/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/lung/,

/clinical/cckm-tools/content/beacon-protocols/lung/name-96951-en.cckm

201611333

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Lung

CSC Lung Erlotinib(28D:1-28) VER 10-3-16 (HL 45)

CSC Lung Erlotinib(28D:1-28) VER 10-3-16 (HL 45) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG ERLOTINIB (28D:1-28) VER:10-3-16 – Properties
Pre-Cycle – 11/21/2016 through 11/27/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 days;
COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
ELECTROLYTES
Expected-S Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S Approximate, Expires-S+397, Routine
BUN
Expected-S Approximate, Expires-S+397, Routine
CREATININE
Expected-S Approximate, Expires-S+397, Routine
CALCIUM
Expected-S Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+397, 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
Cycle 1 – 11/28/2016 through 12/25/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/28/2016
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Shepherd, FA, et al. NEJM;2005;353:123-32.
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 1 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 days;
COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT and Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than 3 X ULN or AST greater than 5 X ULN or ALT greater
than 5 X ULN.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): erlotinib (dispensed Day 1 of Cycle 1 only -
subsequent refills will be ordered through the medication activity).
Take Home Medications (delete all that do not apply)
erlotinib (TARCEVA) 150 MG tab
Take by mouth one time daily., R-0, 1 X DAILY starting S, Local Printer
erlotinib (TARCEVA) 100 MG tab
Take by mouth one time daily., R-0, 1 X DAILY starting S, Local Printer
erlotinib (TARCEVA) 25 MG tab
Take by mouth one time daily., R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC: appointment with provider; LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium,
Albumin, Total Protein, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Cycle 2 – 12/26/2016 through 1/22/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/26/2016
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Shepherd, FA, et al. NEJM;2005;353:123-32.
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 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.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 2 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Pre-Labs
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT and Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than 3 X ULN or AST greater than 5 X ULN or ALT greater
than 5 X ULN.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, erlotinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle): RETURN TO CLINIC: appointment with provider; LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium,
Albumin, Total Protein, Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Cycle 3 – 1/23/2017 through 3/19/2017 (56 days), Planned
Day 1, Cycle 3 – Planned for 1/23/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Shepherd, FA, et al. NEJM;2005;353:123-32.
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 days;
COURSE: until disease progression.
Consent
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 3 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT and Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than 3 X ULN or AST greater than 5 X ULN or ALT greater
than 5 X ULN.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, erlotinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 57 FOLLOW-UP
RETURN TO CLINIC: appointment with provider; LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein,
Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Lab Only - Day 57, Cycle 3 – Planned for 3/19/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 4 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 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
ELECTROLYTES
Expected-S+56 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+56 Approximate, Expires-S+397, Routine
BUN
Expected-S+56 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+56 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+56 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+56 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+56 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+56 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+56 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+56 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+56 Approximate, Expires-S+397, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 3/20/2017 through 5/14/2017 (56 days), Planned
Day 1, Cycle 4 – Planned for 3/20/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Shepherd, FA, et al. NEJM;2005;353:123-32.
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 days;
COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
Actions
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 5 of 15
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
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT and Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than 3 X ULN or AST greater than 5 X ULN or ALT greater
than 5 X ULN.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, erlotinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 57 FOLLOW-UP
RETURN TO CLINIC: appointment with provider; LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein,
Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Lab Only - Day 57, Cycle 4 – Planned for 5/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 days;
COURSE: until disease progression.
IV Access
Insert and Maintain Peripheral IV
Actions
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 6 of 15
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
ELECTROLYTES
Expected-S+56 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+56 Approximate, Expires-S+397, Routine
BUN
Expected-S+56 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+56 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+56 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+56 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+56 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+56 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+56 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+56 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+56 Approximate, Expires-S+397, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 5/15/2017 through 7/9/2017 (56 days), Planned
Day 1, Cycle 5 – Planned for 5/15/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Shepherd, FA, et al. NEJM;2005;353:123-32.
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 days;
COURSE: until disease progression.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 7 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT and Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than 3 X ULN or AST greater than 5 X ULN or ALT greater
than 5 X ULN.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, erlotinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 57 FOLLOW-UP
RETURN TO CLINIC: appointment with provider; LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein,
Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Lab Only - Day 57, Cycle 5 – Planned for 7/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 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
ELECTROLYTES
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 8 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+56 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+56 Approximate, Expires-S+397, Routine
BUN
Expected-S+56 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+56 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+56 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+56 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+56 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+56 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+56 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+56 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+56 Approximate, Expires-S+397, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 7/10/2017 through 9/3/2017 (56 days), Planned
Day 1, Cycle 6 – Planned for 7/10/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Shepherd, FA, et al. NEJM;2005;353:123-32.
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 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
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 9 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT and Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than 3 X ULN or AST greater than 5 X ULN or ALT greater
than 5 X ULN.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, erlotinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 57 FOLLOW-UP
RETURN TO CLINIC: appointment with provider; LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein,
Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Lab Only - Day 57, Cycle 6 – Planned for 9/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 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
ELECTROLYTES
Expected-S+56 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+56 Approximate, Expires-S+397, Routine
BUN
Expected-S+56 Approximate, Expires-S+397, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 10 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CREATININE
Expected-S+56 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+56 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+56 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+56 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+56 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+56 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+56 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+56 Approximate, Expires-S+397, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 – 9/4/2017 through 10/29/2017 (56 days), Planned
Day 1, Cycle 7 – Planned for 9/4/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Shepherd, FA, et al. NEJM;2005;353:123-32.
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 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
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 11 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT and Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than 3 X ULN or AST greater than 5 X ULN or ALT greater
than 5 X ULN.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, erlotinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 57 FOLLOW-UP
RETURN TO CLINIC: appointment with provider; LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein,
Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Lab Only - Day 57, Cycle 7 – Planned for 10/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 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
ELECTROLYTES
Expected-S+56 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+56 Approximate, Expires-S+397, Routine
BUN
Expected-S+56 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+56 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+56 Approximate, Expires-S+397, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 12 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ALBUMIN
Expected-S+56 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+56 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S+56 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+56 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+56 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+56 Approximate, Expires-S+397, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 – 10/30/2017 through 12/24/2017 (56 days), Planned
Day 1, Cycle 8 – Planned for 10/30/2017
Treatment Plan Information
Reference Information (1)
NON-SMALL CELL LUNG CANCER: Shepherd, FA, et al. NEJM;2005;353:123-32.
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 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
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+397, Routine
BUN
Expected-S+28 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+28 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 13 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+397, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Total Bilirubin, AST, ALT and Creatinine.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Total Bilirubin greater than 3 X ULN or AST greater than 5 X ULN or ALT greater
than 5 X ULN.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, erlotinib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 57 FOLLOW-UP
RETURN TO CLINIC: appointment with provider; LABS: Electrolytes, Glucose, BUN, Creatinine, Calcium, Albumin, Total Protein,
Total Bilirubin, AST, ALT and Alkaline Phosphatase.
Lab Only - Day 57, Cycle 8 – Planned for 12/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Non-Small Cell Lung Cancer (Advanced); THERAPY: erlotinib 150 mg by mouth daily; CYCLE LENGTH: 28 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
ELECTROLYTES
Expected-S+56 Approximate, Expires-S+397, Routine
GLUCOSE
Expected-S+56 Approximate, Expires-S+397, Routine
BUN
Expected-S+56 Approximate, Expires-S+397, Routine
CREATININE
Expected-S+56 Approximate, Expires-S+397, Routine
CALCIUM
Expected-S+56 Approximate, Expires-S+397, Routine
ALBUMIN
Expected-S+56 Approximate, Expires-S+397, Routine
PROTEIN, TOTAL
Expected-S+56 Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 14 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+56 Approximate, Expires-S+397, Routine
AST/SGOT
Expected-S+56 Approximate, Expires-S+397, Routine
ALT/SGPT
Expected-S+56 Approximate, Expires-S+397, Routine
ALKALINE PHOSPHATASE
Expected-S+56 Approximate, Expires-S+397, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/28/2016 2:39:59 PM Page 15 of 15
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org