Title:
Chemotherapy/Medication Orders
Regulation ASCO/ONS Chemotherapy Administration Safety Standards;
Reference: COC OMH Accreditation Standard 3.1
Policy Number:
Effective Date:
Purpose:
It is the goal of XXXXX to define the process for medication orders to ensure appropriate treatment,
prevent errors, ensure patient safety, and ensure adequate documentation in the medical record.
Policy:
Personnel affected: Clinicians (Physicians and Advanced Practitioners), Registered Nurses
1. Chemotherapy initiation orders must be written by a licensed, board certified or eligible medical
oncologist, hematologist or gynecologic oncologist. Licensed, certified nurse practitioners and
physician assistants may amend/delay/discontinue chemotherapy orders, but cannot initiate
chemotherapy.
2. All orders for chemotherapy and medication administration should be entered in the electronic
medical record by the clinician. This includes modifications of previous regimens, addition or
deletion of drugs, and changes in schedule or administration orders. For medication orders, other
than Chemotherapy: Faxed or emailed orders are considered written orders, but must be
scanned and/or copied into the EMR and the regimen entered by the RN. Orders copied via
email from the clinician should indicate such; i.e., “email communication from Dr._________ “ and
the date.
3. The treatment decision defines the type of documentation that constitutes the clinician order.
Clinical pathway decisions define the type of order to be generated as follows:
a. On Pathway – When a clinical pathway is assigned, the pathway decision IS the
chemotherapy order. Dose modifications should be noted in the “Administration Notes”
section of the Pathway.
b. Off Pathway – When the decision is made to treat ‘off pathway’ (a regimen other than those
defined in the pathway system), the clinician may use the pathway tool, ‘intent to treat’, or
‘physician order’ in the EMR.
c. Non-pathway – When no pathway exists in the system for a patient’s diagnosis, the order
should be entered in either the ‘intent to treat’ or ‘physician order’ section of the EMR.
4. All written orders should include patient’s name, patient account number, date ordered, full name
of the chemotherapy/medication(s), dosage, route of administration, approximate start date for
the regimen, frequency, number of cycles, instructions for administration (if different from the
Clinical Pharmacy Drug Dilution and Stability Chart), and Clinician’s signature. Abbreviations of
drugs may not be used in the order. Additional information may be added for clarification.
5. All new regimens are entered in the medical record by the Clinician or the RN. Drugs are
approved at the time they are ordered and the appointment for administration scheduled. The
admixture department is prompted by the patient schedule to have medication prepared for
delivery to the site of administration.
6. There should be NO verbal or telephone orders for new regimens or changed regimens.
Verbal or telephone orders should be avoided but may be accepted by an RN in the event that
medication is to be held or delayed. The order must be immediately documented as a verbal
order in the EMR and ‘read back’ to the clinician. The verbal order should also be documented in
a note with a reason; for example, “…chemotherapy regimen (or specific drug) held per Dr.
__________ due to __________.” Orders documented as verbal in the EMR then go into a
clinician’s cue to be approved. Approval of the verbal order is equivalent to a clinician signature.
Clinical Trials
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The order for a patient to be on clinical trial is entered by the physician. Randomization should then
be entered as a verbal order by the research nurse with a note indicating the randomization results (or
which arm of the study). The verbal order will go into the physician’s queue for approval as stated in
no. 4 above. The research nurse then notifies the Chemotherapy/Infusion Room nurses. The
regimen should then be entered and assigned by the Chemotherapy RN or Research RN.
Note: RNs licensed in XXXXX are obligated under the Nursing Practice Act to: “clarify any order or
treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or
contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering
practitioner when the RN makes the decision not to administer the medication or treatment.”
Note: All Q21 and Q28 day regimens within the EMR will be built with six cycles unless otherwise
defined by a written protocol. All Q14 day regimens will be built with twelve cycles unless otherwise
defined by a written protocol. Regimens will be continued indefinitely with physician order stating
“administer until progression.”
Intent to treat – In the Aria EMR system, ‘intent to treat’ enables the clinician to indicate the
regimen wanted for a patient. Intent to treat is restricted to clinicians only in the system.
Entering a regimen in the intent to treat section constitutes a physician or clinician order.
Responsibility and Approval Authority:
This policy shall be reviewed by the appropriate committees, managers and staff to whom it is relevant, approved by the
Executive Committee of the Board, with final signatory authority of the Medical Director.
Version Number:
Original Approval Date:
Reviewed Date:
Prepared by:
Approved by:
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