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Topics: Restrictions to Editing Chemo Orders Changing Chemo Orders in an Oncology Protocol Editing Chemo Orders Before Activation Defining Approval and Authorization Activation Dates and Expiration of Inpatient Chemo Orders Ordering, Activation, and Expiration of Chemo Pre-Admission Orders Activation Dates and Expiration of Ambulatory Chemo Orders |
Approval and Authorization—Chemotherapy orders that are awaiting either authorization or approval are inactive. Orders carrying either of these flags cannot be activated until authorized or approved as needed. In addition, the orders cannot be reused in a subsequent treatment. Inactive orders cannot be transcribed, reviewed by a nurse, or transmitted to the pharmacy. The dates for treatment cannot be changed until orders are approved or authorized as needed; unapproved/unauthorized orders expire on the start date of treatment. (See topic list, left, for links to more information on chemo expiration.) See the following procedures: Authorization—At MGH, exception orders (regimens only) must be approved by an attending with specialized regimen authorization. In addition, orders for pediatric chemo defined as high dose must be authorized every time the orders are written. Orders awaiting authorization of exceptions cannot be edited. Approval, non-exception orders for oncology treatments—All chemotherapy orders written by oncology fellows or a physician assistant must be approved by attendings with chemotherapy authorization. The first set of orders written from a regimen by a nurse practitioner, as well as all orders written from a protocol, must likewise be approved. Unapproved orders can be edited. Approval, new exception orders for oncology treatments—At present, not all of the standard regimens in use at Dana Farber Partners Cancer Care (DFPCC) are available via Order Entry. Until this is done, exception orders and exception regimens are needed. At DFCI sites, these exceptions must be approved by a second oncologist before they can be activated for administration. Approval, non-exception orders for non-oncology treatments—At the BWH non-oncology infusion units, all chemotherapy orders written by fellows or a physician assistant must be approved by an attending. The first set of orders written from a regimen by a nurse practitioner must likewise be approved. Unapproved orders can be edited. Approval, exception orders to non-oncology treatments—At the BWH non-oncology infusion units, attendings and fellows can write chemotherapy exception orders. All orders written by fellows must be approved by an attending. Approval, reuse previous exception orders—NPs and PAs can reuse previously authorized or approved exception orders. At MGH and the BWH non-oncology infusion units, if no changes are made when writing the new orders, no MD approval is required. All reused exception orders at DFCI sites, and those that have been edited by the NP at MGH, require MD approval. Approval, don't reuse previous exception orders—If an NP does not choose to reuse previous orders the contain authorized or approves exceptions, the new orders must be approved by an MD. Approval, post-activation dose change—Chemo dosing is recalculated based on the chemo weight, and in the case of AUC dosing, the patient's creatinine, both confirmed by the nurse at activation. If the dosing changes by more than five percent (5%) due to updates in weight, BSA, creatinine, creatinine clearance, or AUC during activation, an attending oncologist or pediatric oncology NP must approve the orders. Dose changes of more than 5% triggered by NP activation must be approved by an attending oncologist. The ordering clinician can write the orders to prevent recalculation of dosing—see Preventing Recalculation On Activation (Writing or Editing Chemo Orders). Approval of Pediatric Capped Total Dose Modifications—For pediatric treatments only, some modifications calculate a Capped Total Dose. This dose is not automatically recalculated against the patient's BSA on activation. The reason for Do Not Recalculate is provided automatically when you select a Capped Total Dose modification. Recalculated dosing that would increase the total dose is ignored because the dose is capped. If recalculating the dose on activation would decrease the dose by more than 5%, the orders must be approved before they can be activated. Approval, post-activation change in condition—Dosing may also be defined based on an age range, a weight range, or for pediatric patients, a combination of the two. For example, patients under three (3) years old may get one dose, while patients over three (3) get something different. When chemo orders are activated, these conditions are rechecked. Over time, it is possible that a patient has aged or changes weight enough to meet the conditions for a different dose. When this happens, the orders must be approved after they are activated. Orders activated by an RN can be approved by an oncology attending or pediatric oncology NP. Dose changes triggered by NP activation must be approved by an oncology attending. Approval, post-activation by NP—Pediatric NPs can activate order sessions containing chemotherapy. However, if the NP activating the orders also wrote them, an attending oncologist must then approve the orders. The rule for post-activation dose changes also applies (see above). |