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

/clinical/cckm-tools/content/beacon-protocols/melanoma/name-96979-en.cckm

201611333

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100

UWHC,UWMF,

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

CSC Melanoma Interferon Alpha 2-B(28D:3xWeek) Maintenance Home Administered VER 10-3-16 (HL 951)

CSC Melanoma Interferon Alpha 2-B(28D:3xWeek) Maintenance Home Administered VER 10-3-16 (HL 951) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Melanoma


CSC MELANOMA INTERFERON ALPHA 2-B(28D:3XWEEK) MAINTENANCE HOME ADMINISTERED 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: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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
CREATININE
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
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)
MELANOMA: Kirkwood et al. J Clin Oncol 1996;14(1):7-17.
Reference Information (2)
MELANOMA: Moschos SJ et al. J Clin Oncol 2004(1);22:11-3.
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 1 of 24
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.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Reinforce/teach patient to self-administer SC injection and provide supplies.
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.
Pre-Medications
acetaMINOPHEN (TYLENOL) tab 650 mg
650 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy. No more than 4 grams acetaminophen per 24 hours for adults or 15mg/kg per dose
for peds <40kg.
Treatment Medications
interferon alfa-2B (INTRON A) injection NF 17.9 Million Units
17.9 Million Units (10 Million Units/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
Corticosteroids are NOT allowed for routine use. Round to nearest 1 million units. Use patient's own supply.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): interferon alpha-2B ( Dispensed Day 1 of each
cycle) and acetaminophen (Dispensed on Day 1 of Cycle 1)
Take Home Medications
acetaMINOPHEN (TYLENOL) 325 MG tab
Take 1-2 tabs by mouth every 4 hours as needed for fever or pain., 325-650 mg, Disp-100 tab, R-6, EVERY 4 HOURS PRN starting
S, Local Printer
interferon alfa-2B (INTRON A) 10000000 UNIT/ML injection
Inject under skin 3 times per week. Round to nearest 1 million units. Corticosteroids are NOT allowed for routine use., R-0, 3 X
WEEKLY starting S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH.
Labs Only - Day 15, Cycle 1 – Planned for 12/12/2016
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 2 of 24
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: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/26/2016 through 1/22/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 3 of 24
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
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
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Reinforce/teach patient to self-administer SC injection and provide supplies.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): interferon alpha-2B ( Dispensed Day 1 of each
cycle) and acetaminophen (Dispensed on Day 1 of Cycle 1)
Take Home Medications
interferon alfa-2B (INTRON A) 10000000 UNIT/ML injection
Inject under skin 3 times per week. Round to nearest 1 million units. Corticosteroids are NOT allowed for routine use., R-0, 3 X
WEEKLY starting S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH.
Labs Only - Day 15, Cycle 2 – Planned for 1/9/2017
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 4 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/23/2017 through 2/19/2017 (28 days), Planned
Day 1, Cycle 3 – Planned for 1/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 5 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Reinforce/teach patient to self-administer SC injection and provide supplies.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): interferon alpha-2B ( Dispensed Day 1 of each
cycle) and acetaminophen (Dispensed on Day 1 of Cycle 1)
Take Home Medications
interferon alfa-2B (INTRON A) 10000000 UNIT/ML injection
Inject under skin 3 times per week. Round to nearest 1 million units. Corticosteroids are NOT allowed for routine use., R-0, 3 X
WEEKLY starting S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH.
Labs Only - Day 15, Cycle 3 – Planned for 2/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 cycles.
IV Access
Insert and Maintain Peripheral IV
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 6 of 24
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+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
ALKALINE PHOSPHATASE
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 2/20/2017 through 3/19/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 7 of 24
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
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Reinforce/teach patient to self-administer SC injection and provide supplies.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): interferon alpha-2B ( Dispensed Day 1 of each
cycle) and acetaminophen (Dispensed on Day 1 of Cycle 1)
Take Home Medications
interferon alfa-2B (INTRON A) 10000000 UNIT/ML injection
Inject under skin 3 times per week. Round to nearest 1 million units. Corticosteroids are NOT allowed for routine use., R-0, 3 X
WEEKLY starting S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH.
Labs Only - Day 15, Cycle 4 – Planned for 3/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 8 of 24
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+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
ALKALINE PHOSPHATASE
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 5 – 3/20/2017 through 4/16/2017 (28 days), Planned
Day 1, Cycle 5 – Planned for 3/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 9 of 24
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 and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Reinforce/teach patient to self-administer SC injection and provide supplies.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): interferon alpha-2B ( Dispensed Day 1 of each
cycle) and acetaminophen (Dispensed on Day 1 of Cycle 1)
Take Home Medications
interferon alfa-2B (INTRON A) 10000000 UNIT/ML injection
Inject under skin 3 times per week. Round to nearest 1 million units. Corticosteroids are NOT allowed for routine use., R-0, 3 X
WEEKLY starting S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH.
Labs Only - Day 15, Cycle 5 – Planned for 4/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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,Andrew [2428787]
11/28/2016 3:45:25 PM Page 10 of 24
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
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 6 – 4/17/2017 through 5/14/2017 (28 days), Planned
Day 1, Cycle 6 – Planned for 4/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 11 of 24
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 and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline
Phosphatase, Total Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Reinforce/teach patient to self-administer SC injection and provide supplies.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): interferon alpha-2B ( Dispensed Day 1 of each
cycle) and acetaminophen (Dispensed on Day 1 of Cycle 1)
Take Home Medications
interferon alfa-2B (INTRON A) 10000000 UNIT/ML injection
Inject under skin 3 times per week. Round to nearest 1 million units. Corticosteroids are NOT allowed for routine use., R-0, 3 X
WEEKLY starting S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH.
Labs Only - Day 15, Cycle 6 – Planned for 5/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+14 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 12 of 24
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
ALKALINE PHOSPHATASE
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 7 – 5/15/2017 through 6/11/2017 (28 days), Planned
Day 1, Cycle 7 – Planned for 5/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 13 of 24
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 or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Reinforce/teach patient to self-administer SC injection and provide supplies.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): interferon alpha-2B ( Dispensed Day 1 of each
cycle) and acetaminophen (Dispensed on Day 1 of Cycle 1)
Take Home Medications
interferon alfa-2B (INTRON A) 10000000 UNIT/ML injection
Inject under skin 3 times per week. Round to nearest 1 million units. Corticosteroids are NOT allowed for routine use., R-0, 3 X
WEEKLY starting S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH.
Labs Only - Day 15, Cycle 7 – Planned for 5/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 14 of 24
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
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 8 – 6/12/2017 through 7/9/2017 (28 days), Planned
Day 1, Cycle 8 – Planned for 6/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 15 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Patient Instructions(1)
Reinforce/teach patient to self-administer SC injection and provide supplies.
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): interferon alpha-2B ( Dispensed Day 1 of each
cycle) and acetaminophen (Dispensed on Day 1 of Cycle 1)
Take Home Medications
interferon alfa-2B (INTRON A) 10000000 UNIT/ML injection
Inject under skin 3 times per week. Round to nearest 1 million units. Corticosteroids are NOT allowed for routine use., R-0, 3 X
WEEKLY starting S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH.
Labs Only - Day 15, Cycle 8 – Planned for 6/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+14 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 16 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 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 9 – 7/10/2017 through 8/6/2017 (28 days), Planned
Day 1, Cycle 9 – Planned for 7/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Reinforce/teach patient to self-administer SC injection and provide supplies.
Flush Venous Access Device per Guidelines
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 17 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): interferon alpha-2B ( Dispensed Day 1 of each
cycle) and acetaminophen (Dispensed on Day 1 of Cycle 1)
Take Home Medications
interferon alfa-2B (INTRON A) 10000000 UNIT/ML injection
Inject under skin 3 times per week. Round to nearest 1 million units. Corticosteroids are NOT allowed for routine use., R-0, 3 X
WEEKLY starting S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH.
Labs Only - Day 15, Cycle 9 – Planned for 7/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 18 of 24
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
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 10 – 8/7/2017 through 9/3/2017 (28 days), Planned
Day 1, Cycle 10 – Planned for 8/7/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Reinforce/teach patient to self-administer SC injection and provide supplies.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 19 of 24
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): interferon alpha-2B ( Dispensed Day 1 of each
cycle) and acetaminophen (Dispensed on Day 1 of Cycle 1)
Take Home Medications
interferon alfa-2B (INTRON A) 10000000 UNIT/ML injection
Inject under skin 3 times per week. Round to nearest 1 million units. Corticosteroids are NOT allowed for routine use., R-0, 3 X
WEEKLY starting S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH.
Labs Only - Day 15, Cycle 10 – Planned for 8/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
Follow-Up
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ZZtestonc,Andrew [2428787]
11/28/2016 3:45:25 PM Page 20 of 24
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.
Cycle 11 – 9/4/2017 through 10/1/2017 (28 days), Planned
Day 1, Cycle 11 – Planned for 9/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Reinforce/teach patient to self-administer SC injection and provide supplies.
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]
11/28/2016 3:45:25 PM Page 21 of 24
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): interferon alpha-2B ( Dispensed Day 1 of each
cycle) and acetaminophen (Dispensed on Day 1 of Cycle 1)
Take Home Medications
interferon alfa-2B (INTRON A) 10000000 UNIT/ML injection
Inject under skin 3 times per week. Round to nearest 1 million units. Corticosteroids are NOT allowed for routine use., R-0, 3 X
WEEKLY starting S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH.
Labs Only - Day 15, Cycle 11 – Planned for 9/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
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 3:45:25 PM Page 22 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 12 – 10/2/2017 through 10/29/2017 (28 days), Planned
Day 1, Cycle 12 – Planned for 10/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained and resulted: WBC, ANC, Platelets, Creatinine, AST, ALT, Alkaline Phosphatase, Total
Bilirubin.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 50K/µL or Creatinine
greater than or equal to 1.6 mg/dL or AST greater than 3 X ULN or ALT greater than 3 X ULN or Alkaline Phosphatase greater than
3 X ULN or Total Bilirubin greater than 2 X ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Reinforce/teach patient to self-administer SC injection and provide supplies.
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]
11/28/2016 3:45:25 PM Page 23 of 24
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): interferon alpha-2B ( Dispensed Day 1 of each
cycle) and acetaminophen (Dispensed on Day 1 of Cycle 1)
Take Home Medications
interferon alfa-2B (INTRON A) 10000000 UNIT/ML injection
Inject under skin 3 times per week. Round to nearest 1 million units. Corticosteroids are NOT allowed for routine use., R-0, 3 X
WEEKLY starting S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if done locally), Creatinine, Alkaline Phosphatase, AST, ALT, Total Bilirubin.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Creatinine,
Alkaline Phosphatase, AST, ALT, Total Bilirubin, LDH.
Labs Only - Day 15, Cycle 12 – Planned for 10/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma (Adjuvant); THERAPY: MAINTENANCE: interferon alpha-2B 10 million units/m2 subcutaneous three times
weekly for 48 weeks (self-administered at home); CYCLE LENGTH: 28 days; COURSE: 12 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+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
ALKALINE PHOSPHATASE
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
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 3:45:25 PM Page 24 of 24
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org