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

/clinical/cckm-tools/content/beacon-protocols/hem---lymphoma/name-96883-en.cckm

201611327

page

100

UWHC,UWMF,

Tools,

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

CSC Hem Pralatrexate(49D1,8,15,22,29,36) Ver 10-18-16 (HL 4713)

CSC Hem Pralatrexate(49D1,8,15,22,29,36) Ver 10-18-16 (HL 4713) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Lymphoma


CSC HEM PRALATREXATE(49D:1,8,15,22,29,36) VER: 10-18-16 – Properties
Pre-Cycle – 11/15/2016 through 11/21/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/15/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Normal, Routine
Take Home Medications
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
allopurinol (ZYLOPRIM) 300 MG tab
Take 1 tab by mouth one time daily. Take during Cycle 1 only., 300 mg, Disp-10 tab, R-0, 1 X DAILY starting S, Local Printer
folic acid (FOLVITE) 1 MG tab
Take 1 tab by mouth one time daily., 1 mg, Disp-30 tab, R-11, 1 X DAILY starting S, Local Printer
Cycle 1 – 11/22/2016 through 1/9/2017 (49 days), Planned
Day 1, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Reference Information (1)
PERIPHERAL T-CELL LYMPHOMA (RELAPSED OR REFRACTORY): O'Connor OA, et al. J Clin Oncol 2009;27(26):4357-64.
Reference Information (2)
PERIPHERAL T-CELL LYMPHOMA (RELAPSED OR REFRACTORY): O'Connor OA, et al. Blood (ASH Annual Meeting Abstracts)
2008;112:Abstract 261.
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
Consent
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 1 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Creatinine Clearance less than
30 mL/min or Alkaline Phosphatase greater than 5 X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Total
Bilirubin greater than 5 X ULN.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient has taken folic acid daily during the last 10 days and document in a progress note. Notify authorizing prescriber if
patient has not taken medication as prescribed.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Treatment Medications (delete all that do not apply)
cyanocobalamin (RUBIMIN) injection 1,000 mcg
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 2 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1,000 mcg, Intramuscular, ONCE, 1 dose Starting when released
Take Home Medications (delete all that do not apply)
leucovorin 15 MG tab
Take 1 tab by mouth 4 times daily. Start 24 hours after pralatrexate dose for 8 doses., 15 mg, Disp-48 tab, R-0, 4 X DAILY starting
S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, ALT, Total
Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 36 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 50 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
Day 8, Cycle 1 – Planned for 11/29/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 3 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 12/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 4 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 5 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 30
mL/min or Alkaline Phosphatase greater than 5 X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Total Bilirubin
greater than 5 X ULN.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 6 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 1 – Planned for 12/20/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 7 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 36, Cycle 1 – Planned for 12/27/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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]
11/22/2016 12:31:24 PM Page 8 of 49
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 1/10/2017 through 2/28/2017 (50 days), Planned
Day 1, Cycle 2 – Planned for 1/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 9 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Creatinine Clearance less than
30 mL/min or Alkaline Phosphatase greater than 5 X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Total
Bilirubin greater than 5 X ULN.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Treatment Medications (delete all that do not apply)
cyanocobalamin (RUBIMIN) injection 1,000 mcg
1,000 mcg, Intramuscular, ONCE, 1 dose Starting when released
Take Home Medications (delete all that do not apply)
leucovorin 15 MG tab
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 10 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take 1 tab by mouth 4 times daily. Start 24 hours after pralatrexate dose for 8 doses., 15 mg, Disp-48 tab, R-0, 4 X
DAILY starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, ALT, Total
Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 36 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 50 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
Day 8, Cycle 2 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 11 of 49
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 12 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify
authorizing prescriber if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 2 – Planned for 1/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 13 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 30
mL/min or Alkaline Phosphatase greater than 5 X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Total Bilirubin
greater than 5 X ULN.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 14 of 49
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 29, Cycle 2 – Planned for 2/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 15 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 36, Cycle 2 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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]
11/22/2016 12:31:24 PM Page 16 of 49
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 3/1/2017 through 4/19/2017 (50 days), Planned
Day 1, Cycle 3 – Planned for 3/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 17 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Creatinine Clearance less than
30 mL/min or Alkaline Phosphatase greater than 5 X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Total
Bilirubin greater than 5 X ULN.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Treatment Medications (delete all that do not apply)
cyanocobalamin (RUBIMIN) injection 1,000 mcg
1,000 mcg, Intramuscular, ONCE, 1 dose Starting when released
Take Home Medications (delete all that do not apply)
leucovorin 15 MG tab
Take 1 tab by mouth 4 times daily. Start 24 hours after pralatrexate dose for 8 doses., 15 mg, Disp-48 tab, R-0, 4 X DAILY starting
S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 18 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, ALT, Total
Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 36 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 50 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
Day 8, Cycle 3 – Planned for 3/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 19 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 – Planned for 3/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 20 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 3 – Planned for 3/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 21 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 30
mL/min or Alkaline Phosphatase greater than 5 X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Total Bilirubin
greater than 5 X ULN.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 3 – Planned for 3/29/2017
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 22 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 23 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 36, Cycle 3 – Planned for 4/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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]
11/22/2016 12:31:24 PM Page 24 of 49
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 4/20/2017 through 6/8/2017 (50 days), Planned
Day 1, Cycle 4 – Planned for 4/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 25 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Creatinine
Clearance less than 30 mL/min or Alkaline Phosphatase greater than 5 X ULN or AST greater than 5 X ULN or ALT
greater than 5 X ULN or Total Bilirubin greater than 5 X ULN.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Treatment Medications (delete all that do not apply)
cyanocobalamin (RUBIMIN) injection 1,000 mcg
1,000 mcg, Intramuscular, ONCE, 1 dose Starting when released
Take Home Medications (delete all that do not apply)
leucovorin 15 MG tab
Take 1 tab by mouth 4 times daily. Start 24 hours after pralatrexate dose for 8 doses., 15 mg, Disp-48 tab, R-0, 4 X DAILY starting
S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, ALT, Total
Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 26 of 49
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
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 36 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 50 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
Day 8, Cycle 4 – Planned for 4/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 27 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 – Planned for 5/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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]
11/22/2016 12:31:24 PM Page 28 of 49
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 4 – Planned for 5/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 29 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 30
mL/min or Alkaline Phosphatase greater than 5 X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Total Bilirubin
greater than 5 X ULN.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 4 – Planned for 5/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 30 of 49
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 WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 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]
11/22/2016 12:31:24 PM Page 31 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 36, Cycle 4 – Planned for 5/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 32 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 6/9/2017 through 7/28/2017 (50 days), Planned
Day 1, Cycle 5 – Planned for 6/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Creatinine Clearance less than
30 mL/min or Alkaline Phosphatase greater than 5 X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Total
Bilirubin greater than 5 X ULN.
Treatment Condition A
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 33 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Treatment Medications (delete all that do not apply)
cyanocobalamin (RUBIMIN) injection 1,000 mcg
1,000 mcg, Intramuscular, ONCE, 1 dose Starting when released
Take Home Medications (delete all that do not apply)
leucovorin 15 MG tab
Take 1 tab by mouth 4 times daily. Start 24 hours after pralatrexate dose for 8 doses., 15 mg, Disp-48 tab, R-0, 4 X DAILY starting
S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, ALT, Total
Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 36 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 34 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30
minutes.
DAY 50 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine,
AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
Day 8, Cycle 5 – Planned for 6/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 35 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 5 – Planned for 6/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 36 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 5 – Planned for 6/30/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 37 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 30
mL/min or Alkaline Phosphatase greater than 5 X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Total Bilirubin
greater than 5 X ULN.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 5 – Planned for 7/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 38 of 49
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 WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 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]
11/22/2016 12:31:24 PM Page 39 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 36, Cycle 5 – Planned for 7/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 40 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 7/29/2017 through 9/16/2017 (50 days), Planned
Day 1, Cycle 6 – Planned for 7/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 100K/µL or Creatinine Clearance less than
30 mL/min or Alkaline Phosphatase greater than 5 X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Total
Bilirubin greater than 5 X ULN.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 41 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Treatment Medications (delete all that do not apply)
cyanocobalamin (RUBIMIN) injection 1,000 mcg
1,000 mcg, Intramuscular, ONCE, 1 dose Starting when released
Take Home Medications (delete all that do not apply)
leucovorin 15 MG tab
Take 1 tab by mouth 4 times daily. Start 24 hours after pralatrexate dose for 8 doses., 15 mg, Disp-48 tab, R-0, 4 X DAILY starting
S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 22 FOLLOW-UP
RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally), Creatinine, AST, ALT, Total
Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 29 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 36 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally); CHEMOTHERAPY ROOM APPOINTMENT: PRALAtrexate for 30 minutes.
DAY 50 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 42 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done
locally), Creatinine, AST, ALT, Total Bilirubin, Alkaline Phosphatase; CHEMOTHERAPY ROOM
APPOINTMENT: PRALAtrexate for 30 minutes.
Day 8, Cycle 6 – Planned for 8/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 43 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 6 – Planned for 8/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 44 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 6 – Planned for 8/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine, AST, ALT, Alkaline Phosphatase, Total Bilirubin.
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 45 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Hold and notify authorizing prescriber for ANC less than 1000/µL or Platelets less than 50K/µL or Creatinine Clearance less than 30
mL/min or Alkaline Phosphatase greater than 5 X ULN or AST greater than 5 X ULN or ALT greater than 5 X ULN or Total Bilirubin
greater than 5 X ULN.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 29, Cycle 6 – Planned for 8/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1, 8, 15, 22, 29,
and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 46 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 36, Cycle 6 – Planned for 9/2/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 47 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Peripheral T-Cell Lymphoma (Relapsed or Refractory); THERAPY: PRALAtrexate 30 mg/m2 IV Days 1,
8, 15, 22, 29, and 36; CYCLE LENGTH: 49 days; COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 50K/µL.
Treatment Condition A
Hold and notify authorizing prescriber for signs and symptoms of greater than or equal to Grade 2 mucositis. Grade 2 mucositis is
defined as patchy ulceration or pseudomembranes that are symptomatic. Patients can eat, swallow modify diet, and topical
analgesics or oral pain medications are required.
Verify Medication(s) Taken at Home (1)
Verify patient has received cyanocobalamin within the last 10 weeks and document in a progress note. Notify authorizing prescriber
if patient has not received medication as prescribed.
Verify Medication(s) Taken at Home (2)
Verify patient is taking folic acid daily and document in a progress note.
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.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give prior to chemotherapy.
Treatment Medications
PRALAtrexate (FOLOTYN) injection 54 mg
54 mg (rounded from 53.7 mg = 30 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released, Administer over 3 Minutes
Administer over 3 to 5 minutes.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 48 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/22/2016 12:31:24 PM Page 49 of 49
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org