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Microsoft word - chemo%20orders[1]

Mohamed S. Ahmed, MD,PhD,PC
3117 Military Road Suite #2
MOHAMED S AHMED, MD, PHD, PC
Niagara Falls, NY 14304
Phone: 716-298-4869

HEMATOLOGY-ONCOLOGY
Fax: 888-847-3060
CHEMOTHERAPY ORDERS

Patient Name: __________________________________________ Diagnosis: _________________________________
Protocol: _______________________________________________ Course # _____________ Cycle # _______________
Height: ________inches
Dosing Weight: ________lbs/kg [ ] Actual [ ] Ideal [ ] Adjusted BSA* ________m2
Ideal weight in kg = (inches >5’ x 2.3) + 45.5 (females) or 50 (males) Adjusted weight in kg = (total weight – ideal weight) x 0.25 + ideal weight BSA is calculated in Meditech using the Haycock equation Parameters: ANC > 1500, PLTS > 100,000, Creatnine < 1.5
Pre-Chemotherapy Orders
[ ] Zofran 16mg IV and Dexamethasone 20mg IV
[ ] PACLITAXOL PREMEDS: Dexamethasone 20mg IV, Zantac 50mg
[ ] Benadryl 25mg IV [ ] Solucortef 100mg IV
IV, Zofran 16mg IV, Benadryl 25mg IV
Chemotherapy Orders: Pharmacist may round dose by ≤5% to nearest vial size in order to minimize waste.
Calculated
Diluent/Volume/
Frequency
weight/BSA
Modification
Duration (if IVPB)
[ ] IV Push
[ ] One Time
_______mg/kg
Diluent: ___________
[ ] Daily x _____________________________
________mg
Volume:___________
[ ] ___________________________________
_______mg/m2
[ ] ______%
[ ] ________
Duration:__________
______________________________________
[ ] IV Push
[ ] One Time
_______mg/kg
Diluent: ___________
[ ] Daily x _____________________________
________mg
Volume:___________
[ ] ___________________________________
_______mg/m2
[ ] ______%
[ ] ________
Duration:__________
______________________________________
[ ] IV Push
[ ] One Time
_______mg/kg
Diluent: ___________
[ ] Daily x _____________________________
________mg
Volume:___________
[ ] ___________________________________
_______mg/m2
[ ] ______%
[ ] ________
Duration:__________
______________________________________
Carboplatin Only: Target AUC _____ GFR _____ ml/min Dose = Target AUC x (GFR + 25) = _________mg
ALLERGIES: _________________________________________
Post-Chemotherapy Orders: ______________________________________________ ICD Codes ______________________
____________________________________________________ __________________
______________________
____________________________________________________ _____________ _____
______________________
Physician’s signature ______________________________________________ Date ____________________________

Source: http://hematology-oncologycare.com/uploads/CHEMOTHERAPY_ORDER_FORM.pdf

Revista ei num 351 10

NATALIA MARTÍN CRUZ JUAN HERNANGÓMEZ BARAHONA JUAN MANUEL DE LA FUENTE SABATÉ El ámbito institucional en el que se circunscribe la regulación delos medicamentos en España y los cambios que en él se han producidohan influido necesariamente en el proceso de autorización de nuevosmentos genéricos y precios de referenciaen 1996. Los resultados de estas actuacio-rios creados para

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