Advanced Bladder Cancer Palliative Therapy Cycle: of Duration: 21 days Ht Wt BSA Allergies Yes cm kg m2 No Patient Addressograph Planned Administration Dates week(s) Day 1 Delay By (mm/dd/yy) Comments/Changes Date Initials week(s) (mm/dd/yy) Day 2 Delay By (mm/dd/yy) Day 8 Delay By week(s) (mm/dd/yy) Day 1 Requirements within 42 hours ANC Platelets Creatinine 60mL/min ≥ 1 x 109/L ≥ 100 x 109/L ≥ Other: Premedications (Strikeout to exclude) ondansetron 8 mg PO/IV LYCHOPR0032 dexamethasone 12 mg PO/IV Code: prochlorperazine 10 mg PO/IV PPO Other: 08 June Pre-hydration 1 (Strikeout to exclude) 1000 mL NS IV over 60 minutes Date: before treatment on treatment days that CISplatin is ordered Revision Other: Last Continued Day 1 Chemotherapy Orders Reason Date Initials (mm/dd/yy)
Advanced Bladder Cancer Palliative Therapy Cycle: of Duration: 21 days Ht Wt BSA Allergies cm kg m2 Yes No Patient Addressograph Planned Administration Dates Day 1 (mm/dd/yy) Delay By week(s) Day 2 (mm/dd/yy) Delay By week(s) Day 8 (mm/dd/yy) Delay By week(s) Day 1 Requirements within 42 hours ANC Platelets Creatinine ≥ 1 x 109/L ≥ 100 x 109/L ≥ 60mL/min Other: Premedications (Strikeout to exclude) ondansetron 8 mg PO/IV dexamethasone 12 mg PO/IV prochlorperazine 10 mg PO/IV Other: Pre-hydration (Strikeout to exclude) 1000 mL NS IV over 60 minutes before treatment on treatment days that CISplatin is ordered Other: Reason Date (mm/dd/yy) Initials Last Revision Date: 1 June 08 PPO Code: LYCHOPR0032 Comments/Changes Date (mm/dd/yy) Initials Continued Day 1 Chemotherapy Orders
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