ࡱ > bjbjC3C3 4L !Y !Y h h h h h | | | 8 , | 9W ; ; ; V V V V V V V , Y [ X V h ; ; ; ; V i h h V i i i ; h h V i ; V i i N |P TU eY: $R 0 V W 0 9W TR %\ i %\ ` TU i TU h hU 4 ; ; ; V V i ; ; ; 9W %\ ; ; ; ; ; ; ; ; ; . : 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: LabDue timeFrequency/ IntervalSTAT?Clinic collect vs. Lab collectSpecimen Source Communication Orders: Treatment Parameters: Physician Communication: Nursing Orders: Scheduling Communication: Nutrition/Diet Information: Flushes/IV Fluids: DrugDose (mg/mg2, mg/kg,etc)RouteFrequency/ IntervalInfusion DurationTreatment DurationOffset TimeAdmin Instructions Pre Medications/Antiemetics: DrugDose (mg/mg2, mg/kg,etc)RouteFrequency/ IntervalInfusion DurationTreatment DurationOffset TimeAdmin Instructions Chemotherapy/Supportive Care Medications: Drug (including base)Dose (mg/mg2, mg/kg,etc)RouteFrequency/IntervalInfusion DurationTreatment DurationOffset TimeAdmin Instructions Post-Treatment Medications/Line Care: DrugDose (mg/mg2, mg/kg,etc)RouteFrequency/ IntervalInfusion DurationTreatment DurationOffset TimeAdmin Instructions Post Hydrations: DrugDose (mg/mg2, mg/kg,etc)RouteFrequency/ IntervalInfusion DurationTreatment DurationOffset TimeAdmin Instructions PRN/Emergency Medications DrugDose (mg/mg2, mg/kg,etc)RouteFrequency/ IntervalInfusion DurationTreatment DurationOffset TimeAdmin Instructions & + 4 6 V p q " 7 E K L ƾƮƉzume^WSSu hH hR h?* hR hH hR hH 5hR h2R 5 hH 5j h 6UmH nH uj h 5UmH nH uh7E] he| h7E] he| h$ h$ hR h$ h{ h{ 5hR h$ 5 h$ 5ha8s hD 5>*CJ aJ h= 5>*CJ aJ ha8s h+ 5>*CJ aJ ha8s h9 5>*CJ aJ M K B l } $If gd?* `gd$ pH gd$ gd+ gd$ $a$gda8s L T K V Y ! @ A B E G I j l ̿xq`q[ h$ 5 j h$ h$ UmH nH u h$ h$ j h$ 5UmH nH uh