 Yes 否 No 曾接受放射治療? Any Previous Radiotherapy Treatment? 是 Yes / 否 No Treated region 擬定設計日期 Requested Planning Date: 擬定治療日期 Requested Treatment Date: 治療方案 Treatment Plan: CHEMO RT : YES ( ) HRS / NO Phase I 第一期 : 醫生費 Doctor s Professional Fee: 定位 Simulation: 治療用具 Treatment Devices: 治療技術 Technique: Attend Simulation CT (plain / contrast / both) / Conventional S / L Thermocast / Body Fix / Vac-lok / Breast Board / Prone Breast Board/ 0.5cm or 1cm Superflab / GTC / Tongue depressor 2D / 3D / 4DCT / ABC / Clarity / Cyberknife / IMRT / SBRT / SRT / SRS / tomo / VMAT 其他影像融合 Other Image Fusion: PET-CT / PET-MR / MRI / CT / RT-MRI Exam Date: (dd/mm/yy) 照射野數量 No. of Fields: (Dose/fr: ) 治療次數 No. of Fractions: Phase II 第二期 : 醫生費 Doctor s Professional Fee: 定位 / 電腦掃描 Additional Simulation/CT: Yes / No 治療技術 Technique: CT (plain / contrast / both) Attend Simulation 2D / 3D / 4DCT / ABC / Clarity / Cyberknife / IMRT / SBRT / SRT / SRS / tomo / VMAT 其他影像融合 Other Image Fusion: PET-CT / PET-MR / MRI / CT / RT-MRI Exam Date: (dd/mm/yy) 照射野數量 No. of Fields: (Dose/fr: ) 治療次數 No. of Fractions: 醫生簽署 Doctor s Signature 醫生姓名 Doctor s Name 日期 Date ( 日 / 月 / 年 )(dd/mm/yy) 預計部門總額 Estimated Department Total Charges: 備註 Remarks: 1. 此價錢只適用於門診或普通病房病人 The specified estimated price is only applicable to out-patient or general ward patient. 2. 如日後醫生因應需要更改治療計劃, 價錢或有所不同 本部會盡快通知, 並重新報價 If there is a necessary change in the treatment plan, the patient will be informed as soon as possible of the new estimated charge if applicable 3. 所有費用一經繳交, 恕不退還 All payments are non-refundable 預計等候時間 ( 星期 ): Estimated Waiting Time (week): 預計全期醫生費 : Estimated Total Dr s Professional Fee: $ 預計收費 : Estimated fee for RT Dept.: $ 預計總額 : Estimated Total Charges: $ 病人簽署 Patient s Signature 家屬簽署 Relative s Signature 放射治療師簽署 Radiation Therapist s Signature 病人姓名 Patient s Name 病人家屬姓名 Name of Patient s Relative 放射治療師姓名 Radiation Therapist s Name 身份證 / 護照號碼 ID/Passport Number 日期 ( 日 / 月 / 年 ) Date (dd/mm/yy) RAD /B 日期 ( 日 / 月 / 年 ) Date (dd/mm/yy) 關係 Relationship 日期 ( 日 / 月 / 年 ) Date (dd/mm/yy) Tel.: Fax: 通知及收費評估表 Radiotherapy Request & Payment Estimation Form

5 RT CT Planning Request Form (No Film & Report) 1. Clinical Data & Diagnosis RT Machine Use: Linear Accelerator Tomo / Radixact Cyberknife Others Diagnosis: 2. Specify Scan Region for Planning NO FILM & REPORT ( 請提示病人帶回舊片以作比較 Please remind patient to bring all diagnostic films for reference use) Head (vertex to chin) Other Regions Neck (C1 to carina) Pre-RT Dental Check (for H&N case only): 1) (region) to (region) Thorax (C3 to L3) N/A / Done / Arranged 2) (region) to (region) Abdomen (T8 to lower Sl joint) 3) (region) to (region) Pelvis (L3 to perineum+5cm) 3. CT Scan Request *Standard Volume of Ultravist 370 to be injected (ml): Plain study only Special instructions before CT Head (vertex to chin) 45 Contrast study only Fast hours before CT Neck (C1 to carina) 65 I.V contrast* Oral contrast Empty bowel before CT Thorax (C3 to L3) 75 Plain & contrast studies Full / empty / normal bladder before CT Abdomen (T8 to lower SI joint) 85 I.V contrast* Oral contrast Foley size Balloon Size Pelvis (L3 to perineum + 5cm) 85 4DCT Endorectal index Balloon Size Others please specify vol to be injected: ml 4. Special Precautions for Contrast CT (Must be completed) NO pre-med required Body Weight: (kg) (A) For patients with history of major Drugs or Food Allergy, Asthma, Hay Fever, Allergic Rhinitis, any present or previous Skin Allergy/ Urticaria *Please prescribe the most suitable and convenient corticosteroid and/or anti-histamine for your patient 1. Hydrocortisone 100mg (ivi) at 12 hours before examination (dilute in 2ml water for injection) another Hydrocortisone 100mg (ivi) at 6 hours before examination, then another Hydrocortisone 100mg (ivi) at 2 hours before examination OR 2. Prednisolone 40mg (po) at 9 pm before the day of examination, and Prednisolone 40mg (po) in the morning at least 2 hours before examination OR 3. Hydrocortisone 100mg (ivi) STAT to scan (dilute in 2ml water for injection) AND/OR 4. Piriton mg (ivi) STAT to scan (B) For patients age 60 years old OR taking Metformin/ Glucophage/ Galvus met OR suffering from Renal impairment disease, please provide RFT within 1 year Creatinine: (Normal: M: umol/l or mg/dl; F: umol/l or mg/dl) Urea: (Normal: mmol/l or mg/dl) Date of Report: / / (dd/mm/yy) (C) For patients under treatment of Metformin/ Glucophage/ Galvus met *Please instruct the most suitable preparation for your patient For normal RFT: withhold Metformin on scan date, withhold 48 hours & re-hydration after scan For impaired RFT: consult physician for medical advice, withhold Metformin for 48 hrs before & after, reassess RFT before restarting Metformin Prescribed by: Doctor s Signature: Doctor s Name: Date: (dd/mm/yy) (For Nurses use) Date/Time: (For Dept. use ) Contrast Injection Drug Name Label Checked by: Given by: Date: / / (dd/mm/yy) Monitored by Dr.: Given by: Date of Exam: / / (dd/mm/yy) Exam No.: Checked by: Flow rate: ml/sec Vol given: ml Time CT Machine Serial No.: No. of Films: Radiation Therapist s Names: / RAD /E Tel.: Fax: RT CT Planning Request Form (No Film & Report)

6 放射治療同意書 Consent for Radiotherapy 簽署本同意書人士 PERSON(S) SIGNING THIS CONSENT FORM 病人姓名載於本同意書右上角 The Patient is named at the top right corner of this form. 簽署本同意書人士為 :( 請於適當方格填上 號 )The person(s) signing this form is/are: (Please the appropriate box.) 病人本人 Patient 病人家屬 / 監護人 Patient s relative / guardian 正楷姓名 Name in Block Letters: 病人未到法定年齡 Patient is a minor 病人未能簽名, 原因 : Patient is incapable of signing because: 1. 本人同意貴院為本人 / 病人施行放射治療, 包括 X 射線, 伽瑪射線, 電子及放射性同位素於以下部位及內服或注射其有關藥物 I hereby voluntarily give consent for myself / the Patient to undergo treatment to the region stated below by the which may include the use of X-rays, Gamma rays, Electrons and Radioisotopes and any medicines which may be given by mouth or injection in connection with radiotherapy : 2. 本人了解該項治療可能引致全身或局部反應, 包括但不限於 : I understand that this type of treatment may produce general and/or local side effects, including but not limited to: 3. 本人且同意養和醫院有關之醫生有權對本人 / 病人決定治療的性質及所需療程 I agree that the nature of the therapy and the duration of the course of treatment are to be determined by the attending doctor. 4. 本人經已深切了解亦同意養和醫院有關之醫生及職員有權施行上述之治療 有關之醫生及職員無須承擔因此治療所引致的任何後果 I hereby release Hong Kong Sanatorium & Hospital, the doctor and the staff from all responsibilities concerning the effects of radiation, and accept treatment with full knowledge of the possible results. 病人簽署 Patient s Signature 家屬 / 監護人簽署 Relative/Guardian s Signature 見證人簽署 Witness Signature 關係 : Relationship : ID/ Passport No.: 見證人姓名 : Witness Name: ID/ Passport No.: 醫生聲明..本人已向上述之簽署者解釋是項治療的性質 風險及效益, 並已解答其提出的有關問題 據本人所理解, 上述之簽署者已獲得充分的資料及已簽妥同意書, 而這些資料亦已記錄在病人的病歷內 DOCTOR S DECLARATION: I have explained the nature, risks and benefits of the treatment to the above signatory(ies) and have answered the questions asked by the above signatory(ies). To the best of my knowledge, the above signatory(ies) has /have been adequately informed and has/have consented, and the details as such had been documented in the Patient s clinical record. 醫生簽署 Doctor s Signature 醫生姓名 Doctor s Name 日期 ( 日 / 月 / 年 ) Date (dd/mm/yy) 翻譯員解釋建議的治療程序 ( 如適用 ) Explanation of the proposed treatment by Interpreter (if applicable) 本人已向簽署者如實及清楚地將此同意書的內容翻譯成 I,, certify that I have truly, distinctly and audibly interpreted the contents of this document into ( 語言或方言 ) (insert language or dialect) to the above signatory(ies). 翻譯員簽署 Interpreter s Signature 翻譯員姓名 Interpreter s Name 日期 ( 日 / 月 / 年 )Date (dd/mm/yy) RAD /B 放射治療同意書 Consent for Radiotherapy

7 再次接受放射治療同意書 Consent for Another Course of Radiotherapy 簽署本同意書人士 PERSON(S) SIGNING THIS CONSENT FORM 病人姓名載於本同意書右上角 The Patient is named at the top right corner of this form. 簽署本同意書人士為 :( 請於適當方格填上 號 )The person(s) signing this form is/are: (Please the appropriate box.) 病人本人 Patient 病人家屬 / 監護人 Patient s relative / guardian 正楷姓名 Name in Block Letters: 病人未到法定年齡 Patient is a minor 病人未能簽名, 原因 : Patient is incapable of signing because: 1. 本人同意貴院為本人 / 病人再次施行放射治療於本人 / 病人以下部位, 所能有之危險已向本人解釋清楚及明白 I hereby voluntarily give consent for myself / the Patient to undergo another treatment course by the Department of Radiotherapy in the region stated below. I have been duly informed of the risks in connection with the administration of additional radiation treatment. 2. 前此接受之放射治療已限制本人 / 病人身體組織對於再次接受放射治療之抵受力, 故此次建議之放射治療導致組織損傷之可能性有所增加 The previously administered radiation therapy has limited the tolerance of my/the Patient s tissue to additional radiation treatment. There is an increased possibility of tissue damage which may result from the proposed radiation treatment. 3. 本人經已深切了解亦同意養和醫院有關之醫生及職員有權施行上述之治療 有關之醫生及職員無須承擔因此治療所引致的任何後果 I hereby release Hong Kong Sanatorium & Hospital, the doctor and the staff from all responsibilities concerning the effects of radiation, and accept treatment with full knowledge of the possible results. 病人簽署 Patient s Signature 家屬 / 監護人簽署 Relative/Guardian s Signature 見證人簽署 Witness Signature 關係 : Relationship : ID/ Passport No.: 見證人姓名 : Witness Name: ID/ Passport No.: 醫生聲明..本人已向上述之簽署者解釋是項治療的性質 風險及效益, 並已解答其提出的有關問題 據本人所理解, 上述之簽署者已獲得充分的資料及已簽妥同意書, 而這些資料亦已記錄在病人的病歷內 DOCTOR S DECLARATION: I have explained the nature, risks and benefits of the treatment to the above signatory(ies) and have answered the questions asked by the above signatory(ies). To the best of my knowledge, the above signatory(ies) has /have been adequately informed and has/have consented, and the details as such had been documented in the Patient s clinical record. 醫生簽署 Doctor s Signature 醫生姓名 Doctor s Name 日期 ( 日 / 月 / 年 ) Date (dd/mm/yy) 翻譯員解釋建議的治療程序 ( 如適用 ) Explanation of the proposed treatment by Interpreter (if applicable) 本人已向簽署者如實及清楚地將此同意書的內容翻譯成 I,, certify that I have truly, distinctly and audibly interpreted the contents of this document into ( 語言或方言 ) (insert language or dialect) to the above signatory(ies). 翻譯員簽署 Interpreter s Signature 翻譯員姓名 Interpreter s Name 日期 ( 日 / 月 / 年 )Date (dd/mm/yy) RAD /B 再次接受放射治療同意書 Consent for Another Course of Radiotherapy

8 放射治療同意書 ( 眼 / 晶體 ) Consent for Radiotherapy(Eye/Lens) 簽署本同意書人士 PERSON(S) SIGNING THIS CONSENT FORM 病人姓名載於本同意書右上角 The Patient is named at the top right corner of this form. 簽署本同意書人士為 :( 請於適當方格填上 號 )The person(s) signing this form is/are: (Please the appropriate box.) 病人本人 Patient 病人家屬 / 監護人 Patient s relative / guardian 正楷姓名 Name in Block Letters: 病人未到法定年齡 Patient is a minor 病人未能簽名, 原因 : Patient is incapable of signing because: 1. 本人同意貴院為本人 / 病人施行放射治療, 包括 X 射線, 伽瑪射線, 電子及放射性同位素於本人 / 病人之眼部或附近部位 I hereby voluntarily give consent for myself / the Patient to undergo treatment by the which may include the use of X-rays, Gamma rays, Electrons and Radioisotopes treatments near or to my/the Patient s Left/ Right Eye(s)/ Lens(es). 2. 本人明瞭治療可能導致本人 / 病人左 / 右眼 / 晶體永久性失明, 有關之醫生已向本人解釋, 本人 / 病人之眼部 / 晶體不可能完全避免輻射 I am aware that the treatment may permanently cause loss of eyesight. The doctor has explained to me that the radiation to my / the Patient s Left/ Right Eye(s)/ Lens(es) cannot be completely avoided. 3. 本人經已深切了解亦同意本人 / 病人接受治療, 養和醫院有關之醫生及職員對本人 / 病人之眼部 / 晶體損壞無須承擔一切後果 I hereby release Hong Kong Sanatorium & Hospital, the doctor and the staff from all responsibilities concerning damage to my/ the Patient s Left/ Right Eye(s)/ Lens(es) and accept treatment with full knowledge of the complications which may result. 病人簽署 Patient s Signature 家屬 / 監護人簽署 Relative/Guardian s Signature 見證人簽署 Witness Signature 關係 : Relationship : ID/ Passport No.: 見證人姓名 : Witness Name: ID/ Passport No.: 醫生聲明..本人已向上述之簽署者解釋是項治療的性質 風險及效益, 並已解答其提出的有關問題 據本人所理解, 上述之簽署者已獲得充分的資料及已簽妥同意書, 而這些資料亦已記錄在病人的病歷內 DOCTOR S DECLARATION: I have explained the nature, risks and benefits of the treatment to the above signatory(ies) and have answered the questions asked by the above signatory(ies). To the best of my knowledge, the above signatory(ies) has /have been adequately informed and has/have consented, and the details as such had been documented in the Patient s clinical record. 醫生簽署 Doctor s Signature 醫生姓名 Doctor s Name 日期 ( 日 / 月 / 年 ) Date (dd/mm/yy) 翻譯員解釋建議的治療程序 ( 如適用 ) Explanation of the proposed treatment by Interpreter (if applicable) 本人已向簽署者如實及清楚地將此同意書的內容翻譯成 I,, certify that I have truly, distinctly and audibly interpreted the contents of this document into ( 語言或方言 ) (insert language or dialect) to the above signatory(ies). 翻譯員簽署 Interpreter s Signature 翻譯員姓名 Interpreter s Name 日期 ( 日 / 月 / 年 )Date (dd/mm/yy) RAD /B 放射治療同意書 ( 眼 / 晶體 ) Consent for Radiotherapy(Eye/Lens)

9 放射治療同意書 ( 卵巢 / 睪丸 ) Consent for Radiotherapy (Ovaries/Testes) 簽署本同意書人士 PERSON(S) SIGNING THIS CONSENT FORM 病人姓名載於本同意書右上角 The Patient is named at the top right corner of this form. 簽署本同意書人士為 :( 請於適當方格填上 號 )The person(s) signing this form is/are: (Please the appropriate box.) 病人本人 Patient 病人家屬 / 監護人 Patient s relative / guardian 正楷姓名 Name in Block Letters: 病人未到法定年齡 Patient is a minor 病人未能簽名, 原因 : Patient is incapable of signing because: 1. 本人同意貴院為本人 / 病人施行放射治療, 包括 X 射線, 伽瑪射線, 電子及放射性同位素於本人 / 病人之卵巢 / 睪丸或附近部位 I hereby voluntarily give consent for myself / the Patient to undergo treatment by the which may include the use of X-rays, Gamma rays, Electrons and Radioisotopes treatments near or to my/the Patient s Ovaries/Testes. 2. 本人明瞭治療可能導致本人 / 病人從此永久不能生育 有關之醫生已向本人解釋, 本人 / 病人之卵巢 / 睪丸不可能完全避免輻射 I am aware that the treatment may cause permanent sterility. The doctor has explained to me that the radiation to my / the Patient s Ovaries/Testes cannot be completely avoided. 3. 本人經已深切了解亦同意本人 / 病人接受治療, 養和醫院有關之醫生及職員對本人 / 病人之卵巢 / 睪丸損壞無須承擔一切後果 I hereby release Hong Kong Sanatorium & Hospital, the doctor and the staff from all responsibilities concerning damage to my/the Patient s Ovaries/Testes and accept treatment with full knowledge of the complications which may result. 病人簽署 Patient s Signature 家屬 / 監護人簽署 Relative/Guardian s Signature 見證人簽署 Witness Signature 關係 : Relationship : ID/ Passport No.: 見證人姓名 : Witness Name: ID/ Passport No.: 醫生聲明..本人已向上述之簽署者解釋是項治療的性質 風險及效益, 並已解答其提出的有關問題 據本人所理解, 上述之簽署者已獲得充分的資料及已簽妥同意書, 而這些資料亦已記錄在病人的病歷內 DOCTOR S DECLARATION: I have explained the nature, risks and benefits of the treatment to the above signatory(ies) and have answered the questions asked by the above signatory(ies). To the best of my knowledge, the above signatory(ies) has /have been adequately informed and has/have consented, and the details as such had been documented in the Patient s clinical record. 醫生簽署 Doctor s Signature 醫生姓名 Doctor s Name 日期 ( 日 / 月 / 年 ) Date (dd/mm/yy) 翻譯員解釋建議的治療程序 ( 如適用 ) Explanation of the proposed treatment by Interpreter (if applicable) 本人已向簽署者如實及清楚地將此同意書的內容翻譯成 I,, certify that I have truly, distinctly and audibly interpreted the contents of this document into ( 語言或方言 ) (insert language or dialect) to the above signatory(ies). 翻譯員簽署 Interpreter s Signature 翻譯員姓名 Interpreter s Name 日期 ( 日 / 月 / 年 )Date (dd/mm/yy) RAD /B 放射治療同意書 ( 卵巢 / 睪丸 ) Consent for Radiotherapy(Ovaries/Testes)