/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-96955-en.cckm

20170127

page

100

UWHC,UWMF,

Tools,

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

CSC Lung Pemetrexed(21D:1) VER 1-25-17 (HL 60)

CSC Lung Pemetrexed(21D:1) VER 1-25-17 (HL 60) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Lung


CSC LUNG PEMETREXED(21D:1) VER: 1-25-17 – Properties
Pre-Cycle – 1/18/2017 through 1/24/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 1/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Small Cell Lung Cancer (Adjuvant/Advanced), Non-
Squamous Non-Small Cell Carcinoma (Advanced - maintenance therapy), Thymic Malignancies (Advanced); THERAPY:
pemetrexed 500 mg/m2 IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at least 1
week prior to pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 day; COURSE: 4 to 6 cycles or
until disease progression or toxicity for maintenance therapy; COURSE: for Thymic Malignancies maximum of 6 cycles.
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
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
CALCIUM
Expected-S Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 1 tab twice daily the day prior, day of and day after chemo, then 2 tabs once daily X 2 days, Disp-48 tab, R-1, starting S, Local
Printer
To prevent pemetrexed rash and post chemotherapy nausea
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
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 – 1/25/2017 through 2/14/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 1/25/2017
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Zztestonc,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 1 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Treatment Plan Information
Reference Information (1)
MALIGNANT PLEURAL MESOTHELIOMA: Scagliotti GV, et al. J Clin Oncol 2003;21:1556-61.
Reference Information (2)
NON-SMALL CELL LUNG CANCER: Hanna N, et al. J Clin Oncol 2004;22:1589-97.
Reference Information (3)
NON-SQUAMOUS NON-SMALL CELL CARCINOMA: Belani CP, et al. J Clin Oncol 2009;27:18s:407
Reference Information (4)
THYMIC MALIGNANCY: Loehrer, PJ. J Clin Oncol 2006;24:abstract #7079.
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Small Cell Lung Cancer (Adjuvant/Advanced), Non-
Squamous Non-Small Cell Carcinoma (Advanced - maintenance therapy), Thymic Malignancies (Advanced); THERAPY:
pemetrexed 500 mg/m2 IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at least 1
week prior to pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 day; COURSE: 4 to 6 cycles or
until disease progression or toxicity for maintenance therapy; COURSE: for Thymic Malignancies maximum of 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home(1)
Verify that patient has been taking folic acid and document in a progress note. Notify authorizing prescriber if patient has not
taken as prescribed.
Verify Medication(s) Taken at Home(2)
Verify that patient has received cyanocobalamin and document in a progress note. Notify authorizing prescriber if patient has not
received as prescribed.
Verify Medication(s) Taken at Home(3)
Verify that patient has taken dexamethasone premedication and document in a progress note. Notify authorizing prescriber if
patient has not taken dexamethasone 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.
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Zztestonc,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 2 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) 10 MG/ML injection 8 mg
8 mg, Intravenous, ONCE PRN Starting when released Until Discontinued, If PO not taken at home.
For use in patients who did not take dexamethasone at home.
Treatment Medications
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: pemetrexed for 30 minutes.
Lab Only - Day 10, Cycle 1 – Planned for 2/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Small Cell Lung Cancer (Adjuvant/Advanced), Non-
Squamous Non-Small Cell Carcinoma (Advanced - maintenance therapy), Thymic Malignancies (Advanced); THERAPY:
pemetrexed 500 mg/m2 IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at least 1
week prior to pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 day; COURSE: 4 to 6 cycles or
until disease progression or toxicity for maintenance therapy; COURSE: for Thymic Malignancies maximum of 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 2/15/2017 through 3/7/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 2/15/2017
Treatment Plan Information
Reference Information (1)
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Zztestonc,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 3 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

MALIGNANT PLEURAL MESOTHELIOMA: Scagliotti GV, et al. J Clin Oncol 2003;21:1556-61.
Reference Information (2)
NON-SMALL CELL LUNG CANCER: Hanna N, et al. J Clin Oncol 2004;22:1589-97.
Reference Information (3)
NON-SQUAMOUS NON-SMALL CELL CARCINOMA: Belani CP, et al. J Clin Oncol 2009;27:18s:407
Reference Information (4)
THYMIC MALIGNANCY: Loehrer, PJ. J Clin Oncol 2006;24:abstract #7079.
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Small Cell Lung Cancer (Adjuvant/Advanced), Non-
Squamous Non-Small Cell Carcinoma (Advanced - maintenance therapy), Thymic Malignancies (Advanced); THERAPY:
pemetrexed 500 mg/m2 IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at least 1
week prior to pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 day; COURSE: 4 to 6 cycles or
until disease progression or toxicity for maintenance therapy; COURSE: for Thymic Malignancies maximum of 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home(1)
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Zztestonc,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 4 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Verify that patient has been taking folic acid and document in a progress note. Notify authorizing prescriber if
patient has not taken as prescribed.
Verify Medication(s) Taken at Home(2)
Verify that patient has taken dexamethasone premedication and document in a progress note. Notify authorizing prescriber if
patient has not taken dexamethasone 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
Treatment Medications
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: pemetrexed for 30 minutes; cyanocobalamin administration.
Lab Only - Day 10, Cycle 2 – Planned for 2/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Small Cell Lung Cancer (Adjuvant/Advanced), Non-
Squamous Non-Small Cell Carcinoma (Advanced - maintenance therapy), Thymic Malignancies (Advanced); THERAPY:
pemetrexed 500 mg/m2 IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at least 1
week prior to pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 day; COURSE: 4 to 6 cycles or
until disease progression or toxicity for maintenance therapy; COURSE: for Thymic Malignancies maximum of 6 cycles.
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,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 5 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 3/8/2017 through 3/28/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 3/8/2017
Treatment Plan Information
Reference Information (1)
MALIGNANT PLEURAL MESOTHELIOMA: Scagliotti GV, et al. J Clin Oncol 2003;21:1556-61.
Reference Information (2)
NON-SMALL CELL LUNG CANCER: Hanna N, et al. J Clin Oncol 2004;22:1589-97.
Reference Information (3)
NON-SQUAMOUS NON-SMALL CELL CARCINOMA: Belani CP, et al. J Clin Oncol 2009;27:18s:407
Reference Information (4)
THYMIC MALIGNANCY: Loehrer, PJ. J Clin Oncol 2006;24:abstract #7079.
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Small Cell Lung Cancer (Adjuvant/Advanced), Non-
Squamous Non-Small Cell Carcinoma (Advanced - maintenance therapy), Thymic Malignancies (Advanced); THERAPY:
pemetrexed 500 mg/m2 IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at least 1
week prior to pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 day; COURSE: 4 to 6 cycles or
until disease progression or toxicity for maintenance therapy; COURSE: for Thymic Malignancies maximum of 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 6 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home(1)
Verify that patient has been taking folic acid and document in a progress note. Notify authorizing prescriber if patient has not
taken as prescribed.
Verify Medication(s) Taken at Home(2)
Verify that patient has taken dexamethasone premedication and document in a progress note. Notify authorizing prescriber if
patient has not taken dexamethasone 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
Treatment Medications
cyanocobalamin (RUBIMIN) injection 1,000 mcg
1,000 mcg, Intramuscular, ONCE, 1 dose Starting when released
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: pemetrexed for 30 minutes.
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Zztestonc,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 7 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Lab Only - Day 10, Cycle 3 – Planned for 3/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Small Cell Lung Cancer (Adjuvant/Advanced), Non-
Squamous Non-Small Cell Carcinoma (Advanced - maintenance therapy), Thymic Malignancies (Advanced); THERAPY:
pemetrexed 500 mg/m2 IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at least 1
week prior to pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 day; COURSE: 4 to 6 cycles or
until disease progression or toxicity for maintenance therapy; COURSE: for Thymic Malignancies maximum of 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 3/29/2017 through 4/18/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 3/29/2017
Treatment Plan Information
Reference Information (1)
MALIGNANT PLEURAL MESOTHELIOMA: Scagliotti GV, et al. J Clin Oncol 2003;21:1556-61.
Reference Information (2)
NON-SMALL CELL LUNG CANCER: Hanna N, et al. J Clin Oncol 2004;22:1589-97.
Reference Information (3)
NON-SQUAMOUS NON-SMALL CELL CARCINOMA: Belani CP, et al. J Clin Oncol 2009;27:18s:407
Reference Information (4)
THYMIC MALIGNANCY: Loehrer, PJ. J Clin Oncol 2006;24:abstract #7079.
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Small Cell Lung Cancer (Adjuvant/Advanced), Non-
Squamous Non-Small Cell Carcinoma (Advanced - maintenance therapy), Thymic Malignancies (Advanced); THERAPY:
pemetrexed 500 mg/m2 IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at least 1
week prior to pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 day; COURSE: 4 to 6 cycles or
until disease progression or toxicity for maintenance therapy; COURSE: for Thymic Malignancies maximum of 6 cycles.
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,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 8 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home(1)
Verify that patient has been taking folic acid and document in a progress note. Notify authorizing prescriber if patient has not
taken as prescribed.
Verify Medication(s) Taken at Home(2)
Verify that patient has taken dexamethasone premedication and document in a progress note. Notify authorizing prescriber if
patient has not taken dexamethasone 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
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Zztestonc,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 9 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: pemetrexed for 30 minutes.
Lab Only - Day 10, Cycle 4 – Planned for 4/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Small Cell Lung Cancer (Adjuvant/Advanced), Non-
Squamous Non-Small Cell Carcinoma (Advanced - maintenance therapy), Thymic Malignancies (Advanced); THERAPY:
pemetrexed 500 mg/m2 IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at least 1
week prior to pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 day; COURSE: 4 to 6 cycles or
until disease progression or toxicity for maintenance therapy; COURSE: for Thymic Malignancies maximum of 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 4/19/2017 through 5/9/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 4/19/2017
Treatment Plan Information
Reference Information (1)
MALIGNANT PLEURAL MESOTHELIOMA: Scagliotti GV, et al. J Clin Oncol 2003;21:1556-61.
Reference Information (2)
NON-SMALL CELL LUNG CANCER: Hanna N, et al. J Clin Oncol 2004;22:1589-97.
Reference Information (3)
NON-SQUAMOUS NON-SMALL CELL CARCINOMA: Belani CP, et al. J Clin Oncol 2009;27:18s:407
Reference Information (4)
THYMIC MALIGNANCY: Loehrer, PJ. J Clin Oncol 2006;24:abstract #7079.
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 10 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

DISEASE: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Small Cell Lung Cancer (Adjuvant/Advanced), Non-
Squamous Non-Small Cell Carcinoma (Advanced - maintenance therapy), Thymic Malignancies (Advanced); THERAPY:
pemetrexed 500 mg/m2 IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at least 1
week prior to pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 day; COURSE: 4 to 6 cycles or
until disease progression or toxicity for maintenance therapy; COURSE: for Thymic Malignancies maximum of 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home(1)
Verify that patient has been taking folic acid and document in a progress note. Notify authorizing prescriber if patient has not
taken as prescribed.
Verify Medication(s) Taken at Home(2)
Verify that patient has taken dexamethasone premedication and document in a progress note. Notify authorizing prescriber if
patient has not taken dexamethasone as prescribed.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
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Zztestonc,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 11 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@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
Treatment Medications
cyanocobalamin (RUBIMIN) injection 1,000 mcg
1,000 mcg, Intramuscular, ONCE, 1 dose Starting when released
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: pemetrexed for 30 minutes; cyanocobalamin administration.
Lab Only - Day 10, Cycle 5 – Planned for 4/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Small Cell Lung Cancer (Adjuvant/Advanced), Non-
Squamous Non-Small Cell Carcinoma (Advanced - maintenance therapy), Thymic Malignancies (Advanced); THERAPY:
pemetrexed 500 mg/m2 IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at least 1
week prior to pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 day; COURSE: 4 to 6 cycles or
until disease progression or toxicity for maintenance therapy; COURSE: for Thymic Malignancies maximum of 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 12 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 5/10/2017 through 5/30/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 5/10/2017
Treatment Plan Information
Reference Information (1)
MALIGNANT PLEURAL MESOTHELIOMA: Scagliotti GV, et al. J Clin Oncol 2003;21:1556-61.
Reference Information (2)
NON-SMALL CELL LUNG CANCER: Hanna N, et al. J Clin Oncol 2004;22:1589-97.
Reference Information (3)
NON-SQUAMOUS NON-SMALL CELL CARCINOMA: Belani CP, et al. J Clin Oncol 2009;27:18s:407
Reference Information (4)
THYMIC MALIGNANCY: Loehrer, PJ. J Clin Oncol 2006;24:abstract #7079.
Treatment Plan Summary
DISEASE: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Small Cell Lung Cancer (Adjuvant/Advanced), Non-
Squamous Non-Small Cell Carcinoma (Advanced - maintenance therapy), Thymic Malignancies (Advanced); THERAPY:
pemetrexed 500 mg/m2 IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at least 1
week prior to pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 day; COURSE: 4 to 6 cycles or
until disease progression or toxicity for maintenance therapy; COURSE: for Thymic Malignancies maximum of 6 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+21 Approximate, Expires-S+365, Routine
ALBUMIN
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+21 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 13 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC, Creatinine.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
Clearance less than 45 mL/minute or any results not within normal limits.
Verify Medication(s) Taken at Home(1)
Verify that patient has been taking folic acid and document in a progress note. Notify authorizing prescriber if patient has not
taken as prescribed.
Verify Medication(s) Taken at Home(2)
Verify that patient has taken dexamethasone premedication and document in a progress note. Notify authorizing prescriber if
patient has not taken dexamethasone 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
Treatment Medications
cyanocobalamin (RUBIMIN) injection 1,000 mcg
1,000 mcg, Intramuscular, ONCE, 1 dose Starting when released
pemetrexed (ALIMTA) 1,815 mg in sodium chloride 0.9 % 100 mL bag
1,815 mg (500 mg/m2 × 3.63 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Administer over 10 minutes.
Follow-Up
DAY 10 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, BUN, Creatinine, Calcium, Alkaline Phosphatase, AST, Albumin and Total Bilirubin; CHEMOTHERAPY ROOM
APPOINTMENT: pemetrexed for 30 minutes.
Lab Only - Day 10, Cycle 6 – Planned for 5/19/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 14 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

DISEASE: Malignant Pleural Mesothelioma (Adjuvant/Advanced), Non-Small Cell Lung Cancer (Adjuvant/Advanced), Non-
Squamous Non-Small Cell Carcinoma (Advanced - maintenance therapy), Thymic Malignancies (Advanced); THERAPY:
pemetrexed 500 mg/m2 IV Day 1, folic acid at least 300 mcg orally once daily to begin at least 1 week prior to pemetrexed and
continue for 3 weeks after last dose of pemetrexed, cyanocobalamin (Vitamin B12) 1 mg IM once every 9 weeks to begin at least 1
week prior to pemetrexed and to continue until pemetrexed is discontinued; CYCLE LENGTH: 21 day; COURSE: 4 to 6 cycles or
until disease progression or toxicity for maintenance therapy; COURSE: for Thymic Malignancies maximum of 6 cycles.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+9 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+9 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
1/25/2017 8:43:30 AM Page 15 of 15
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org