Mitomycin Instillation Name: Date of birth: DATE TREATMENT NUMBER 1 2 3 4 5 6 7 8 SIGNATURE TESTS NORMAL ABNORMAL APPROVED BY – PHYSICIAN URINE DIPSTICK NORMAL ABNORMAL APPROVED BY – PHYSICIAN Remember to document the findings in the patient chart. See the local guideline about mitomycin instillation. Remember to hand out the patient information about mitomycin instillation.
Mitomycin Instillation Name: Date of birth: DATE TREATMENT NUMBER 1 2 3 4 5 6 7 8 SIGNATURE TESTS NORMAL ABNORMAL – APPROVED BY PHYSICIAN URINE DIPSTICK NORMAL ABNORMAL – APPROVED BY PHYSICIAN Remember to document the findings in the patient chart. See the local guideline about mitomycin instillation. Remember to hand out the patient information about mitomycin instillation.
EAUN-Mitomycin-Instillation-WEEKLY-def.docx