/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-96985-en.cckm

201611333

page

100

UWHC,UWMF,

Tools,

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

CSC Melanoma Vemurafenib(28D:1-28) VER 10-3-16 (HL 4420)

CSC Melanoma Vemurafenib(28D:1-28) VER 10-3-16 (HL 4420) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Melanoma


CSC MELANOMA VEMURAFENIB(28D:1-28) VER: 10-3-16 – Properties
Pre-Cycle – 11/21/2016 through 11/27/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/21/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma with BRAF (V600E) mutation (Advanced); THERAPY: vemurafenib 960 mg by mouth twice daily
continuously ;CYCLE LENGTH: 28 days; COURSE: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
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
MAGNESIUM
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
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Pre-Labs (delete all that do not apply)
HCG, QUALITATIVE
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Treatment Condition A
Verify ECG obtained.
Take Home Medications
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 1 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Cycle 1 - with ECG – 11/28/2016 through 12/25/2016 (28 days), Planned
Day 1 - MD Visit with ECG, Cycle 1 - with ECG – Planned for 11/28/2016
Treatment Plan Information
Reference Information (1)
MELANOMA: Chapman PB, et al. N Engl J Med. 2011;364(26):2507-16.
Treatment Plan Summary
DISEASE: Melanoma with BRAF (V600E) mutation (Advanced); THERAPY: vemurafenib 960 mg by mouth twice daily
continuously ;CYCLE LENGTH: 28 days; COURSE: until disease progression
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alk
Phosphatase, LDH.
Treatment Condition A
Verify melanoma with BRAF (V600E) mutation
Treatment Condition B
Verify ECG obtained.
Treatment Parameters
Hold and notify authorizing prescriber for QTc exceeds 500 ms
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.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): vemurafenib (dispensed on Day 1 of Cycle 1
only - subsequent refills will be ordered through the medication activity).
Take Home Medications
vemurafenib (ZELBORAF) 240 MG tab
Take 4 tabs by mouth 2 times daily., 960 mg, Disp-224 tab, R-0, 2 X DAILY starting S, Local Printer
Follow-Up
DAY 15 FOLLOW-UP
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 2 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

RETURN TO CLINIC for appointment with provider; PROCEDURE: ECG; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total LD.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; PROCEDURE: ECG; LABS: CBC with DIFF, Electrolytes,
Glucose, BUN, Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total LD.
Day 15 MD Visit with ECG, Cycle 1 - with ECG – Planned for 12/12/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma with BRAF (V600E) mutation (Advanced); THERAPY: vemurafenib 960 mg by mouth twice daily
continuously ;CYCLE LENGTH: 28 days; COURSE: until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
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
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
Treatment Conditions
Treatment Condition A
Verify ECG obtained.
Treatment Parameters
Hold and notify authorizing prescriber for QTc exceeds 500 ms
Follow-Up
VERIFY APPOINTMENTS
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 3 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 - with ECG – 12/26/2016 through 1/22/2017 (28 days), Planned
Day 1 - MD Visit with ECG, Cycle 2 - with ECG – Planned for 12/26/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma with BRAF (V600E) mutation (Advanced); THERAPY: vemurafenib 960 mg by mouth twice daily
continuously ;CYCLE LENGTH: 28 days; COURSE: until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
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
ALKALINE PHOSPHATASE
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: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alk
Phosphatase, LDH.
Treatment Condition A
Verify ECG obtained.
Treatment Parameters
Hold and notify authorizing prescriber for QTc exceeds 500 ms
Nursing Procedure, Assessment and Monitoring
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 4 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

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
Oral Chemotherapy Order Management
For this regimen, vemurafenib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 15 FOLLOW-UP
LABS: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline
Phosphatase, Total LD.
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; PROCEDURE: ECG; LABS: CBC with DIFF, Electrolytes,
Glucose, BUN, Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total LD.
Day 15, Cycle 2 - with ECG – Planned for 1/9/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma with BRAF (V600E) mutation (Advanced); THERAPY: vemurafenib 960 mg by mouth twice daily
continuously ;CYCLE LENGTH: 28 days; COURSE: until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 5 of 16
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
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
LD, 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 - with ECG – 1/23/2017 through 2/19/2017 (28 days), Planned
Day 1 - MD Visit with ECG, Cycle 3 - with ECG – Planned for 1/23/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma with BRAF (V600E) mutation (Advanced); THERAPY: vemurafenib 960 mg by mouth twice daily
continuously ;CYCLE LENGTH: 28 days; COURSE: until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
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
ALKALINE PHOSPHATASE
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 3:55:02 PM Page 6 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alk
Phosphatase, LDH.
Treatment Condition A
Verify ECG obtained.
Treatment Parameters
Hold and notify authorizing prescriber for QTc exceeds 500 ms
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.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, vemurafenib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total LD.
Day 15, Cycle 3 - with ECG – Planned for 2/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Melanoma with BRAF (V600E) mutation (Advanced); THERAPY: vemurafenib 960 mg by mouth twice daily
continuously ;CYCLE LENGTH: 28 days; COURSE: until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 7 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
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
ALKALINE PHOSPHATASE
Expected-S+14 Approximate, Expires-S+365, Routine
LD, 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 with BRAF (V600E) mutation (Advanced); THERAPY: vemurafenib 960 mg by mouth twice daily
continuously ;CYCLE LENGTH: 28 days; COURSE: until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+14 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+14 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+14 Approximate, Expires-S+365, Routine
BUN
Expected-S+14 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+14 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+14 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+14 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+14 Approximate, Expires-S+365, Routine
AST/SGOT
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 8 of 16
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
ALT/SGPT
Expected-S+14 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
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: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alk
Phosphatase, LDH.
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.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, vemurafenib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total LD.
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 with BRAF (V600E) mutation (Advanced); THERAPY: vemurafenib 960 mg by mouth twice daily
continuously ;CYCLE LENGTH: 28 days; COURSE: until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 9 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alk
Phosphatase, LDH.
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.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, vemurafenib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; PROCEDURE: ECG; LABS: CBC with DIFF, Electrolytes,
Glucose, BUN, Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total LD.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 10 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Melanoma with BRAF (V600E) mutation (Advanced); THERAPY: vemurafenib 960 mg by mouth twice daily
continuously ;CYCLE LENGTH: 28 days; COURSE: until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alk
Phosphatase, LDH.
Treatment Condition A
Verify ECG obtained every 3 months on Cycle 6, 9, 12, etc
Treatment Parameters
Hold and notify authorizing prescriber for QTc exceeds 500 ms every 3 months on Cycle 6, 9, 12, etc.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 11 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, vemurafenib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total LD.
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 with BRAF (V600E) mutation (Advanced); THERAPY: vemurafenib 960 mg by mouth twice daily
continuously ;CYCLE LENGTH: 28 days; COURSE: until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 12 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alk
Phosphatase, LDH.
Treatment Condition A
Verify ECG obtained every 3 months on Cycle 6, 9, 12, etc
Treatment Parameters
Hold and notify authorizing prescriber for QTc exceeds 500 ms every 3 months on Cycle 6, 9, 12, etc.
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.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, vemurafenib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total LD.
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 with BRAF (V600E) mutation (Advanced); THERAPY: vemurafenib 960 mg by mouth twice daily
continuously ;CYCLE LENGTH: 28 days; COURSE: until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 13 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alk
Phosphatase, LDH.
Treatment Condition A
Verify ECG obtained every 3 months on Cycle 6, 9, 12, etc
Treatment Parameters
Hold and notify authorizing prescriber for QTc exceeds 500 ms every 3 months on Cycle 6, 9, 12, etc.
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.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, vemurafenib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total LD.
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
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 14 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Melanoma with BRAF (V600E) mutation (Advanced); THERAPY: vemurafenib 960 mg by mouth twice
daily continuously ;CYCLE LENGTH: 28 days; COURSE: until disease progression
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected-S+28 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+28 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+28 Approximate, Expires-S+365, Routine
BUN
Expected-S+28 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+28 Approximate, Expires-S+365, Routine
CALCIUM
Expected-S+28 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+28 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+28 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+28 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+28 Approximate, Expires-S+365, Routine
LD, TOTAL
Expected-S+28 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF, Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Alk
Phosphatase, LDH.
Treatment Condition A
Verify ECG obtained every 3 months on Cycle 6, 9, 12, etc
Treatment Parameters
Hold and notify authorizing prescriber for QTc exceeds 500 ms every 3 months on Cycle 6, 9, 12, etc.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 15 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, vemurafenib will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose, BUN,
Creatinine, Calcium, Magnesium, Total Bilirubin, AST, ALT, Alkaline Phosphatase, Total LD.
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ZZtestonc,Andrew [2428787]
11/28/2016 3:55:02 PM Page 16 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org