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/clinical/cckm-tools/content/beacon-protocols/head-and-neck/name-123235-en.cckm

201712341

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UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Head and Neck

CSC Head-Neck Docetaxel(21D:1)/Doxorubicin(21D:1) Ver 12-4-17 (HL 6056)

CSC Head-Neck Docetaxel(21D:1)/Doxorubicin(21D:1) Ver 12-4-17 (HL 6056) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Head and Neck


CSC HEAD/NECK DOCETAXEL(21D:1)/DOXORUBICIN(21D:1) VER: 12-4-17 –  Properties
Pre-Cycle –  11/27/2017 through 12/3/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 11/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer; THERAPY: doxorubicin 60 mg/m2 IV Day 1, DOCEtaxel 60 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S Approximate, Expires: S+365, Routine
Treatment Conditions
Treatment Condition A
Verify patient has obtained pretreatment MUGA or ECHO.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth 2 times daily. Take for 3 days, starting AM on the day prior to DOCEtaxel., 8 mg, Disp-36 tab,
R-1, 2 X DAILY starting S
famotidine (PEPCID) 20 MG tab
Take 1 tab by mouth 2 times daily., 20 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take for 2 days following chemotherapy., 80 mg, Disp-2 cap, R-5, 1 X DAILY
starting S
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed (For nausea)., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 1 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after
nadir., 300 mcg, Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after
nadir., 480 mcg, Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Cycle 1 –  12/4/2017 through 12/24/2017 (21 days), Planned
Day 1, Cycle 1 –  Planned for 12/4/2017
Treatment Plan Information
Reference Information (1)
THYROID CANCER: Foote RL, et al. Thyroid 2011;21(1):25-30.
Reference Information (2)
THYROID CANCER: Smallridge RC, et al. Thyroid 2012;22(11):1104-39.
Reference Information (3)
THYROID CANCER: Haddad RI, et al. J Natl Compr Canc Netw 2015;13(9):1140-50.
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer; THERAPY: doxorubicin 60 mg/m2 IV Day 1, DOCEtaxel 60 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, AST and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL
or AST greater than 1.5 X ULN or Total Bilirubin greater than ULN.
Treatment Condition A
Verify patient has obtained pretreatment MUGA or ECHO.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
This medication will not be e-prescribed. If patient is present, script will go to printer. Otherwise,
script will go to nursing or tech pool.   Invalid items: Pharmacy   Details...
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 2 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of DOCEtaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 60 mg/m2 (Treatment Plan)
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 3 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

DOCEtaxel (TAXOTERE) 60 mg/m2 in sodium chloride 0.9 % 100 mL non-PVC bag
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC
tubing.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, DOCEtaxel for 120 minutes.
Lab Only - Day 10, Cycle 1 –  Planned for 12/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer; THERAPY: doxorubicin 60 mg/m2 IV Day 1, DOCEtaxel 60 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+9 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 –  12/25/2017 through 1/14/2018 (21 days), Planned
Day 1, Cycle 2 –  Planned for 12/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer; THERAPY: doxorubicin 60 mg/m2 IV Day 1, DOCEtaxel 60 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 4 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, AST and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL
or AST greater than 1.5 X ULN or Total Bilirubin greater than ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of DOCEtaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 5 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 60 mg/m2 (Treatment Plan)
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
DOCEtaxel (TAXOTERE) 60 mg/m2 in sodium chloride 0.9 % 100 mL non-PVC bag
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC
tubing.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, DOCEtaxel for 120 minutes.
Lab Only - Day 10, Cycle 2 –  Planned for 1/3/2018
Treatment Plan Information
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 6 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer; THERAPY: doxorubicin 60 mg/m2 IV Day 1, DOCEtaxel 60 mg/m2
IV Day 1; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+9 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 –  1/15/2018 through 2/4/2018 (21 days), Planned
Day 1, Cycle 3 –  Planned for 1/15/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer; THERAPY: doxorubicin 60 mg/m2 IV Day 1, DOCEtaxel 60 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 7 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, AST and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL
or AST greater than 1.5 X ULN or Total Bilirubin greater than ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of DOCEtaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 8 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 60 mg/m2 (Treatment Plan)
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
DOCEtaxel (TAXOTERE) 60 mg/m2 in sodium chloride 0.9 % 100 mL non-PVC bag
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC
tubing.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, DOCEtaxel for 120 minutes.
Lab Only - Day 10, Cycle 3 –  Planned for 1/24/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer; THERAPY: doxorubicin 60 mg/m2 IV Day 1, DOCEtaxel 60 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+9 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 –  2/5/2018 through 2/25/2018 (21 days), Planned
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 9 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Day 1, Cycle 4 –  Planned for 2/5/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer; THERAPY: doxorubicin 60 mg/m2 IV Day 1, DOCEtaxel 60 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, AST and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL
or AST greater than 1.5 X ULN or Total Bilirubin greater than ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of DOCEtaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 10 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 60 mg/m2 (Treatment Plan)
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
DOCEtaxel (TAXOTERE) 60 mg/m2 in sodium chloride 0.9 % 100 mL non-PVC bag
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC
tubing.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 11 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, DOCEtaxel for 120 minutes.
Lab Only - Day 10, Cycle 4 –  Planned for 2/14/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer; THERAPY: doxorubicin 60 mg/m2 IV Day 1, DOCEtaxel 60 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+9 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 –  2/26/2018 through 3/18/2018 (21 days), Planned
Day 1, Cycle 5 –  Planned for 2/26/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer; THERAPY: doxorubicin 60 mg/m2 IV Day 1, DOCEtaxel 60 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 12 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, AST and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL
or AST greater than 1.5 X ULN or Total Bilirubin greater than ULN.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing prescriber if patient
has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of DOCEtaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 13 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 60 mg/m2 (Treatment Plan)
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
DOCEtaxel (TAXOTERE) 60 mg/m2 in sodium chloride 0.9 % 100 mL non-PVC bag
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC
tubing.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, DOCEtaxel for 120 minutes.
Lab Only - Day 10, Cycle 5 –  Planned for 3/7/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer; THERAPY: doxorubicin 60 mg/m2 IV Day 1, DOCEtaxel 60 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 14 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+9 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 –  3/19/2018 through 4/8/2018 (21 days), Planned
Day 1, Cycle 6 –  Planned for 3/19/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer; THERAPY: doxorubicin 60 mg/m2 IV Day 1, DOCEtaxel 60 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+21 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+21 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+21 Approximate, Expires: S+365, Routine
BILIRUBIN, TOTAL
Expected: S+21 Approximate, Expires: S+365, Routine
AST/SGOT
Expected: S+21 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, AST and Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL
or AST greater than 1.5 X ULN or Total Bilirubin greater than ULN.
Verify Medication(s) Taken at Home (1)
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 15 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Verify that patient has taken dexamethasone and document in a progress note.  Notify authorizing
prescriber if patient has not taken medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to DOCEtaxel can occur.  For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for
the first and second dose of DOCEtaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if
previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
dexamethasone (DECADRON) 10 MG/ML injection 20 mg
20 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Emergency Medications
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
famotidine (PEPCID) injection 20 mg
20 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 60 mg/m2 (Treatment Plan)
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 16 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
DOCEtaxel (TAXOTERE) 60 mg/m2 in sodium chloride 0.9 % 100 mL non-PVC bag
60 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC
tubing.
1st dose or if patient reacted to previous dose:
50 mL/hr for 3 to 5 min,
100 mL/hr for 3 to 5 min,
150 mL/hr for 3 to 5 min,
then max rate for remainder. RN to remain at bedside for additional 3 to 5 minutes.
If patient did not react to 1st or subsequent doses, administer volume of bag over ordered duration.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally)
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Creatinine, Total Bilirubin, AST; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, DOCEtaxel for 120 minutes.
Lab Only - Day 10, Cycle 6 –  Planned for 3/28/2018
Treatment Plan Information
Treatment Plan Summary
DISEASE: Anaplastic Thyroid Cancer; THERAPY: doxorubicin 60 mg/m2 IV Day 1, DOCEtaxel 60 mg/m2 IV Day 1;
GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected: S+9 Approximate, Expires: S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected: S+9 Approximate, Expires: S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Fiona F [2462287]
12/4/2017 10:47:25 AM Page 17 of 17
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org