Download Physician Simulation Orders: Brain

Whole Brain Palliative (30 Min)
Use Match and 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.)
Use Match and Adjust Anatomy for Portal Imaging to establish isocenter daily for the entire course of treatment.
Required
MRI Date:
MRI Date:
Series #
Series #
Pre-sim:
Do not page attending prior to immobilization or
Patient immobilization:
Supine or
H & N board or
Head rest or
3 point mask or
Knee fix or
Scheduling/Authorization Approval
Simulations will not be scheduled unless filled out
Stage:
ECOG status: Choose
Treatment method: 3DCRT
Total Gy:
Scheduling Needs (optional):
# of Fractions 10 fractions
TX5/6 eligible (6x only): Yes
Scan Parameters:
Upper border: Air above scalp or
Lower border: C3/C4 interspace or
Slice thickness 3mm or
CT reference point @ EAM or
Additional Simulation Instructions: (e.g., placements of markers, wires, bite block, pacemaker, IV
contrast, etc.)
Field Parameters:
Field arrangement: Opposed lateral fields or
Energy: Both 6X or
Isocenter: Central axis, mid-plane depth or
Field borders: Anterior, posterior and superior to flash 1.5 cm beyond skin surface; inferior at
C1/C2 interspace, or
Blocking: Apply standard whole brain MLC shape; to be edited by resident and attending
Page attending
Resident to check CT Set Fields
Simulation Directive Completed By: <Entered By>
Simulation Ordered by: <Signed By>
<Current Date>
<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
Copyright * 2008
The Regents of The University of Michigan
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
consult)
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),
Adult
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