Order Chemotherapy—Steps

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• Select the patient

• Start the chemo order session

• For inpatient and ambulatory orders, click Write (ALT+W).
  New inpatient chemo orders are not allowed if the patient has post-op orders awaiting activation.

• For pre-admission orders, click Special Orders (ALT+O), then Pre-Admit (ALT+I), then New (ALT+N).

• Ambulatory or pre-admission: Enter the expected visit date

• Ambulatory only: Select the visit location

• Click Chemo (ALT+H)

• Click Add (ALT+A)

• If the patient is registered to more than one protocol

• If the patient has a finalized treatment plan in the LMR

• If the patient has chemotherapy orders awaiting activation

• If the patient has active chemo orders

• Set up the treatment—Regimen/protocol, diagnosis, numbering, day 1/day 0, patient height and weight

• Select the treatment—protocol

• Select the treatment—regimen

• Enter height and weight

• Validate the weight (triggered alert as outlier for age group)

• Validate the height (triggered alert as outlier for age group)

• Click OK (ALT+ O).

• Confirm treatment setup

• LMR Users using COE weight with greater than 5% difference from LMR weight

• Validate weight and height

• Confirm or change treatment number

• Confirm or change if day 1 or day 0 is in the past

• Indicate reasons if writing orders that start before the end of the current treatment

• Reusing previous order parameters

• See Chemo Overview: Reusing Exception Orders for information on the requirements for reusing previous orders.

• This patient has previously signed chemo orders. The orders as defined by the standard regimen or protocol are displayed by default. Up to three (3) previous order sessions from the last six (6) months are displayed on the tabs beneath. Each previous tab is labeled with the date the orders were signed.

• Hold the mouse pointer over a dated tab to display the name of the regimen or protocol.

• Click a dated tab to display the orders in that previous session.

• Orders from a previous session that differ from the standard for the regimen or protocol are highlighted with bold text.

• On the initial implementation of this enhancement, only the standard regimen or protocol and the last signed previous session is available. Additional sessions will be included as they are signed.

• To access the LMR Oncology Infusion Flowsheet, click Infusion Flowsheet (ALT+F).

• To display details of an order, click its line to select it, then click Zoom (ALT+Z).

• To generate a paper copy of the orders, click to select a session (standard or dated previous), then click Print (ALT+P).

• To continue:

• To use the standard regimen or protocol, click the Standard Regimen or Standard Protocol tab, then click Select (ALT+S).

• To start with what was ordered on a previous treatment, click the dated tab for the previous session, then click Select (ALT+S).

• If prompted that orders were discontinued after the session was signed, click OK (ALT+O) to acknowledge the message.

• The effect of discontinuing a chemo order that has been signed—whether it has been activated or not—is to delete the scheduled days, not to omit or uncheck it on the order set. You must enter the days to administer that drug if you want to include it in the orders.

• Open the chemo player

• Acknowledge treatment-specific physician instructions

• Select one (for mutually exclusive treatments)

• Select folder (treatment as needed)

• Check information on the actual treatment administered previously—access the LMR Oncology Infusion Flowsheet

1. Click Infusion Flowsheet (ALT+F).

2. Click Orders in the CAS to return to the chemo player, and LMR to toggle back to the Infusion flowsheet.

• Non-chemo orders—select, edit, add

• Select orders from a non-chemo set

• Edit a general care order

• Edit a medication order

• Edit an IV fluid order

• Add orders to a non-chemo set

• Chemo orders—select

• Click Next (ALT+N) to open the Chemotherapy folder and display the orders in the grid to the right.

• Results for relevant laboratory tests are displayed in a grid above the order list. If no results are displayed, check the Results viewer by clicking Results in the CAS toolbar on the left—see Checking Last Known Values for Lab Results.

• Set up AUC dosing if prompted

• Set up weight for dosing if prompted

• If any of the orders is PO, a message reminding you to use dose options appears. Click OK (ALT+O).

• Missing scheduled days: If an order for chemo was discontinued, a message displays that an order does not have scheduled days. Click OK (ALT+O). You must restore the scheduled days to include the order in this session. See Editing scheduled days.

• Select orders from the chemo set

• Undo order selections in the chemo set

• Edit a chemo order

• Click the line for an order to highlight it and display its parameters in the section beneath the order list.

• Dose modifications

• AUC dose modifications

• Change the preset weight

• Adjust dosing of oral medications

• If needed, make limited changes to the scheduled day(s)

• If needed, prevent recalculation of dosing of chemotherapeutics at activation—based on adjustments made to the patient's weight, height, or creatinine

• Order desensitization

• Update administration instructions

• Write or Edit a prescription for an oral investigational chemo med

• Add a chemo exception order (MD only)

Only chemotherapeutic or chemo-related medications can be added via this form. Dosing methods and scheduling on the Chemo form are set up for chemo and medications that are administered like chemo. To add a different kind of drug, cancel out of this form, click Previous to move to a non-chemo folder, and edit the folder list. See above, Add Orders to a Non-Chemo Set .

1. Click Add Chemo (ALT+A).

2. Look up the medication

   1. Type all or part of the name of the medication in the Med name field, then press TAB.

   2. Select an administration method from the Route list to narrow the list of results. Combo or multiple routes are not allowed.

   3. Click Search (ALT+ S ). Results that match your criteria are listed.

3. Select from the search results

   1. If available, to restart the search based on a different age-based population, click the option at the bottom of the results window.

   2. Press the down arrow key or click a line to select from the displayed list.

   3. Click OK (ALT+ O ) or press ENTER .

   4. If applicable, the IV Type window opens. Click to select an option, then click OK (ALT+ O ).

4. Define the dosing and other information

   1. Wait a moment for the system to pull up dosing information on the med you selected. Select the method for dosing (dosed by).

   2. Click the Standard Dose field to set the values for calculating the total dose.

   • For other dosing (non-AUC), type the amount of the standard dose based on the units you selected. The Total Dose is calculated automatically and displayed when you move to the next entry.

   • For AUC dosing, click to select either the Cockroft-Gault or Jelliffe formula. Type the patient's most current serum creatinine, then press TAB. The Creatinine Clearance is calculated automatically, based on the formula you chose. Type a Target AUC, then press TAB to calculate the AUC Dose. By default, the order is set to recalculate based on the creatinine level entered by the nurse when the order is activated. If you don't want this, click the Do Not Recalculate option, then type a reason in the field beneath. Click OK (ALT+O O ). The calculated Total Dose is displayed on the form.

5. Set the schedule

   One-time (X1) medications cannot have scheduled days.

   1. Click Scheduled days/doses (ALT+ H ).

   2. Click Days (ALT+Y).

   3. Type numbers separated by commas (,) to designate days of the treatment. Use negative numbers for days prior to a defining event—for example, a bone marrow transplant. To indicate a number of consecutive days, type the first and last day of the range, separated by a colon (:).

   4. Click OK (ALT+ O ) to return to the medications form.

6. For pediatrics only, as needed define fluids and additives for IV drugs

   1. If you haven't already, click Mix-In... on the Chemo Medication Orders form.  (Fluids and Additives for mix-in are only available for IV routes.)

   2. Select an option from the Fluid drop-down list as the primary diluent. For Other, type a description when prompted, then click OK.

   3. Type the amount of fluid needed.

   4. Select the appropriate unit of measure. For Other, type a description when prompted, then click OK. (Weight-based amounts are calculated automatically when the order is written.)

   5. For each one needed, select from an Additive drop-down list.

   • For Other, type a description when prompted, then click OK.

   • Up to eight (8) additives are allowed.

   6. Type the amount of each additive needed.

   7. Select the appropriate unit of measure for each additive. For Other, type a description when prompted, then click OK.

   8. Click OK (ALT+O).

7. If the order needs to be activated by a chemo attending, fellow, NP, or PA, click to check This chemotherapy medication will be administered by the Provider.

8. For a PO med and an adult patient, to allow the modifications to the administration (to accommodate available tablet strength, or to allow splitting the administration) , click to check Adult PO dose options.

9. Click OK (ALT+ O ). The order is added to the open Chemo folder.

• Complete the session

• If you haven't already, after you have opened the Chemo folder (last in the group), having selected and adjusted all orders as needed, click OK (ALT+ O) .

• Provide the reason for writing exception orders

• Respond to the Chemo High Dose Warning

• Respond to Interventions

• Add a memo as needed (which is saved as a General Care order)

1. Click Memo (ALT+M).

2. Type to add, edit, or delete the note.

3. Click OK (ALT+O).

• As needed, view order details, view or print a list of chemo and medication orders only, or make changes before signing.

• To view order details, select a line from the list and click Zoom (ALT+Z). Click Close (ALT+C) to return to the list.

• To view or print a list of chemo and medication orders only, click View Chemo (ALT+V).

• To print a list of these orders, click Print All (ALT+A).

• To print a single order, click to select it on the list, then click Print Order (ALT+P).

• To view order details, select a line from the list and click Zoom (ALT+Z).

• Click Close (ALT+C) to return to the review and sign list.

• To make changes before signing, click Return to Player (ALT+R). Select, deselect, and edit orders as needed, then click OK (ALT+O).

• Sign the session

1. Click Sign (ALT+S).

2. Define parameters for treatment when prompted.

3. Type your signing key.

4. Assign provider for orders requiring either approval or authorization. To look up a provider:

1. Type at least three letters of the last name, followed by a comma (,), and one or more letters from the first name (no spaces).

2. Press ENTER. The Providers list opens, displaying any names that matched your input.

3. Click to select a name, or press ENTER to take as typed.

5. Life-Sustaining Treatment—All inpatients must have orders. If the patient needs and doesn't have active orders for Life-Sustaining Treatment, the three options—Full, Limited, or Unknown—are active beneath the key field. To change from the default of Unknown, click another option.

6. Click OK (ALT+O).

7. Allergies—If there is no allergy information on the patient, the Allergies tab pops to the front.

• To open the Allergies order form and record known allergies, click Enter Allergies (ALT+E).

• If the patient has no known allergies, click NKA (ALT+K).

• If you have no information on drug allergies for this patient, click Allergies Unknown (ALT+K).

• Click OK (ALT+O).

• Check the orders awaiting activation

• If the orders were written using the Special Orders > Pre-Admit function, the orders awaiting activation are displayed in the Pre-Admit/NICO session list. See Viewing Pre-Admission/NICO orders.

• Inpatient orders written via the Write function are new inpatient chemo orders (NICO) awaiting activation. To access these orders, see Viewing Pre-Admission/NICO Orders.

• Ambulatory orders written via the Write function are pending activation. To access these orders, see Viewing Ambulatory Chemo Orders.

• See also Overview of Chemo Order Entry .