Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
MRI Pelvis 3D Sim Directive (60 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. Pre-sim: Tape buttocks apart for simulation and treatment or Instruct patient to have full bladder for simulation and treatment or Patient immobilization: Supine Cradle Vac bag Blue Pad Frog legged Knee Fix Toes banded Prone Belly Board Pubic symphysis at inferior belly opening or Arms up around top of board or Knee Fix reversed under ankles or Scheduling/Authorization Approval Simulations will not be scheduled unless filled out Stage: III ECOG status: Choose Treatment method: Choose Total Gy: 50.4 Scheduling Needs (optional): # Fractions: 28 (usually) Concurrent chemo: Yes, pill Start Date with chemo (schedule today): Volumes Date: 3 business days CBCT: : No Scan Parameters: Upper Border @ top of L4 or Lower Border ½ femurs or Slice Thickness 3mm or CT reference point midline @ top of gluteal fold or If patient answers yes, to any of the questions below – contact MRI @ 30490 1) Do you have a Cardiac Pacemaker? Choose 2) Do you have any metal implanted in your body? Stent, Filter, Coil? Choose 3) Do you have any metal in your eyes or sought medical attention to have eyes flushed? Choose If yes to #3, Orbital x-rays are required prior to MRI Simulation Is IV Contrast needed for the MRI? Choose (If yes, answer the questions below) Multihance per weight or If patient answers yes to any of these questions below – order a steroid prep 1) Do you have a MR IV contrast (Gadolinium) 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, tampon, pacemaker etc.) BB on anal verge Copyright * 2008 The Regents of The University of Michigan For information, questions, or permission requests please Contact: (Kathy Lash, BS, RT (R) (T), Radiation Oncology, B2C511, 734-936-4291 Page attending Resident to check CT scan 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 Attending Signature: <Approved By> <Approved date time> Electronically signed by controlled access password MRI Patient Activity Document Interpreter (Language) Pre-Simulation Screening Schedule: _ Consent or Reconsent Completed: _ Protocol consent submitted to Data Manager: _ Anesthesia 90 min (Peds Scheduling 5-5841; <24 Hrs 3-2430) MRI Orbital X-Rays required (Add note to Cadence apt) 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 For information, questions, or permission requests please Contact: (Kathy Lash, BS, RT (R) (T), Radiation Oncology, B2C511, 734-936-4291