Download Physician Simulation Orders

General Physician Simulation Orders (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
Do not page attending prior to immobilization or
Patient Set-Up: (check all that apply)
Position:
Supine
Immobilization:
Arms:
Legs:
Head:
Prone
Thorax board
Blue Pad
Up
On abdomen
Kneefix
Headrest
Breast board
Cradle
At side
On chest
Toes banded
Pillow
3 pt mask
5 pt mask
Akimbo
Scheduling/Authorization Approval
Simulations will not be scheduled unless filled out
Stage:
ECOG status: Choose
Treatment method: 3DCRT
Total Gy:
Scheduling Needs (optional):
# Fractions:
Concurrent Chemo: No
TX5/6 Eligible: Choose
Volumes Date: 3 business days
Location of targets:
Additional immobilization & simulation instructions: (e.g. placement of markers, wires, bite block, pacemaker
etc…)
Scan Parameters:
Upper border:
Lower border:
Slice thickness 3mm or
CT reference point: middle of site or
Field Parameters: (check all that apply & fill in appropriate information)
Field arrangement:
AP/PA
AP
PA
Opposed Laterals
Energy:
6X
16X
Isocenter:
MPD
100 SSD (prescribed to desired depth)
Field borders: Superior @
, Inferior @
, Lateral borders @
Structures to be contoured by sim therapist: None or
Blocking: None or
Page attending
Resident to check 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
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
Obliques
CT Patient Activity Document
Interpreter (Language)
Special Scheduling Instructions
Pre-Simulation Screening
Schedule: When Provider is in Clinic
Consent or Reconsent Completed: _
Protocol consent submitted to Data Manager: _
Blood Draw order entered into Mi-Chart
Schedule Lupron Injection Date
Anesthesia 90 min (Peds Scheduling 5-5841; <24 Hrs 3-2430)
Child Life Specialist
Pacemaker or AICD Patient (if so call 5-3968 for urgent
consult)
Pediatric patient (18 and under),
Adult
Page 30435 with patient name, registration number
and appointment information
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 :
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