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