Patient Name: ______________________________________________ MRN #: _________________ DOB: _____________ Diagnosis: ________________________________________ Chemotherapy Treatment Regimen/Protocol: _____________________________________________________________ Chemotherapy Treatment Start Date: ______________________ Draw Labs: CBC w/diff CMP Mg Phos LDH Other _____________ Prior to Chemotherapy Daily Every Other Day Current Cycle #: ________ Uric Acid Urine pH Q4H Notify Provider Parameters: Notify Provider and hold chemotherapy if ANC is less than ___________ and/or platelets are less than ___________. Notify Provider if: _____________________________________________________________________________________. Clinical Assessment/Treatment Instructions: If new IVF is ordered for chemotherapy regimen, discontinue all currently active IVF orders. OK to administer chemotherapy with an ANC greater than or equal to ________ and platelets greater than or equal to _________. Other: ________________________________________________________________________________________________. MD Name (Printed) ______________________________ MD Signature _______________________ Date / Time _______________ Inpatient Adult Chemotherapy Order Set Height:__________ Weight: _________ BSA: ________ m 2 on Date/Day __________ Version Date: April 2017 Revision Date: October 2017 Pre-Chemotherapy “Other” Medications: Acetaminophen (Tylenol) 650 mg PO ONCE on Day(s): _____ Dexamethasone (Decadron) _____ mg IV ONCE on Day(s): ____ DiphenhydrAMINE (Benadryl) ___ mg IV ONCE on Day(s): ___ Hydrocortisone ____ mg IV ONCE on Day(s): ____ LORazepam (Ativan) 0.5 mg IV ONCE on Day(s): _____ Famotidine (Pepcid) 20 mg IV ONCE on Day(s): _____ Ondansetron (Zofran) 4 mg IV ONCE on Day(s): ____ Granisetron (Kytril) 1 mg IV ONCE on Day(s): _____ MetoCLOPramide (Reglan) 10 mg IV ONCE on Day(s): _____ Other _______________________________________________ Flush Lines: Ok to establish and flush vascular access. Flush Panel: • Heparin 5 mL (100 units/mL) IV PRN Saline Lock Flush 20 mL IV PRN • Chemotherapeutic Drugs: (Please do not use unapproved abbreviations such as “d” for dose or Day…) Route & Frequency Chemotherapeutic Drugs: (Please do not use unapproved abbreviations such as “d” for dose or Day…) * Usual dose of intrathecal Methotrexate is 15 mg (12 mg if administered via Ommaya) Drug Name Actual Dose* (mg)

Drug Name Actual Dose*

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Patient Name: ______________________________________________ MRN #: _________________ DOB: _____________

Diagnosis: ________________________________________

Chemotherapy Treatment Regimen/Protocol: _____________________________________________________________

Chemotherapy Treatment Start Date: ______________________

Draw Labs: CBC w/diff CMP Mg Phos LDH Other _____________

Prior to Chemotherapy Daily Every Other Day

Current Cycle #: ________

Uric Acid Urine pH Q4H

Notify Provider Parameters: Notify Provider and hold chemotherapy if ANC is less than ___________ and/or platelets are less than ___________. Notify Provider if: _____________________________________________________________________________________.

Clinical Assessment/Treatment Instructions: If new IVF is ordered for chemotherapy regimen, discontinue all currently active IVF orders. OK to administer chemotherapy with an ANC greater than or equal to ________ and platelets greater than or equal to _________. Other: ________________________________________________________________________________________________.

MD Name (Printed) ______________________________ MD Signature _______________________ Date / Time _______________

Inpatient Adult Chemotherapy Order Set

Height:__________ Weight: _________ BSA: ________ m2

on Date/Day __________

Version Date: April 2017 Revision Date: October 2017

Pre-Chemotherapy “Other” Medications: Acetaminophen (Tylenol) 650 mg PO ONCE on Day(s): _____ Dexamethasone (Decadron) _____ mg IV ONCE on Day(s): ____DiphenhydrAMINE (Benadryl) ___ mg IV ONCE on Day(s): ___ Hydrocortisone ____ mg IV ONCE on Day(s): ____

LORazepam (Ativan) 0.5 mg IV ONCE on Day(s): _____Famotidine (Pepcid) 20 mg IV ONCE on Day(s): _____ Ondansetron (Zofran) 4 mg IV ONCE on Day(s): ____ Granisetron (Kytril) 1 mg IV ONCE on Day(s): _____

MetoCLOPramide (Reglan) 10 mg IV ONCE on Day(s): _____ Other _______________________________________________

Flush Lines: Ok to establish and flush vascular access. Flush Panel: • Heparin 5 mL (100 units/mL) IV PRN

Saline Lock Flush 20 mL IV PRN•

Chemotherapeutic Drugs: (Please do not use unapproved abbreviations such as “d” for dose or Day…)

Route & Frequency

Chemotherapeutic Drugs: (Please do not use unapproved abbreviations such as “d” for dose or Day…)

* Usual dose of intrathecal Methotrexate is 15 mg (12 mg if administered via Ommaya)

Drug Name Actual Dose* (mg)