Gastric Lymphoma Cycle: of Duration: 21 days Ht Wt BSA Allergies Yes cm kg m2 No Patient Addressograph Planned Administration Dates Reason Date Initials Day 1 Delay By week(s) (mm/dd/yy) (mm/dd/yy) Day 2 Delay By week(s) (mm/dd/yy) Comments/Changes Date Initials (mm/dd/yy) Day 1 Requirements within 96 hours ANC Platelets ≥ 0.8 x 109/L ≥ 100 x 109/L Other: Pre-medications (Strikeout to exclude) ondansetron 8mg PO/IV dexamethasone 12mg PO/IV Other: LYCHOPR0032 Pre-hydration (Strikeout to exclude) Infuse NS as primary line at 75 mL/hr while drugs Code: administered PPO Other: 08 June 1 Date: Revision Last Day 1 Continued
Gastric Lymphoma 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 1 Requirements within 96 hours ANC Platelets ≥ 0.8 x 109/L ≥ 100 x 109/L Other: Pre-medications (Strikeout to exclude) ondansetron 8mg PO/IV dexamethasone 12mg PO/IV Other: Pre-hydration (Strikeout to exclude) Infuse NS as primary line at 75 mL/hr while drugs administered Other: Reason Date (mm/dd/yy) Initials Last Revision Date: 1 June 08 PPO Code: LYCHOPR0032 Comments/Changes Date (mm/dd/yy) Initials Day 1 Continued
chopr-final-Jan-11-2011.docx