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CSC Sarcoma Doxorubicin(21D:1,2,3) Ifosfamide(21D:1,2,3) VER 5-1-17 (HL 5120)

CSC Sarcoma Doxorubicin(21D:1,2,3) Ifosfamide(21D:1,2,3) VER 5-1-17 (HL 5120) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Sarcoma


CSC SARCOMA DOXORUBICIN(21D1,2,3)IFOSFAMIDE(21D1,2,3) VER 5-1-17 – Properties
Pre-Cycle – 6/6/2017 through 6/12/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+397, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Ejection Fraction
Confirm MUGA scan or ECHO-left ejection fraction reviewed by MD prior to Cycle 1 (required at baseline). Document confirmation of
review in progress note.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Day 4 and 5., 8 mg, Disp-24 tab, R-0, 1 X DAILY starting S, Local Printer
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
ondansetron (ZOFRAN) 8 MG tab
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 1 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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
Take Home Medications (delete all that do not apply)
TBO-filgrastim (GRANIX) 300 MCG/0.5ML soln prefilled syringe
Inject 300 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 300 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
TBO-filgrastim (GRANIX) 480 MCG/0.8ML soln prefilled syringe
Inject 480 mcg under skin one time daily in evening. Begin Day ***. Continue until ANC is greater than *** after nadir., 480 mcg,
Disp-10 Syringe, R-5, 1 X DAILY (PM) starting S, Local Printer
RPh may substitute filgrastim at an equivalent dose and qty based on insurance coverage.
Cycle 1 – 6/13/2017 through 7/3/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/13/2017
Treatment Plan Information
Reference Information (1)
SOFT TISSUE SARCOMA: Pervaiz N, et al. Cancer 2008;113(3): 573-81.
Reference Information (2)
SOFT TISSUE SARCOMA: Blum RH, et al. Cancer Chemother. Pharmacol 1993; 31(Suppl 2):S238-40.
Reference Information (3)
SOFT TISSUE SARCOMA: Grobmyer SR, et al. Ann Oncol 2004;15:1667-72.
Reference Information (4)
SOFT TISSUE SARCOMA: Edmonson JH, et al. J Clin Oncol 1993;11:1269-75.
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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 Ejection Fraction
Confirm MUGA scan or ECHO-left ejection fraction reviewed by MD prior to Cycle 1 (required at baseline). Document confirmation of
review in progress note.
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Urinalysis with Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
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.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 2 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 4 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, & 3., 1,600 mg (rounded from 1,666
mg = 850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 3 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Magnesium, Urinalysis with Microscopy; CHEMOTHERAPY
ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
Day 2, Cycle 1 – Planned for 6/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 4 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
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,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 5 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 1 – Planned for 6/20/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 6 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 1 – Planned for 6/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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+12 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+12 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 – 7/4/2017 through 7/24/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/4/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 7 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Urinalysis with Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 8 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 4 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, & 3., 1,600 mg (rounded from 1,666
mg = 850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Magnesium, Urinalysis with Microscopy; CHEMOTHERAPY
ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
Day 2, Cycle 2 – Planned for 7/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 9 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Follow-Up
VERIFY APPOINTMENTS
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 10 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 2 – Planned for 7/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 11 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 2 – Planned for 7/11/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 2 – Planned for 7/18/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 12 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL
Expected-S+12 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+12 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 – 7/25/2017 through 8/14/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 7/25/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 13 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+19 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Urinalysis with Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 14 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 4 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, & 3., 1,600 mg (rounded from 1,666
mg = 850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Magnesium, Urinalysis with Microscopy; CHEMOTHERAPY
ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
Day 2, Cycle 3 – Planned for 7/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 15 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 3 – Planned for 7/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 16 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 17 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Lab Only - Day 8, Cycle 3 – Planned for 8/1/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 3 – Planned for 8/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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+12 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+12 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 – 8/15/2017 through 9/4/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 8/15/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 18 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Urinalysis with Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 19 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 4 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, & 3., 1,600 mg (rounded from 1,666
mg = 850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 20 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Magnesium, Urinalysis with Microscopy; CHEMOTHERAPY
ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
Day 2, Cycle 4 – Planned for 8/16/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 21 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous,
ONCE, 1 dose Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 4 – Planned for 8/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 22 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 4 – Planned for 8/22/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 23 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 4 – Planned for 8/29/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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+12 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+12 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 – 9/5/2017 through 9/25/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 9/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Routine
GLUCOSE
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 24 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+19 Approximate, Expires-S+365, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Urinalysis with Microscopy.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to 100K/µL or Urine
Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 25 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
Take 4 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, & 3., 1,600 mg (rounded from 1,666
mg = 850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Magnesium, Urinalysis with Microscopy; CHEMOTHERAPY
ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
Day 2, Cycle 5 – Planned for 9/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 26 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 5 – Planned for 9/7/2017
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 27 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 28 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 5 – Planned for 9/12/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 5 – Planned for 9/19/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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+12 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 29 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Expected-S+12 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 – 9/26/2017 through 10/16/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 9/26/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+19 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+19 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+19 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+19 Approximate, Expires-S+365, Routine
BUN
Expected-S+19 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+19 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+19 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+19 Approximate, Expires-S+365, Routine
ALKALINE PHOSPHATASE
Expected-S+19 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+19 Approximate, Expires-S+365, Routine
URINALYSIS WITH MICROSCOPY
Expected-S+19 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Urinalysis with Microscopy.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 30 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1500/µL or Platelets less than or equal to
100K/µL or Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
fosaprepitant (EMEND) 150 mg in sodium chloride 0.9 % 250 mL bag
150 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 minutes. Do not infuse with CA++, Mg++, Lactated Ringer's solutions
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Take Home Medications (delete all that do not apply)
mesna (MESNEX) 400 MG tab
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 31 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Take 4 tabs by mouth 2 times daily. Take 4 & 8 hours after start of ifosfamide on Day 1, 2, & 3., 1,600 mg (rounded from 1,666
mg = 850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), R-0, 2 X DAILY starting S
MD may delete this order and order IV mesna.
Follow-Up
DAY 2 FOLLOW-UP
LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
DAY 3 FOLLOW-UP
LABS: Urinalysis with Microscopy; CHEMOTHERAPY ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
DAY 8 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 15 FOLLOW-UP
LABS: CBC, ANC (DIFF if to be done locally).
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if to be done locally),
Electrolytes, Glucose, BUN, Creatinine, Total Bilirubin, AST, ALT, Magnesium, Urinalysis with Microscopy; CHEMOTHERAPY
ROOM APPOINTMENT: doxorubicin, ifosfamide, and mesna for 200 minutes.
Day 2, Cycle 6 – Planned for 9/27/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy.
Treatment Parameters
Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 32 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 3, Cycle 6 – Planned for 9/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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
URINALYSIS WITH MICROSCOPY
Expected-S+1 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: Urinalysis with Microscopy.
Treatment Parameters
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 33 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Hold treatment and notify authorizing prescriber for Urine Hemoglobin greater than Trace.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9% BOLUS
1,000 mL, Intravenous, ONCE, 1 dose Starting when released
Give bolus 1 hour prior to chemotherapy.
sodium chloride 0.9 % infusion 1,000 mL
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse an additional 1000ml throughout treatment
Pre-Medications
ondansetron (ZOFRAN) tab 16 mg
16 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
dexamethasone (DECADRON) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Administer 30 minutes prior to chemotherapy.
Treatment Medications
doxorubicin CONVENTIONAL (ADRIAMYCIN) injection 39 mg
39 mg (rounded from 39.2 mg = 20 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose
Starting when released
IV side arm push 3-5 mL/minute into running IV.
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse prior to ifosfamide infusion. Infuse over 10 minutes.
ifosfamide (IFEX) 4,900 mg in sodium chloride 0.9 % 500 mL bag
4,900 mg (2,500 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, ONCE, 1 dose Starting when released
Infuse over 60 minutes.
Treatment Medications (delete all that do not apply)
mesna (MESNEX) 1,666 mg in sodium chloride 0.9 % 50 mL bag
1,666 mg (850 mg/m2 × 1.96 m2 Treatment plan BSA from recorded weight), Intravenous, EVERY 4 HOURS, 2 doses Starting
when released
Administer over 10 minutes. Infuse 4 and 8 hours after start of ifosfamide infusion. Omit 4 and 8 hour IV doses if 4 and 8 hour oral
doses to be taken at home.
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 8, Cycle 6 – Planned for 10/3/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 34 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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+5 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+5 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Lab Only - Day 15, Cycle 6 – Planned for 10/10/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Soft Tissue Sarcoma (Adjuvant/Advanced); THERAPY: doxorubicin 20 mg/m2 IV Day 1, 2, and 3, mesna 850 mg/m2 IV
prior to ifosfamide and mesna 850 mg/m2 by mouth or IV 4 and 8 hours after the start of ifosfamide Day 1, 2, and 3, ifosfamide 2500
mg/m2 IV Day 1, 2, and 3; GROWTH FACTOR REQUIRED; CYCLE LENGTH: 21 days; COURSE: 6 cycles (Adjuvant) or until
disease progression (Advanced).
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+12 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+12 Approximate, Expires-S+365, Routine
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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Zztestonc,Jeff J [2507481]
6/13/2017 12:02:43 PM Page 35 of 35
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org