Abdomen Sim Directive (non liver/pancreas)
90 MIN- 4DCT with SDX – FB TX Only
90min if 4DCT needed to asses SDX or FB
60 min if definitely SDX or 4DCT
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.
Authorization Approval
Simulations will not be scheduled unless filled out
Stage:
ECOG status: Choose
Treatment method: Choose
Total Gy:
Scheduling Needs (optional):
# Fractions:
Concurrent Chemo: Choose
Start Date:
CBCT: Choose
Pre-sim
Do not page attending prior to immobilization or
Prescription Written: Compazine
Patient immobilization
Supine or
Immobilization device: Choose
Arms up or
Head rest or
Knee fix or
Scan Parameters:
Scout & Scan on Free breathing
Motion Assessment Strategy:
ABC only (expiration)
4DCT scan to determine ABC or Free-breathing tx (ABC for target motion >1cm)
4DCT scan for volume delineation (no contrast)
Voluntary breath hold scan (exhale) with IV contrast, then immediate 4DCT for motion
Shallow expiration and shallow inspiration voluntary breath hold scans for planning
Free breathing scan (no 4DCT or ABC)
Upper border @ 2 cm above diaphragm or
Lower border @ Pelvic Brim or
Slice Thickness 3mm or
CT reference point midline at level of xyphoid tip or
Is IV Contrast needed for the Simulation? Choose (If yes, answer the questions below)
Oral contrast: 1 bottle Scan-C given 30 min prior to scans
If patient answers yes to any of these questions below – order a steroid prep
1) Do you have a CT IV contrast (x-ray dye) 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, pacemaker etc.)
Page attending
Resident to check CT
Simulation Directive Completed By: <Authored By>
Simulation Ordered by: <Signed By>
<Current Date>
<Signed date time>
Electronically signed by controlled access password
Simulation Note:
Copyright * 2008
The Regents of The University of Michigan
I was present to Choose
Attending Signature: <Approved By>
<Approved date time>
Electronically signed by controlled access password
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