CLINICIAN ORDER ZOLEDRONIC ACID (RECLAST ) INJECTION

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					                                                                                                         PATIENT’S NAME



                                                                                                         MED. REC. #
            CLINICIAN ORDER
                            ®
    ZOLEDRONIC ACID (RECLAST ) INJECTION                                                                 DOB
Note: Medication to be started within 10 business days of order date
                                                                                                                                     Patient Identification
       or within 10 business days of next infusion date.




                                                                                        Time
                                                                                                          ORDER DATE: _____/_____/_____
   Date: _____/_____/_____
   Diagnosis: _____________________________________                                                                                                   ®
                                                                                                                 Zoledronic Acid (Reclast ) Injection




                                                                                        Date
   ICD-9 Code: _________                                                                                  DOSE        ROUTE       FREQUENCY

       Medical Necessity Documented in Patient’s Chart
                                                                                                           5 mg       IV             X1
                                                                                                          Special Instructions: Premixed in 100 mL sterile water. Administer slowly to




                                                                                        R.N. Signature
   Allergies:            NONE KNOWN               IF YES, LIST: ___________                               prevent renal dysfunction. Give over no less than 15 minutes.
   ____________________________________________________                                                   SIGNATURE:
   _____________________________________________________
                                                                                                          X______________________________________________________M.D. / N.P.

   LABS:
                                                                                                          ORDER DATE: _____/_____/_____




                                                                                        Time
   Estimated CrCl: __________ Date: _____/_____/_____
   Lab result valid if drawn within the last 30 days

                                                                                        Date
                                                                                                          DOSE        ROUTE       FREQUENCY

   Calcium: ___________             Date: _____/_____/_____
   Lab result valid if drawn within the last 60 days                                                      Special Instructions:
                                                                                        R.N. Signature




   NOTE: “Reclast is NOT indicated in patients with a CrCl
          less than 35 mL/minute”                                                                         SIGNATURE:

   Approved to Infuse:                 Yes          No                                                    X______________________________________________________M.D. / N.P.

   Other Labs to be drawn (describe): ___________________                                                 ORDER DATE: _____/_____/_____
                                                                                        Time




   ______________________________________________
   _______________________________________________
                                                                                        Date




                                                                                                          DOSE        ROUTE       FREQUENCY

   Special Instructions:
     Call Clinician if temperature is greater than: ___________                                           Special Instructions:
                                                                                        R.N. Signature




      Other (describe): ________________________________
                                                                                                          SIGNATURE:

   X___________________________________________________ M.D. / N.P.                                       X______________________________________________________M.D. / N.P.
                          Ordering Clinician’s Signature
   Specialty: _________________________                    Pager ID#: ________
                                                                                        Time




                                                                                                          ORDER DATE: _____/_____/_____

   Administrative
                                                                                        Date




   Patient’s Primary Insurance Plan Name:________________                                                 DOSE        ROUTE       FREQUENCY

   Patient’s Secondary Insurance Plan Name:__________________
                                                                                                          Special Instructions:
   Ordering Clinician’s Name: _______________________________
                                                                                        R.N. Signature




   Office Phone Number: (                    ) ________ - __________
                                                                                                          SIGNATURE:
   Fax Number: (                  ) ________ - __________
                                                                                                          X______________________________________________________M.D. / N.P.
   Office Contact Name: ____________________________________
                                                                                        Time




                                                                                                          ORDER DATE: _____/_____/_____
    Prohibited Abbreviation              Preferred Term
    MS or MSO                            Write: Morphine Sulfate
                4
    MgSO                                 Write: Magnesium Sulfate
          4
                                                                                        Date




                                                                                                          DOSE        ROUTE       FREQUENCY
    Trailing Zeros (e.g. 5.0)            Write: 5 Do not use a zero after the decimal
    Leading Zeros (e.g. .5)              Write: 0.5 Use a zero before the decimal
    U (for Unit)                         Write: Unit
    IU                                   Write: Unit or International Unit                                Special Instructions:
                                                                                        R.N. Signature




    µg                                   Write: mcg or Microgram
    QD, or q.d.                          Write: Daily or Once Daily
    QOD                                  Write: Every Other Day
    d                                    Write: Days or Doses                                             SIGNATURE:
    TIW or tiw                           Specify which three days of the week.
                                                                                                          X______________________________________________________M.D. / N.P.
  MR 1963 OP (01/08)
                                                                    PATIENT’S NAME



                                                                    MED. REC. #
             CLINICIAN ORDER
                             ®
     ZOLEDRONIC ACID (RECLAST ) INJECTION
                                                                    DOB
                 REFERENCE SHEET                                                     Patient Identification

                                                                                                              ®
 FDA APPROVED INDICATIONS FOR THE ADMINISTRATION OF ZOLEDRONIC ACID (RECLAST ) INJECTION


 DIAGNOSIS

 Osteoporosis
 733.01              Senile Osteoporosis (Postmenopausal Osteoporosis)
 731.0               Paget’s disease of bone (Osteitis deformans)




MR 1963 - REF OP (01/08)