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Fòm Lòd Swen Lajounen Medikal

Pou founisè kominotè ki pa sou sistèm Epic la.

Mèsi dèske w chwazi Swen Lajounen Medikal Cooley Dickinson pou pasyan w lan. Lè w ap voye lòd pasyan yo, tanpri chwazi, telechaje, enprime epi faksye fòm lòd ki pi apwopriye a nan dosye ki anba yo.

Lè w ap ranpli yon fòm lòd, tanpri:

  • Ranpli tout fòm nan, enkli siyati ou ak nenpòt kesyon sou nesesite medikal la.
  • Sonje pou w bay lòd pou medikaman prensipal la, ansanm ak nenpòt medikaman pre oswa ijans ki asosye yo.

Lè w ap faksye fòm lòd yo:

  • Faksye bay Sant Planifikasyon Cooley Dickinson nan 413-582-2183, tout sa ki annapre yo:

    • Fòm lòd ki ranpli a
    • H&P aktyèl pasyan an
    • Yon lis medikaman ak alèji aktyèl pasyan an
    • Nenpòt konsantman ki siyen ki ta ka nesesè pou tretman an

Si w gen nenpòt kesyon, tanpri kontakte depatman Cooley Dickinson ki pi byen koresponn ak demann ou a:

Transfizyon san

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Category


Form ID


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Blood transfusions


208-201


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Info and consent


21-12


Piki ak terapi IV

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Category


Form ID


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Medical infusion therapy plan (to be used when specific medication therapy plan being ordered is not available)


208-200


Enfizyon (“plan terapi”)

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Category


Form ID


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Abatacept (Orencia) for rheumatology maintenance


208-204


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Access and flush


208-226


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Albumin


208-234


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Anifrolumab


208-274


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Antibiotics


208-235


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Belatacept maintenance


208-255


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Belatacept load dose


208-256


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Bezlotoxumab


208-252


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Cortrosyn stimulation test


208-232


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Denosumab (Prolia)


208-273


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Dexamethasone


208-257


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Epoetin Alfa


208-268


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Ferumoxytol


208-253


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Golimumab maintenance


208-262


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Golimumab load


208-261


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Infliximab load and maintenance every 6 weeks


208-225


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Infliximab load and maintenance every 8 weeks


208-275


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Iron Sucrose Venofer (MGH)


208-244


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IVIG Allergy


208-243


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IVIG Neurology


208-240


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IVIG Neurology - schedule 2 days monthly


208-239


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Mepolizumab


208-209


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Methylprednisolone monthly


208-258


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Methylprednisolone daily


208-259


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Ocrelizumab maintenance dose


208-223


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Ocrelizumab load dose (schedule weeks 0-2)


208-224


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Omalizumab


208-208


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Pentamidine 2.18


208-245


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Prolastin


208-227


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Reclast Rheumatology


208-242


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Rituximab Dermatology (RA protocol 1000mg x 2 doses 2 weeks apart)


208-238


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Rituximab Hematology


208-246


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Rituximab Neurology 2.18


208-247


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Rituximab Rheumatology


208-213


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Romosozumab-AQQG


208-276


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Solumedrol


208-228


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Stelara 2.18


208-248


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Thymoglobulin


208-236


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Tixagevimab/Cilgavimab


208-266


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Tocilizumab Rheumatology


208-212


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Vedolizumab load (schedule weeks 0, 2, 6) and maintenance


208-229


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Vitamin B-12


208-254


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Zoledronic acid (Reclast)


208-214


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Eculizumab load


208-264


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Eculizumab maintenance


208-265