Download Physician Simulation Orders: Body Stereo - Lung

Body Stereo – Liver Sim Directive
Research Protocol:
SDX Only (90 MIN)
Free Breathing Tx or 4DCT (60 MIN)
4DCT Motion Assess or? SDX tolerance (90 MIN)
2009.053 Liver SBRT
2003.081 IC Green
Scheduling/Authorization Approval
Simulations will not be scheduled unless filled out
Stage:
ECOG status: CHOOSE
Treatment method: Standard SBRT
Total Gy:
Patient immobilization:
Supine in Vac Bag w/ sheet under patient or
Arms up or
Head rest or
Knee Fix or
Scan Parameters:
Scout Expiration and Scan 16 slices in treatment region to do physics
check for body rotation - (SDX not required for this portion of the
scan)
SDX reproducibility test, scan 16 slices centered at dome of the liver 2
times to evaluate reproducibility of breath hold.
Motion Assessment Strategy:
SDX only (expiration scan for planning – PREFERRED)
SDX if patient can tolerate. Otherwise 4DCT immediately after
exhale breath hold scan
Voluntary exhale breath hold scan followed by 4DCT. Patient
cannot tolerate SDX.
4DCT scan to determine SDX or Free-breathing tx
Free-breathing tx (shallow expiration and shallow inspiration
breath hold scans for planning)
Upper border @ 7cm above diaphragm or
Scheduling Needs (optional):
# Fractions:
(total for all tumors)
Schedule treatments today:
Yes, liver protocol form
CBCT: Yes, daily
SDX: CHOOSE AT SIM
Is IV Contrast needed for the Simulation? Choose (If yes, answer the questions below)
If contrast, both arterial and portal venous scans
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.)
Export these scans to Eclipse for planning: Choose
Page attending
Resident to check CT
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
Copyright * 2008
The Regents of The University of Michigan
Note: Consider
potential use of nonaxial treatment fields
in determining length
of scan
Tumor location and image registration:
Paste image here:
Imaging and Registration
Primary Imaging:
CT
SDX:
Yes
No
Secondary Imaging: MRI: MRI sim 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