Download Physician Simulation Order

Liver Non-SBRT Sim Directive
Free Breathing Tx or 4DCT (60 min)
4DCT Motion Assess or ?SDX tolerance (90 min)
SDX (90 min)
Match &Adjust Anatomy with Portal Imaging to establish isocenter daily for the entire course of treatment.
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.)
Daily CBCT, only physics review
Research Protocol:
2003.081 IC Green
Patient immobilization:
Supine or
Thorax Board or
Arms up or
Head rest
Knee Fix
Other
CBCT: Choose
Scheduling/Authorization Approval
Simulations will not be scheduled unless filled out
Stage:
ECOG status: Choose
Treatment method: VMAT
Total Gy:
Scheduling Needs (optional):
# Fractions:
Concurrent Chemo: Choose
Start Date:
CBCT: Choose
Scan Parameters:
Motion Assessment Strategy:
SDX only (expiration scan for planning – PREFERRED OPTION)
SDX if patient can tolerate. Otherwise 4DCT immediately after exhale breath hold scan
4DCT scan to determine SDX or Free-breathing tx
Free-breathing tx (shallow expiration and shallow inspiration breath hold scans for planning)
Upper Border @ 7 cm above diaphragm or
Note: Consider potential
Lower Border @ 2cm below Pelvic Brim or
use of non-axial treatment
Slice thickness 3mm
fields in determining length
CT reference point midline at level of xyphoid tip or
of scan
Is IV Contrast needed for the Simulation? Choose (If yes, answer the questions below)
Bolus tracking (for HCC, provide diagram of ROI) in addition to standard delayed imaging
Contrast screening:
1) Do you have a CT IV contrast (x-ray dye) allergy? Choose
2) Do you require a steroid prep? Choose
3) Have you had a Renal Transplant? Choose
4) Do you have kidney disease or failure? Choose
Additional Simulation Instructions: (e.g., placement of markers, wires, etc.)
Page to check CT
Attending
Resident
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
Copyright * 2008
The Regents of The University of Michigan
Attending Signature: <Approved By> <Approved date time>
Electronically signed by controlled access password
Tumor location and image registration:
Paste image here:
Imaging and Registration
Primary Imaging:
CT
SDX:
Yes
No
Secondary Imaging:
MRI
Date:
Series:
Registration Technique:
Rigid
Deformable
Local Region of Importance: Select
Comments:
Intended use of Registered Images:
Tumor Definition
Normal Tissue Definition
Treatment Adaptation
Images:
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