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Section 1: Ordering Chemotherapy 
Section 2: Pharmacy 
Section 3: Nursing 
Administration of New Agents 
Appendix 1  

 
Section 1: Ordering Chemotheraphy

1. Ordering Process:

a) Oncologists, Hematologists and Cancer Care Program General Practitioners in Oncology may prescribe chemotherapy. In addition, responsible physicians with a special interest in Oncology may prescribe chemotherapy under the direction of the Oncologist, however, only after the completion of education/orientation as coordinated by the Division of Medical Oncology or Division Gynecologic Oncology.

b) The prescribing physician must obtain written patient consent prior to ordering chemotherapy.

c) Prescriptions for all chemotherapy drugs must be written, not verbal, and changes to any of these prescriptions or doctors’ orders must be written.  All chemotherapy prescriptions must be written on the institutions approved medication order form. If an order or prescription requires a change, a new order must be written, signed and dated by the physician before the treatment is administered or dispensed. Prescriptions for oral chemotherapy agents must NOT indicate repeats or refills.

d) Whenever possible, physicians should order chemotherapy immediately after examining the patient, and treatment should take place as soon as possible.

e) All prescribing physicians are responsible for the drugs dosage calculations, and route of administration specified in the chemotherapy order.  They ensure the body surface area calculations are accurate and all relevant safety parameters such as complete blood counts or bio-chemical tests have been checked.  A maximum of a 5% variance from the original prescription (according to protocol dosages) in dosage calculation is permitted. If the variance exceeds 5% the treating Oncologist is to be consulted.

f) Body surface area (BSA) calculations are based on actual body weight for all medical/gynecologic oncology protocols. If the patient’s body weight changes by more than 10%, then the BSA must be recalculated and the dose adjusted accordingly.

g) When ordering and administering Carboplatin refer to the specific guideline for the dosing and administration of Carboplatin (See Appendix 1).
 
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2.  Prescription Elements:
 
Prescriptions for chemotherapy drugs must be complete, clear and simple to follow. When chemotherapy medication orders are completed by the physician and noted by nursing, they are forwarded to pharmacy. Treatment information must contain the following elements for each order:
  • Prescribing date and time of order
  • Patient name and HCN (Health Care Number) on each page
  • Patient’s height and weight
  • Body surface area (BSA)
  • Relevant lab data to calculate dose (e.g., serum creatinine, bilirubin)
  • Specific indication for the treatment (cancer type and site)
  • Protocol name
  • Name of drug – use approved generic drug names; no abbreviations
  • Protocol dosage of the drug (usually units/m2, units/kg, or AUC)
  • Calculated patient dose and number of days of treatment\
  • Calculated dose [if dosage reduction is required, the standard total dose is provided minus the amount of percentage reduction (e.g., 400 mg/m2 minus 30% = 280 mg/m2 dose)]
  • Number of cycles and day number
  • Route of administration and any administration instructions
  • Starting dates (and times when appropriate)
  • Allergies or sensitivities.
3. Physician Assessment:
  • All patients must be seen and assessed by the responsible physician prior to day one of each cycle of chemotherapy
  • Patients do not have to be seen on the same day as treatment, however, patients are to be seen within five (5) days prior to treatment
  • Physicians are also required to see and assess patients that are identified during the nursing assessment as having a change in condition
  • Patients may be seen in the physician’s office, the hospital, or clinic setting
  • The physician must complete a history and physical examination on all patients.  The patient history must be taken to verify the presence of side effects and toxicities of chemotherapy treatment. If necessary, dosage adjustments are made in accordance with the instructions of the treating Oncologist.  In addition, the history and physical examination provide an opportunity to assess for evidence of disease response/progression
  • The physical examination must include an assessment of vitals, oral mucosa, skin, chest, abdomen, cardiovascular, respiratory and the known site of the disease
  • Blood work should be ordered within forty-eight (48) hours prior to treatment. [Top] 

Chemotherapy Ordering Process for Patients Receiving Chemotherapy outside the Dr. H. Bliss Murphy Cancer Center

1. All patients receiving chemotherapy treatment (IV or Oral) at health care facilities outside the Dr. H. Bliss Murphy Cancer Center must have a chemotherapy letter written. The chemotherapy letter is to serve as a guide for therapy and care, and forms the basis for the chemotherapy prescription. A copy of the letter must be maintained on the patient’s chart in the outpatient nursing unit in the treating hospital. 
 
2. The chemotherapy letter is to be written by the attending Oncologist.
 
3. The chemotherapy letter is to be personally addressed to the physician in the regional center who will be overseeing the patient’s care and chemotherapy administration. Letters addressed to the “Physician In-Charge” are unacceptable.
 
4. If the patient is transferred to another site or to be treated by a physician, other than the responsible physician named on the chemotherapy letter, the responsible physician overseeing the patient’s treatment must contact the Oncologist for approval, and to arrange transfer of the patient. A new chemotherapy letter must be written.
 
5. The Oncologist must write all chemotherapy letters on the Eastern Health Care letter template.  The hand written chemotherapy letter must be typed.  Hand written chemotherapy letters are not acceptable.
 
6. The Oncologist and the Clinical Pharmacist must check and sign all typed chemotherapy letters before they are sent out to the regional centers.
 
7. All chemotherapy letters, including those for oral chemotherapy agents, must be faxed to the responsible physician caring for the patient, the pharmacy department preparing the chemotherapy, and the nursing unit responsible for administering the chemotherapy.
 
8. All chemotherapy letters must have the following information:
a) Patient name, address and HCN (Health Care Number) on each page
b) Patient data pertinent to the medication being administered such as: age, height, weight, BSA, serum creatinine, and estimated creatinine clearance
c) Diagnosis and intent of treatment
d) Chemotherapy regimen including the name of the protocol
e) Dose and dosing information such as the percentage dosage reduction if dose reduced.  If dosage is based on BSA, the dose per meter squared and the calculated dose to be administered should be written.  If based on AUC, the body weight used in the calculations must also be included
f) Anti-emetics and pre-medications to be administered
g) Cycle frequency
h) Duration of therapy
i) Allergies or sensitivities
j) Details of required follow-up
9. All chemotherapy letters must be accompanied by the patients 1st assessment summary and/or recent progress notes.  If there is no patient 1st assessment available from the primary Oncologist, then the covering physician should be contacted to review the patient’s chart. Otherwise, if there is no urgency the chart should be put on hold until the primary physician returns.
10. Oncologists who see patients in the regional center, where they are to be treated, must write a chemotherapy letter for the patient.  The nursing staff at the regional center will fax the handwritten chemotherapy letter template to the health records staff of the Dr. H. Bliss Murphy Cancer Center for typing.
 
11. Chemotherapy letters written for protocols that are not approved must be reviewed and approved by the Provincial Systemic Therapy Advisory Committee and the Clinical Chief of the Cancer Care Program.  The prescribing Oncologist must attach the published scientific literature and other supporting evidence to the chemotherapy letter.

12. Upon receipt of a chemotherapy letter, the physician in the regional center overseeing the care of the patient must transcribe the chemotherapy orders onto the institutions approved medication order form. Signed chemotherapy letters are not to be sent to the pharmacy department for the ordering of chemotherapy. 

13. Changes to chemotherapy prescriptions or doctors’ orders must be written.  If an order or prescription is changed, the reason for the change(s) must be documented, and the change(s) must be signed and dated by the physician before the treatment is administered or dispensed. In this situation, a new prescription or doctors’ order must be written.

14. Physicians in the regional centers are responsible for the drug dosage calculations and must specify route of administration in the orders.  They ensure that the body surface area calculations are accurate and all relevant safety parameters such as complete blood counts or bio-chemical tests have been checked.  A maximum of a 5% variance from the original prescription (according to protocol dosages) in dosage calculation is permitted. If the variance exceeds 5% the treating Oncologist is to be consulted.

15. When ordering and administering Carboplatin refer to the specific guidelines for the dosing and administration of Carboplatin (Guideline for the Dosing and Administration of Carboplatin, See Appendix 1).  In addition, the Cancer Care Program Website has a carboplatin calculator. The Oncologist will indicate on the chemotherapy letter the formula and weight used in calculating the dose.

16. Physicians in the regional centers are responsible for performing the physician assessment as outlined above.
 
  
Back - Chemotheraphy Guidelines |  CONTENTS  | Next - Section 2: Pharmacy

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Updated Dec 4, 2013