Download Physician Simulation Orders: Pelvis GI 3D

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