Parenteral Chemotherapy/Immunotherapy pre-printed order form

VGH / UBCH / GFS
PHYSICIAN’S ORDERS
ADDRESSOGRAPH
PARENTERAL CHEMOTHERAPY/IMMUNOTHERAPY
Page 1 of 2
Date: ________________________
Time: __________________________
Diagnosis:__________________________________________________________
Protocol or Drug Name:________________________________________________
Written chemotherapy consent obtained and consent form is on chart: yes
Wt__________kg
Ht___________cm
Body Surface Area Calculation:
BSA =
( m 2
)
Height( cm)
xWeight(
kg)
3600
BSA = __________m 2
IV Access : Peripheral Central Line
Blood work reviewed and appropriate to proceed with chemotherapy
yes
Chemotherapy:
Drug:_______________________
dose: ______/kg or _______/m² = _____________
Date(s): ______________________________________________________________
Drug:_______________________
dose: ______/kg or _______/m² = _____________
Date(s): ______________________________________________________________
Drug:_______________________
dose: ______/kg or _______/m² = _____________
Date(s): ______________________________________________________________
Drug:_______________________
dose: ______/kg or _______/m² = _____________
Date(s): ______________________________________________________________
45
_______________________________
Physician Signature
CCO
_________________________________
Printed Name/PIC
Rev. Sept-03

VGH / UBCH / GFS
PHYSICIAN’S ORDERS
ADDRESSOGRAPH
PARENTERAL CHEMOTHERAPY/IMMUNOTHERAPY
Page 2 of 2
Date: ________________________
Time: __________________________
Adjunctive Medications (including antiemetics):
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
IV FLUIDS:_______________________________________________________________
Bloodwork
CBC + DIFF. + Platelets
Lytes, Urea, Creatinine
Magnesium/Calcium
Bili T/D, AST, Alk Phos, LDH
q____________
q____________
q____________
q____________
Other____________________ q____________
Results to Dr. _________________________________
45
_______________________________
Physician Signature
CCO
_________________________________
Printed Name/PIC
Rev. Sept-03