/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-96822-en.cckm

201611326

page

100

UWHC,UWMF,

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

CSC HEM Decitabine(28D:1- 5) VER 10-3-16 (HL 1516)

CSC HEM Decitabine(28D:1- 5) VER 10-3-16 (HL 1516) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Leukemia


CSC HEM DECITABINE(28D:1- 5) VER: 10-3-16 – Properties
Pre-Cycle – 11/14/2016 through 11/20/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/14/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 cycles to
determine response or failure
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
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
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 – 11/21/2016 through 12/18/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/21/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 cycles to
determine response or failure
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 1 of 51
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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Creatinine greater than or
equal to 2 mg/dL or Total Bilirubin greater than or equal to 2.8 mg/dL or ALT greater than or equal to 2 X 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 2 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 25 FOLLOW-UP
LABS: CBC with DIFF
DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin, ALT; CHEMOTHERAPY
ROOM APPOINTMENT: decitabine infusion for 210 minutes
Day 2, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 11/23/2016
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 3 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 11/24/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 4 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 5, Cycle 1 – Planned for 11/25/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 cycles to
determine response or failure
IV Access
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 5 of 51
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.
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 11/28/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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]
11/21/2016 2:11:18 PM Page 6 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 12/1/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 12/5/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 cycles to
determine response or failure
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 7 of 51
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+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 12/8/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 12/12/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 8 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 12/15/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 2 – 12/19/2016 through 1/15/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/19/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 9 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood
2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 WITH DIFFERENTIAL
Expected-S+24 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Creatinine greater than or
equal to 2 mg/dL or Total Bilirubin greater than or equal to 2.8 mg/dL or ALT greater than or equal to 2 X 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 10 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 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 with DIFF, Creatinine, Total Bilirubin, ALT; CHEMOTHERAPY
ROOM APPOINTMENT: decitabine infusion for 210 minutes
Day 2, Cycle 2 – Planned for 12/20/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 11 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 12/21/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 12 of 51
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.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 12/22/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 13 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 60 minutes.
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 12/23/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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]
11/21/2016 2:11:18 PM Page 14 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Lab Only - Day 8, Cycle 2 – Planned for 12/26/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 12/29/2016
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 15 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 1/2/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 1/5/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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]
11/21/2016 2:11:18 PM Page 16 of 51
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+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 1/9/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 2 – Planned for 1/12/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 cycles to
determine response or failure
IV Access
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 17 of 51
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 3 – 1/16/2017 through 2/12/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/16/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 WITH DIFFERENTIAL
Expected-S+24 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, ALT
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 18 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Creatinine greater than or
equal to 2 mg/dL or Total Bilirubin greater than or equal to 2.8 mg/dL or ALT greater than or equal to 2 X 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 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 with DIFF, Creatinine, Total Bilirubin, ALT; CHEMOTHERAPY
ROOM APPOINTMENT: decitabine infusion for 210 minutes
Day 2, Cycle 3 – Planned for 1/17/2017
Treatment Plan Information
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 19 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 1/18/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 20 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 3 – Planned for 1/19/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 cycles to
determine response or failure
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 21 of 51
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 1/20/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 22 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 1/23/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 3 – Planned for 1/26/2017
Treatment Plan Information
Reference Information (1)
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 23 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 1/30/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 24 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Lab Only - Day 18, Cycle 3 – Planned for 2/2/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 3 – Planned for 2/6/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 25 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 2/9/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 – 2/13/2017 through 3/12/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/13/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 cycles to
determine response or failure
Consent
Verify Consent
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 26 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+24 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Creatinine greater than or
equal to 2 mg/dL or Total Bilirubin greater than or equal to 2.8 mg/dL or ALT greater than or equal to 2 X 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 5 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 27 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 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 with DIFF, Creatinine, Total Bilirubin, ALT; CHEMOTHERAPY
ROOM APPOINTMENT: decitabine infusion for 210 minutes
Day 2, Cycle 4 – Planned for 2/14/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 28 of 51
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.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 2/15/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 29 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 4, Cycle 4 – Planned for 2/16/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 2/17/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 30 of 51
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 and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 4 – Planned for 2/20/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 31 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia,
Myelodysplastic Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days;
COURSE: minimum of 3 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 2/23/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 2/27/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 32 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 4 – Planned for 3/2/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 3/6/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 33 of 51
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 and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 3/9/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 5 – 3/13/2017 through 4/9/2017 (28 days), Planned
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 34 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 1, Cycle 5 – Planned for 3/13/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 WITH DIFFERENTIAL
Expected-S+24 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
ALT/SGPT
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Creatinine greater than or
equal to 2 mg/dL or Total Bilirubin greater than or equal to 2.8 mg/dL or ALT greater than or equal to 2 X 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 35 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 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 with DIFF, Creatinine, Total Bilirubin, ALT; CHEMOTHERAPY
ROOM APPOINTMENT: decitabine infusion for 210 minutes
Day 2, Cycle 5 – Planned for 3/14/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 cycles to
determine response or failure
IV Access
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 36 of 51
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.
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 3/15/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 37 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 3/16/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 38 of 51
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.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 3/17/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 39 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting
when released
Administer over 60 minutes.
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 3/20/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 3/23/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 cycles to
determine response or failure
IV Access
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 40 of 51
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+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 3/27/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 3/30/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 41 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 4/3/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 5 – Planned for 4/6/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 42 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 – 4/10/2017 through 5/7/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/10/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 WITH DIFFERENTIAL
Expected-S+24 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
BILIRUBIN, TOTAL
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 43 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ALT/SGPT
Expected-S+24 Approximate, Expires-S+365, Normal, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Creatinine, Total Bilirubin, ALT
Treatment Parameters
Hold treatment and notify authorizing prescriber for ANC less than 500/µL or Platelets less than 50K/µL or Creatinine greater than or
equal to 2 mg/dL or Total Bilirubin greater than or equal to 2.8 mg/dL or ALT greater than or equal to 2 X 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
Follow-Up
DAY 2 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 3 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 4 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 minutes.
DAY 5 FOLLOW-UP
CHEMOTHERAPY THERAPY ROOM APPOINTMENT: decitabine infusion for 210 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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 44 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 29 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Creatinine, Total Bilirubin, ALT; CHEMOTHERAPY
ROOM APPOINTMENT: decitabine infusion for 210 minutes
Day 2, Cycle 6 – Planned for 4/11/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 4/12/2017
Treatment Plan Information
Reference Information (1)
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 45 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 4/13/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 46 of 51
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: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 4/14/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 cycles to
determine response or failure
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 47 of 51
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 lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Treatment Medications
decitabine 35.8 mg in sodium chloride 0.9 % 100 mL bag
35.8 mg (20 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes.
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 4/17/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 48 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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 4/20/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 4/24/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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]
11/21/2016 2:11:18 PM Page 49 of 51
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 6 – Planned for 4/27/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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 6 – Planned for 5/1/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 cycles to
determine response or failure
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/21/2016 2:11:18 PM Page 50 of 51
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+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 5/4/2017
Treatment Plan Information
Reference Information (1)
MYELODYSPLASTIC SYNDROME: Steensma DP, et al. J Clin Oncol 2009;27(23):3842-8.
Reference Information (2)
MYELODYSPLASTIC SYNDROME and ACUTE MYELOID LEUKEMIA: Ravandi F et al. Cancer 2009;115(24):5746-51
Reference Information (3)
MYELODYSPLASTIC SYNDROME and CHRONIC MYELOMONOCYTIC LEUKEMIA: Kantarjian H, et al. Blood 2007;109(1):52-7,
Reference Information (4)
ACUTE MYELOID LEUKEMIA: Cashen AF, et al. J Clin Oncol 2010;28(4):556-61.
Treatment Plan Summary
DISEASE: Acute Myelogenous Leukemia, Chronic Myelomonocytic Leukemia, Chronic Myelogenous Leukemia, Myelodysplastic
Syndrome; THERAPY: decitabine 20 mg/m2 IV Day 1 through 5 ; CYCLE LENGTH: 28 days; COURSE: minimum of 3 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]
11/21/2016 2:11:18 PM Page 51 of 51
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org