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Therapy Plan Request Form
Requested by Name and Role: _________________________________________________________________________
Date: _____________________________________________________________________________________________
Therapy Plan Name: _________________________________________________________________________________
Is this a new plan or it is an edit to an existing plan?: New Plan Existing Plan
For edits to current therapy plans, please only fill out applicable fields. Please indicate if the edit is an addition, deletion, or replacement to a current plan.
Description: ____________________________________________________________________________________________________________________________________________________________________________________________________
Specialties that use this plan:
GI Neuro Podiatry Nephrology Oncology
ID Rheumatology Ortho Endocrine Ophthalmology
Other (please list):_____________________________________________________________
Common Synonyms:
|1. |2. |
|3. |4. |
|5. |6. |
Orders:
Labs:
|Lab |Due time |Frequency/ Interval|STAT? |Clinic collect vs. Lab collect |Specimen Source |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
Communication Orders:
• Treatment Parameters:
• Physician Communication:
• Nursing Orders:
• Scheduling Communication:
• Nutrition/Diet Information:
Flushes/IV Fluids:
Drug |Dose (mg/mg2, mg/kg,etc) |Route |Frequency/ Interval |Infusion Duration |Treatment Duration |Offset Time |Admin Instructions | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Pre Medications/Antiemetics:
Drug |Dose (mg/mg2, mg/kg,etc) |Route |Frequency/ Interval |Infusion Duration |Treatment Duration |Offset Time |Admin Instructions | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Chemotherapy/Supportive Care Medications:
Drug (including base) |Dose (mg/mg2, mg/kg,etc) |Route |Frequency/Interval |Infusion Duration |Treatment Duration |Offset Time |Admin Instructions | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Post-Treatment Medications/Line Care:
Drug |Dose (mg/mg2, mg/kg,etc) |Route |Frequency/ Interval |Infusion Duration |Treatment Duration |Offset Time |Admin Instructions | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Post Hydrations:
Drug |Dose (mg/mg2, mg/kg,etc) |Route |Frequency/ Interval |Infusion Duration |Treatment Duration |Offset Time |Admin Instructions | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
PRN/Emergency Medications
Drug |Dose (mg/mg2, mg/kg,etc) |Route |Frequency/ Interval |Infusion Duration |Treatment Duration |Offset Time |Admin Instructions | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
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