Radioiodine Therapy Outpatient Worksheet
| Patient's Name Patient ID Number | ||
| 1. Will the administered activity of 131I exceed 33 mCi? | ||
| No | → | The patient may be treated as an outpatient. Ensure that written and oral patient instructions are provided, and a written directive completed. |
| Yes | → | The patient may require hospitalization for treatment. Continue to Item 2. |
| 2. Determine if the following criteria apply: | ||
| Yes | No | |
| □ | □ | The patient will maintain a prudent distance from others for at least the first 2 days. |
| □ | □ | The patient will sleep alone in a room for at least the first night. |
| □ | □ | The patient will not travel by airplane or mass transportation for at least the first day. |
| □ | □ | The patient will not travel on a prolonged automobile trip with others for at least the first 2 days. |
| □ | □ | The patient will have sole use of a bathroom for at least the first 2 days. |
| □ | □ | The patient will drink plenty of fluids for at least the first 2 days. |
| 3. If the answer is No to any one or more of the criteria in Item 2 above, the patient must be hospitalized for treatment if the administered activity exceeds 33 mCi 131I. | ||
| 4. If the answer is Yes to all of the criteria in Item 2, perform the necessary calculations in Item 5, below, to determine whether the patient can be released immediately in accordance with NRC Regulatory Guide 8.39, Appendix B, as discussed below. | ||
| 5. Patient-specific dose calculations (Check 1 of the 3 boxes, whichever applies, and calculate D). | ||
| □ For Na131I treatment of a patient post-thyroidectomy for thyroid cancer: | ||
| D (mrem) = 2.27 Qo = ________ mrem, | ||
| where D (mrem) is the maximum likely dose to an individual exposed to the patient and Qo is the administered activity in millicuries (e.g., if you administer 100 mCi to the patient, then D (mrem) = 2.27 ∗ 100 = 227 mrem). | ||
| □ For Na131I treatment of hyperthyroidism: | ||
| D (mrem) = 8.84 Qo = ________ mrem, | ||
| where D (mrem) is the maximum likely dose to an individual exposed to the patient and Qo is the administered activity in millicuries. | ||
| Note: the above 2 calculations use occupancy factors discussed in Appendix B, section B.1.2 of NRC Regulatory Guide 8.39, and effective half-lives and uptake components found in Table B-1 of NRC Regulatory Guide 8.39. If you use other values, as determined for your specific patient, you must use Equation B-5 of the Regulatory Guide. You must write the entire equation below: | ||
| □ D (mrem) = | ||
| 6. Answer the following: | ||
| Yes | No | |
| □ | □ | The maximum likely dose to an individual exposed to the patient [D (mrem)] is less than 500 millirem? |
| If yes, the patient may be released. Keep this worksheet (including any other calculations) and a copy of the patient instructions for documentation of compliance with 10 CFR 35.75. | ||
| 7. Further restrictions apply if the patient is breast-feeding (see Regulatory Guide). | ||
| Yes | No | |
| □ | □ | This patient is breast-feeding an infant or child. |
| Worksheet completed by _____________ | Date ____________________ | |
| (Signature) |