/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/hem---leukemia/,

/clinical/cckm-tools/content/beacon-protocols/hem---leukemia/name-96808-en.cckm

201611320

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100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Hem - Leukemia

CSC HEM Azacitidine IV or Subcutaneous(28D:1-5) VER 10-3-16 (HL 1541)

CSC HEM Azacitidine IV or Subcutaneous(28D:1-5) VER 10-3-16 (HL 1541) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM AZACITIDINE IV OR SUBCUTANEOUS (28D,1-5) VER: 10-3-16 – Properties
Pre-Cycle – 11/8/2016 through 11/14/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/8/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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
CARBON DIOXIDE
Expected-S Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Normal, Routine
Take Home Medications
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 – 11/15/2016 through 12/12/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/15/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME, ACUTE MYELOGENOUS LEUKEMIA, CHRONIC MYELOMONOCYTIC LEUKEMIA: Silverman
LR, et al. J Clin Oncol 2006;24(24):3895-903.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 1 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (2)
MYELODYSPLASTIC SYNDROME, ACUTE MYELOGENOUS LEUKEMIA, CHRONIC MYELOMONOCYTIC
LEUKEMIA: Fili C, et al. Clin Cancer Res 2013;19(12):3297-308
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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, Carbon Dioxide, BUN, Creatinine, Albumin, Total Bilirubin, AST, Alkaline
Phosphatase
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Carbon Dioxide less than
20 mmol/L or BUN greater than 20 mg/dL or Creatinine greater than 1.3 mg/dL or Albumin less than 3 gm/dL or Total Bilirubin
greater than 1.4 mg/dL or AST or Alkaline Phosphatase greater than ULN.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) 134.25 mg in sodium chloride 0.9 % 100 mL bag
134.25 mg (75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 2 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 2 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with diff
DAY 11 FOLLOW-UP
LABS: CBC with diff
DAY 15 FOLLOW-UP
LABS: CBC with diff
DAY 18 FOLLOW-UP
LABS: CBC with diff
DAY 22 FOLLOW-UP
LABS: CBC with diff
DAY 25 FOLLOW-UP
LABS: CBC with diff
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Carbon Dioxide, BUN, Creatinine, Albumin, Total Bilirubin,
AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30
minutes.
Day 2, Cycle 1 – Planned for 11/16/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 3 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) 134.25 mg in sodium chloride 0.9 % 100 mL bag
134.25 mg (75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 1 – Planned for 11/17/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection 134 mg
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 4 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) 134.25 mg in sodium chloride 0.9 % 100 mL bag
134.25 mg (75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 1 – Planned for 11/18/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) 134.25 mg in sodium chloride 0.9 % 100 mL bag
134.25 mg (75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 5 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 5, Cycle 1 – Planned for 11/19/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) 134.25 mg in sodium chloride 0.9 % 100 mL bag
134.25 mg (75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 6 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 WITH DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 11, Cycle 1 – Planned for 11/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 – Planned for 11/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 18, Cycle 1 – Planned for 12/2/2016
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 7 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+13 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 1 – Planned for 12/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 25, Cycle 1 – Planned for 12/9/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+20 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,Andrew [2428787]
11/15/2016 3:18:33 PM Page 8 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 2 – 12/13/2016 through 1/9/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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+24 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+24 Approximate, Expires-S+365, Routine
CARBON DIOXIDE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Carbon Dioxide, BUN, Creatinine, Albumin, Total Bilirubin, AST, Alkaline
Phosphatase
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Carbon Dioxide less than
20 mmol/L or BUN greater than 20 mg/dL or Creatinine greater than 1.3 mg/dL or Albumin less than 3 gm/dL or Total Bilirubin
greater than 1.4 mg/dL or AST or Alkaline Phosphatase greater than ULN.
Nursing Procedure, Assessment and Monitoring
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.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 9 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) 134.25 mg in sodium chloride 0.9 % 100 mL bag
134.25 mg (75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with diff
DAY 11 FOLLOW-UP
LABS: CBC with diff
DAY 15 FOLLOW-UP
LABS: CBC with diff
DAY 18 FOLLOW-UP
LABS: CBC with diff
DAY 22 FOLLOW-UP
LABS: CBC with diff
DAY 25 FOLLOW-UP
LABS: CBC with diff
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Carbon Dioxide, BUN, Creatinine, Albumin, Total Bilirubin,
AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30
minutes.
Day 2, Cycle 2 – Planned for 12/14/2016
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 10 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia;
THERAPY: azacitidine 75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase
azacitidine to 100mg/m2 IV or subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4
to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) 134.25 mg in sodium chloride 0.9 % 100 mL bag
134.25 mg (75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 2 – Planned for 12/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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,Andrew [2428787]
11/15/2016 3:18:33 PM Page 11 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) 134.25 mg in sodium chloride 0.9 % 100 mL bag
134.25 mg (75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 2 – Planned for 12/16/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 12 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) 134.25 mg in sodium chloride 0.9 % 100 mL bag
134.25 mg (75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 2 – Planned for 12/17/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 13 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection 134 mg
134 mg (rounded from 134.25 mg = 75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) 134.25 mg in sodium chloride 0.9 % 100 mL bag
134.25 mg (75 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 2 – Planned for 12/20/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 11, Cycle 2 – Planned for 12/23/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 2 – Planned for 12/27/2016
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 14 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 18, Cycle 2 – Planned for 12/30/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+13 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 2 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 15 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 25, Cycle 2 – Planned for 1/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+20 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 – 1/10/2017 through 2/6/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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+24 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+24 Approximate, Expires-S+365, Routine
CARBON DIOXIDE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 16 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ALBUMIN
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Carbon Dioxide, BUN, Creatinine, Albumin, Total Bilirubin, AST, Alkaline
Phosphatase
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Carbon Dioxide less than
20 mmol/L or BUN greater than 20 mg/dL or Creatinine greater than 1.3 mg/dL or Albumin less than 3 gm/dL or Total Bilirubin
greater than 1.4 mg/dL or AST or Alkaline Phosphatase greater than ULN.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 17 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with diff
DAY 11 FOLLOW-UP
LABS: CBC with diff
DAY 15 FOLLOW-UP
LABS: CBC with diff
DAY 18 FOLLOW-UP
LABS: CBC with diff
DAY 22 FOLLOW-UP
LABS: CBC with diff
DAY 25 FOLLOW-UP
LABS: CBC with diff
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Carbon Dioxide, BUN, Creatinine, Albumin, Total Bilirubin,
AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30
minutes.
Day 2, Cycle 3 – Planned for 1/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 18 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 3 – Planned for 1/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 19 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 4, Cycle 3 – Planned for 1/13/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 3 – Planned for 1/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 20 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 3 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+3 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,Andrew [2428787]
11/15/2016 3:18:33 PM Page 21 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Lab Only - Day 11, Cycle 3 – Planned for 1/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 3 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 18, Cycle 3 – Planned for 1/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 22 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+13 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 3 – Planned for 1/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 25, Cycle 3 – Planned for 2/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+20 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 – 2/7/2017 through 3/6/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
Consent
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 23 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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+24 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+24 Approximate, Expires-S+365, Routine
CARBON DIOXIDE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Carbon Dioxide, BUN, Creatinine, Albumin, Total Bilirubin, AST, Alkaline
Phosphatase
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Carbon Dioxide less than
20 mmol/L or BUN greater than 20 mg/dL or Creatinine greater than 1.3 mg/dL or Albumin less than 3 gm/dL or Total Bilirubin
greater than 1.4 mg/dL or AST or Alkaline Phosphatase greater than ULN.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 24 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with diff
DAY 11 FOLLOW-UP
LABS: CBC with diff
DAY 15 FOLLOW-UP
LABS: CBC with diff
DAY 18 FOLLOW-UP
LABS: CBC with diff
DAY 22 FOLLOW-UP
LABS: CBC with diff
DAY 25 FOLLOW-UP
LABS: CBC with diff
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Carbon Dioxide, BUN, Creatinine, Albumin, Total Bilirubin,
AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30
minutes.
Day 2, Cycle 4 – Planned for 2/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 25 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 4 – Planned for 2/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 26 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 4 – Planned for 2/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 27 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 4 – Planned for 2/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 28 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 4 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 11, Cycle 4 – Planned for 2/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 4 – Planned for 2/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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,Andrew [2428787]
11/15/2016 3:18:33 PM Page 29 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITH DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 18, Cycle 4 – Planned for 2/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+13 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 4 – Planned for 2/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 25, Cycle 4 – Planned for 3/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
IV Access
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 30 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 WITH DIFFERENTIAL
Expected-S+20 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 – 3/7/2017 through 4/3/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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+24 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+24 Approximate, Expires-S+365, Routine
CARBON DIOXIDE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 31 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC, Carbon Dioxide, BUN, Creatinine, Albumin, Total Bilirubin, AST, Alkaline
Phosphatase
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Carbon Dioxide less than
20 mmol/L or BUN greater than 20 mg/dL or Creatinine greater than 1.3 mg/dL or Albumin less than 3 gm/dL or Total Bilirubin
greater than 1.4 mg/dL or AST or Alkaline Phosphatase greater than ULN.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with diff
DAY 11 FOLLOW-UP
LABS: CBC with diff
DAY 15 FOLLOW-UP
LABS: CBC with diff
DAY 18 FOLLOW-UP
LABS: CBC with diff
DAY 22 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 32 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

LABS: CBC with diff
DAY 25 FOLLOW-UP
LABS: CBC with diff
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Carbon Dioxide, BUN, Creatinine, Albumin, Total Bilirubin,
AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30
minutes.
Day 2, Cycle 5 – Planned for 3/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 5 – Planned for 3/9/2017
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 33 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 5 – Planned for 3/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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,Andrew [2428787]
11/15/2016 3:18:33 PM Page 34 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 5 – Planned for 3/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 35 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 5 – Planned for 3/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 11, Cycle 5 – Planned for 3/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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,Andrew [2428787]
11/15/2016 3:18:33 PM Page 36 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 5 – Planned for 3/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 18, Cycle 5 – Planned for 3/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+13 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 5 – Planned for 3/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 37 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 WITH DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 25, Cycle 5 – Planned for 3/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+20 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 – 4/4/2017 through 5/1/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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+24 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 38 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT
Expected-S+24 Approximate, Expires-S+365, Routine
CARBON DIOXIDE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BUN
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
CREATININE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
ALBUMIN
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
AST/SGOT
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
ALKALINE PHOSPHATASE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Carbon Dioxide, BUN, Creatinine, Albumin, Total Bilirubin, AST, Alkaline
Phosphatase
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Carbon Dioxide less than
20 mmol/L or BUN greater than 20 mg/dL or Creatinine greater than 1.3 mg/dL or Albumin less than 3 gm/dL or Total Bilirubin
greater than 1.4 mg/dL or AST or Alkaline Phosphatase greater than ULN.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 39 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30 minutes.
DAY 8 FOLLOW-UP
LABS: CBC with diff
DAY 11 FOLLOW-UP
LABS: CBC with diff
DAY 15 FOLLOW-UP
LABS: CBC with diff
DAY 18 FOLLOW-UP
LABS: CBC with diff
DAY 22 FOLLOW-UP
LABS: CBC with diff
DAY 25 FOLLOW-UP
LABS: CBC with diff
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC, Carbon Dioxide, BUN, Creatinine, Albumin, Total Bilirubin,
AST, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: azacitidine infusion for 60 minutes OR injection for 30
minutes.
Day 2, Cycle 6 – Planned for 4/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 40 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 6 – Planned for 4/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 41 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 6 – Planned for 4/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 6 – Planned for 4/8/2017
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 42 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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.
Nursing Procedure, Assessment and Monitoring
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 10 UNIT/ML lock flush 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. If azacitidine is to be given subcutaneously, delete this hydration order.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications (delete all that do not apply)
azacitidine (VIDAZA) injection
Subcutaneous, ONCE, 1 dose Starting when released
If azacitidine is be given subcutaneously, delete the Normal Saline for flushing.
azacitidine (VIDAZA) in sodium chloride 0.9 % 100 mL bag
Intravenous, ONCE, 1 dose Starting when released
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 6 – Planned for 4/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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,Andrew [2428787]
11/15/2016 3:18:33 PM Page 43 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+3 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 11, Cycle 6 – Planned for 4/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+6 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 6 – Planned for 4/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+10 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 18, Cycle 6 – Planned for 4/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:18:33 PM Page 44 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 WITH DIFFERENTIAL
Expected-S+13 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 22, Cycle 6 – Planned for 4/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+17 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 25, Cycle 6 – Planned for 4/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Myelodysplastic Syndrome/ Acute Myelogenous Leukemia/ Chronic Myelomonocytic Leukemia; THERAPY: azacitidine
75 mg/m2 IV or subcutaneous Day 1 through 5. If no response after 2 cycles, may increase azacitidine to 100mg/m2 IV or
subcutaneous Day 1 through 5; CYCLE LENGTH: 28 days; COURSE: minimum of 4 to 6 cycles to determine response or failure.
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 WITH DIFFERENTIAL
Expected-S+20 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,Andrew [2428787]
11/15/2016 3:18:33 PM Page 45 of 45
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org