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/clinical/cckm-tools/content/beacon-protocols/supportive-care/name-122938-en.cckm

201711331

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CSC SC Epoetin Every 2 Weeks Ver 11-20-17 (HL 1854)

CSC SC Epoetin Every 2 Weeks Ver 11-20-17 (HL 1854) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Supportive Care


CSC SC EPOETIN EVERY 2 WEEKS VER: 11-20-17 –  Properties
Cycle 1 –  11/21/2017 through 12/18/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 11/21/2017
Treatment Conditions
Treatment Condition A
Progress note MUST be completed for each dose administered. Select and complete one of the following in the
Progress Notes section: DARBE/EPO CSC ONC NEW, DARBE/EPO CSC ONC CONTINUING, DARBE/EPO CSC RENAL NEW
or DARBE/EPO CSC RENAL CONTINUING.
Supportive Care Medications
Patient Medication Guide: epoetin  (PROCRIT)
ONCE, 1 dose Starting when released
Please provide medication guide to patient
epoetin alfa (PROCRIT) injection
Subcutaneous, ONCE, 1 dose Starting when released
Refer to applicable Clinical Practice Guideline - Use of Darbepoetin and Epoetin in Non-Nephrology Patients or Anemia
Management in Chronic Kidney Disease.
Day 15, Cycle 1 –  Planned for 12/5/2017
Treatment Conditions
Treatment Condition A
Progress note MUST be completed for each dose administered. Select and complete one of the following in the
Progress Notes section: DARBE/EPO CSC ONC NEW, DARBE/EPO CSC ONC CONTINUING, DARBE/EPO CSC RENAL NEW
or DARBE/EPO CSC RENAL CONTINUING.
Supportive Care Medications
Patient Medication Guide: epoetin  (PROCRIT)
ONCE, 1 dose Starting when released
Please provide medication guide to patient
epoetin alfa (PROCRIT) injection
Subcutaneous, ONCE, 1 dose Starting when released
Refer to applicable Clinical Practice Guideline - Use of Darbepoetin and Epoetin in Non-Nephrology Patients or Anemia
Management in Chronic Kidney Disease.
Cycle 2 –  12/19/2017 through 1/15/2018 (28 days), Planned
Day 1, Cycle 2 –  Planned for 12/19/2017
Treatment Conditions
Treatment Condition A
Progress note MUST be completed for each dose administered. Select and complete one of the following in the
Progress Notes section: DARBE/EPO CSC ONC NEW, DARBE/EPO CSC ONC CONTINUING, DARBE/EPO CSC RENAL NEW
or DARBE/EPO CSC RENAL CONTINUING.
Supportive Care Medications
Patient Medication Guide: epoetin  (PROCRIT)
ONCE, 1 dose Starting when released
Please provide medication guide to patient
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
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Actions
Actions
Zztestonc,Fiona F [2462287]
11/21/2017 10:20:54 AM Page 1 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

epoetin alfa (PROCRIT) injection
Subcutaneous, ONCE, 1 dose Starting when released
Refer to applicable Clinical Practice Guideline - Use of Darbepoetin and Epoetin in Non-Nephrology
Patients or Anemia Management in Chronic Kidney Disease.
Day 15, Cycle 2 –  Planned for 1/2/2018
Treatment Conditions
Treatment Condition A
Progress note MUST be completed for each dose administered. Select and complete one of the following in the
Progress Notes section: DARBE/EPO CSC ONC NEW, DARBE/EPO CSC ONC CONTINUING, DARBE/EPO CSC RENAL NEW
or DARBE/EPO CSC RENAL CONTINUING.
Supportive Care Medications
Patient Medication Guide: epoetin  (PROCRIT)
ONCE, 1 dose Starting when released
Please provide medication guide to patient
epoetin alfa (PROCRIT) injection
Subcutaneous, ONCE, 1 dose Starting when released
Refer to applicable Clinical Practice Guideline - Use of Darbepoetin and Epoetin in Non-Nephrology Patients or Anemia
Management in Chronic Kidney Disease.
Cycle 3 –  1/16/2018 through 2/12/2018 (28 days), Planned
Day 1, Cycle 3 –  Planned for 1/16/2018
Treatment Conditions
Treatment Condition A
Progress note MUST be completed for each dose administered. Select and complete one of the following in the
Progress Notes section: DARBE/EPO CSC ONC NEW, DARBE/EPO CSC ONC CONTINUING, DARBE/EPO CSC RENAL NEW
or DARBE/EPO CSC RENAL CONTINUING.
Supportive Care Medications
Patient Medication Guide: epoetin  (PROCRIT)
ONCE, 1 dose Starting when released
Please provide medication guide to patient
epoetin alfa (PROCRIT) injection
Subcutaneous, ONCE, 1 dose Starting when released
Refer to applicable Clinical Practice Guideline - Use of Darbepoetin and Epoetin in Non-Nephrology Patients or Anemia
Management in Chronic Kidney Disease.
Day 15, Cycle 3 –  Planned for 1/30/2018
Treatment Conditions
Treatment Condition A
Progress note MUST be completed for each dose administered. Select and complete one of the following in the
Progress Notes section: DARBE/EPO CSC ONC NEW, DARBE/EPO CSC ONC CONTINUING, DARBE/EPO CSC RENAL NEW
or DARBE/EPO CSC RENAL CONTINUING.
Supportive Care Medications
Patient Medication Guide: epoetin  (PROCRIT)
ONCE, 1 dose Starting when released
Please provide medication guide to patient
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/21/2017 10:20:54 AM Page 2 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

epoetin alfa (PROCRIT) injection
Subcutaneous, ONCE, 1 dose Starting when released
Refer to applicable Clinical Practice Guideline - Use of Darbepoetin and Epoetin in Non-Nephrology Patients or Anemia
Management in Chronic Kidney Disease.
Cycle 4 –  2/13/2018 through 3/12/2018 (28 days), Planned
Day 1, Cycle 4 –  Planned for 2/13/2018
Treatment Conditions
Treatment Condition A
Progress note MUST be completed for each dose administered. Select and complete one of the following in the
Progress Notes section: DARBE/EPO CSC ONC NEW, DARBE/EPO CSC ONC CONTINUING, DARBE/EPO CSC RENAL NEW
or DARBE/EPO CSC RENAL CONTINUING.
Supportive Care Medications
Patient Medication Guide: epoetin  (PROCRIT)
ONCE, 1 dose Starting when released
Please provide medication guide to patient
epoetin alfa (PROCRIT) injection
Subcutaneous, ONCE, 1 dose Starting when released
Refer to applicable Clinical Practice Guideline - Use of Darbepoetin and Epoetin in Non-Nephrology Patients or Anemia
Management in Chronic Kidney Disease.
Day 15, Cycle 4 –  Planned for 2/27/2018
Treatment Conditions
Treatment Condition A
Progress note MUST be completed for each dose administered. Select and complete one of the following in the
Progress Notes section: DARBE/EPO CSC ONC NEW, DARBE/EPO CSC ONC CONTINUING, DARBE/EPO CSC RENAL NEW
or DARBE/EPO CSC RENAL CONTINUING.
Supportive Care Medications
Patient Medication Guide: epoetin  (PROCRIT)
ONCE, 1 dose Starting when released
Please provide medication guide to patient
epoetin alfa (PROCRIT) injection
Subcutaneous, ONCE, 1 dose Starting when released
Refer to applicable Clinical Practice Guideline - Use of Darbepoetin and Epoetin in Non-Nephrology Patients or Anemia
Management in Chronic Kidney Disease.
Cycle 5 –  3/13/2018 through 4/9/2018 (28 days), Planned
Day 1, Cycle 5 –  Planned for 3/13/2018
Treatment Conditions
Treatment Condition A
Progress note MUST be completed for each dose administered. Select and complete one of the following in the
Progress Notes section: DARBE/EPO CSC ONC NEW, DARBE/EPO CSC ONC CONTINUING, DARBE/EPO CSC RENAL NEW
or DARBE/EPO CSC RENAL CONTINUING.
Supportive Care Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/21/2017 10:20:54 AM Page 3 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Patient Medication Guide: epoetin  (PROCRIT)
ONCE, 1 dose Starting when released
Please provide medication guide to patient
epoetin alfa (PROCRIT) injection
Subcutaneous, ONCE, 1 dose Starting when released
Refer to applicable Clinical Practice Guideline - Use of Darbepoetin and Epoetin in Non-Nephrology Patients or Anemia
Management in Chronic Kidney Disease.
Day 15, Cycle 5 –  Planned for 3/27/2018
Treatment Conditions
Treatment Condition A
Progress note MUST be completed for each dose administered. Select and complete one of the following in the
Progress Notes section: DARBE/EPO CSC ONC NEW, DARBE/EPO CSC ONC CONTINUING, DARBE/EPO CSC RENAL NEW
or DARBE/EPO CSC RENAL CONTINUING.
Supportive Care Medications
Patient Medication Guide: epoetin  (PROCRIT)
ONCE, 1 dose Starting when released
Please provide medication guide to patient
epoetin alfa (PROCRIT) injection
Subcutaneous, ONCE, 1 dose Starting when released
Refer to applicable Clinical Practice Guideline - Use of Darbepoetin and Epoetin in Non-Nephrology Patients or Anemia
Management in Chronic Kidney Disease.
Cycle 6 –  4/10/2018 through 5/7/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 4/10/2018
Treatment Conditions
Treatment Condition A
Progress note MUST be completed for each dose administered. Select and complete one of the following in the
Progress Notes section: DARBE/EPO CSC ONC NEW, DARBE/EPO CSC ONC CONTINUING, DARBE/EPO CSC RENAL NEW
or DARBE/EPO CSC RENAL CONTINUING.
Supportive Care Medications
Patient Medication Guide: epoetin  (PROCRIT)
ONCE, 1 dose Starting when released
Please provide medication guide to patient
epoetin alfa (PROCRIT) injection
Subcutaneous, ONCE, 1 dose Starting when released
Refer to applicable Clinical Practice Guideline - Use of Darbepoetin and Epoetin in Non-Nephrology Patients or Anemia
Management in Chronic Kidney Disease.
Day 15, Cycle 6 –  Planned for 4/24/2018
Treatment Conditions
Treatment Condition A
Progress note MUST be completed for each dose administered. Select and complete one of the following in the
Progress Notes section: DARBE/EPO CSC ONC NEW, DARBE/EPO CSC ONC CONTINUING, DARBE/EPO CSC RENAL NEW
or DARBE/EPO CSC RENAL CONTINUING.
Supportive Care Medications
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Zztestonc,Fiona F [2462287]
11/21/2017 10:20:54 AM Page 4 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

Patient Medication Guide: epoetin  (PROCRIT)
ONCE, 1 dose Starting when released
Please provide medication guide to patient
epoetin alfa (PROCRIT) injection
Subcutaneous, ONCE, 1 dose Starting when released
Refer to applicable Clinical Practice Guideline - Use of Darbepoetin and Epoetin in Non-Nephrology Patients or Anemia
Management in Chronic Kidney Disease.
Actions
Actions
Zztestonc,Fiona F [2462287]
11/21/2017 10:20:54 AM Page 5 of 5
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org