Download Physician Simulation Orders: Lung Set Fields

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Lung Set Fields Sim Directive (60 min)
Iso Verification: Choose
Match &Adjust Anatomy with Portal Imaging to establish isocenter on days 1 and 2. If isocenter is within tolerance limits
continue to use Match and Adjust Anatomy every 5th fraction to verify patient setup. (If tolerance is out of limits follow portal
imaging policy.)
Match &Adjust Anatomy with Portal Imaging to establish isocenter daily for the entire course of treatment.
Page prior to immobilization:
Scheduling/Authorization Approval
Simulations will not be scheduled unless filled out
ECOG status: Choose
Treatment method: 3DCRT
Total Gy:
Patient immobilization:
Supine or
Thorax Board or
Arms up or
Head rest or
Knee Fix
Scheduling Needs (optional):
# Fractions: Choose
TX5/TX6 eligible (6x only): Choose
Concurrent Chemo: Choose
Scan Parameters:
Free breathing or
Upper Border @ C1/2 interspace or
Lower Border @ L1/2 interspace or
Slice thickness 3mm
Is IV Contrast needed for the Simulation? Choose (If yes, answer the questions below)
Oral contrast, 3 oz Scan-C immediately prior to first scan with contrast
If patient answers yes to any of these questions below – order a steroid prep
1) Do you have a CT IV contrast (x-ray dye) allergy? Choose
2) Do you require a steroid prep? Choose
If patient answers yes to the question below and has not had Creatinine drawn within 6
months - order and send patient for lab draw
Have you had the following medical conditions or procedures?
a) Renal Transplant? Choose
b) Kidney disease or failure? Choose
Additional Simulation Instructions: (e.g., placement of markers, wires, etc.)
Field Parameters:
Field arrangement: opposed AP and PA fields or
Energy 6X or
Isocenter @ MPD or
Field borders: Upper border @
Lower border @
Lateral borders @
Structures to be contoured by sim therapists:
No Blocking or
Custom blocking by MD
Page attending
Page Resident to set & check set fields
Simulation Directive Completed By: <Entered By>
<Current Date>
Copyright * 2008
The Regents of The University of Michigan
Simulation Ordered by: <Signed By>
<Signed date time>
Electronically signed by controlled access password
Simulation Note:
I was present to Choose
Generate Isodose Plan
Attending Signature: <Approved By>
<Approved date time>
Electronically signed by controlled access password
CT Patient Activity Document
Interpreter (Language)
Pre-Simulation Screening
Schedule: When Provider is in Clinic
Consent or Reconsent Completed: _
Protocol consent submitted to Data Manager: _
Anesthesia 90 min (Peds Scheduling 5-5841; <24 Hrs 3-2430)
Pacemaker or AICD Patient (if so call 5-3968 for urgent
Woman age 11-55 (pregnancy screening form ) _
Medical Assistant has completed test
Prior RT at outside institution and records (including treatment
Plan) needed
If yes, please provide location/physician name and approximate
dates of treatment and notify Record Room @ 64286 :
Special Scheduling Instructions
Blood Draw order entered into Mi-Chart
Schedule Lupron Injection Date
Child Life Specialist
Pediatric patient (18 and under),
Page 30435 with patient name, registration number
and appointment information
Radiation Oncology Protocol Coordinator
Rad Onc Protocol No.
Check Rad Onc Protocol Coordination below:
April Proudlock 936-9521 (Pager 35596)
Mary Akagi
936-3187 (Pager 34329)
Michelle Castle 615-8492 (Pager 34592)
Kevin Doyle
232-3841 (Pager 34665)
Copyright * 2008
The Regents of The University of Michigan