/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/ambulatory/,/clinical/cckm-tools/content/order-sets/ambulatory/breast-center/,

/clinical/cckm-tools/content/order-sets/ambulatory/breast-center/name-120502-en.cckm

201712341

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Breast Center

OP - Breast Center Surgical Case Request [5024]

OP - Breast Center Surgical Case Request [5024] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Breast Center


OP - Breast Center Surgical Case Request [5024]
Diagnosis
Diagnosis - Breast Disorders [150244]
Atypical ductal hyperplasia of breast [292228] Other specified benign mammary dysplasias
Abnormal finding on radiological examination of
breast [963953]
Diagnosis
Fibroadenoma of Breast [303602] Benign neoplasm of breast
Gynecomastia [128581] Hypertrophy of breast
Breast Mass [154167] Lump or mass in breast
Nipple Discharge [128600] Other sign and symptom in breast
Abscess of Breast [128547] Inflammatory disease of breast
Breast Cancer [207293]
Breast Cancer [172793] Malignant neoplasm of breast (female), unspecified
site
DCIS (Ductal Carcinoma in Situ) of Breast
[310432]
Carcinoma in situ of breast
Metastasis to Breast [173208] Secondary malignant neoplasm of breast
Metastatic Malignant Neoplasm to Skin of Breast
[216229]
Secondary malignant neoplasm of skin
Personal History of Malignant Neoplasm of Breast
(aka BREAST CANCER HX) [V10.3.ICD-9-CM]
Personal history of malignant neoplasm of breast
Family History of Breast Cancer [247277] Family history of malignant neoplasm of breast
Genetic susceptibility to malignant neoplasm of
breast [V84.01.ICD-9-CM]
Genetic susceptibility to malignant neoplasm of breast
Breast neoplasm, Tis (LCIS) [1008990] Diagnosis
Post OP [208456]
Surgical wound infection [159832] Other postoperative infection
Postoperative complication [136207] Unspecified complication of procedure, not elsewhere
classified
Encounter for removal of sutures [V58.32.ICD-9-
CM]
Encounter for removal of sutures
Hematoma of breast [298825] Other specified disorders of breast
Pre-operative Consults
Consult Orders - INSIDE UW Health [207291]
Consult to Genetics [1009035] Is this consult for oncology genetic counseling? No
Consult to Plastic Surgery - INSIDE UW Health
[1009107]
What question regarding the patient's medical care
would you like the specialist to answer? (REQUIRED):
Consult to Carewear - INSIDE UW Heatlh
[1009019]
What question regarding the patient's medical care
would you like the specialist to answer? (REQUIRED):
Consult to Health Psychology - INSIDE UW
Health [9138]
Request Type:
Reason for this request:
Consult to Home Health Services - INSIDE UW
Health [151501]
Both of the following orders MUST be completed in order for this patient to receive home care.
CONSULT TO HOME HEALTH SERV [9055] Details
HOME HEALTH JUSTIFICATION [1009439] Internal referral, Routine, Qty-1
Consult to Social Services - INSIDE UW Health
[1009273]
What question regarding the patient's medical care
would you like the specialist to answer? (REQUIRED):
Consult to Anesthesiology - INSIDE UW Health
[1009009]
What question regarding the patient's medical care
would you like the specialist to answer? (REQUIRED):
Page 1 of 8
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:49:42 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org

Consult to Cardiology - INSIDE UW Health
[1009017]
Details
Consult to Internal Medicine - INSIDE UW Health
[1009051]
What question regarding the patient's medical care
would you like the specialist to answer? (REQUIRED):
Imaging
Imaging Orders - Mammogram, diagnostic [2466]
location.requires completion of paper form with diagram of Radiology
Mammogram Diagnostic Digital, Unilateral, Left
[R77055AL]
Status: Future, Expires: 2/7/2019, Normal, Routine,
LEFT SIDE
Mammogram Diagnostic Digital, Unilateral, Right
[R77055AR]
Status: Future, Expires: 2/7/2019, Normal, Routine,
RIGHT SIDE
Mammogram Diagnostic Digital, Bilateral
(R77056A) [R77056A]
Status: Future, Expires: 2/7/2019, Normal, Routine
Imaging Orders - Breast MRI [207294]
Breast MRI Bilateral - w and/or w/o contrast
[R77059]
Status: Future, Expires: 2/7/2019, Normal, Routine
Imaging Orders - Breast Ultrasound [153589]
Breast Ultrasound, Unilateral - Left [R76645L] Status: Future, Expires: 2/7/2019, Normal, Routine,
LEFT SIDE
Breast Ultrasound, Unilateral - Right [R76645R] Status: Future, Expires: 2/7/2019, Normal, Routine,
RIGHT SIDE
Breast Ultrasound, Bilateral [R76645B] Status: Future, Expires: 2/7/2019, Normal, Routine,
BILATERAL PROCEDURE
Imaging Orders - CT and Bone Scan [184970]
CT Abdomen w & w/o IV Contrast [R74170] Status: Future, Expires: 12/7/18, Normal, Routine
CT Abdomen w IV Contrast [R74160] Status: Future, Expires: 12/7/18, Normal, Routine
CT Abdomen w/o IV Contrast [R74150] Status: Future, Expires: 12/7/18, Normal, Routine
CT Abdomen Pelvis w & w/o IV Contrast
[R07033]
Status: Future, Expires: 12/7/18, Normal, Routine
CT Abdomen Pelvis w IV Contrast [R07416] Status: Future, Expires: 12/7/18, Normal, Routine
CT Abdomen Pelvis w/o IV Contrast [R07005] Status: Future, Expires: 12/7/18, Normal, Routine
CT CHEST WO & CT ABD/PELVIS W [218169]
CT CHEST W/ O IV CONTRAST [R71250] Status: Future, Expires: 2/7/2019, Normal, Routine,
CT Chest W/O & CT Abd/Pelvis W to be scheduled
together
CT ABDOMEN PELVIS W IV CONTRAST
[R07416]
Status: Future, Expires: 2/7/2019, Normal, Routine,
CT Chest W/O & CT Abd/Pelvis W to be scheduled
together
CT Chest Abdomen Pelvis w IV Contrast
[R07129]
Status: Future, Expires: 12/7/18, Normal, Routine
CT Chest Abdomen w & w/o IV Contrast [R07127] Status: Future, Expires: 12/7/18, Normal, Routine
CT Chest Abdomen w IV Contrast [R07126] Status: Future, Expires: 12/7/18, Normal, Routine
CT Chest Abdomen w/o IV Contrast [R07125] Status: Future, Expires: 12/7/18, Normal, Routine
CT Chest w/o IV Contrast [R71250] Status: Future, Expires: 12/7/18, Normal, Routine
CT Pelvis w & w/o IV Contrast [R72194] Status: Future, Expires: 12/7/18, Normal, Routine
CT Pelvis w IV Contrast [R72193] Status: Future, Expires: 12/7/18, Normal, Routine
CT Pelvis w/o IV Contrast [R72192] Status: Future, Expires: 12/7/18, Normal, Routine
Bone Scan Whole Body [R78306] Status: Future, Expires: 12/7/18, Normal, Routine
Breast Case Request
Partial Mastectomy, No Localization [208460]
Partial Mastectomy without Localization [332964] Internal referral
Partial Mastectomy with duct excision [332964] Internal referral
Page 2 of 8
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:49:42 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Re-Excision Lumpectomy [332964] Internal referral
Partial Mastectomy, Needle Localization [208465]
Partial Mastectomy with Breast Needle
Localization Mammogram Guided LEFT [153939]
Partial Mastectomy with Breast Needle
Localization Mammogram Guided LEFT [332964]
Internal referral
Breast Needle Localization Mammogram Guided
Left [R77032L]
Status: Future, Expires: 2/7/2019, Normal, Routine
X-Ray Breast Surgery Specimen Left [R76098L] Status: Future, Expires: 2/7/2019, Normal, Routine
Partial Mastectomy with Breast Needle
Localization Ultrasound Guided LEFT [153940]
Partial Mastectomy with Breast Needle
Localization Ultrasound Guided LEFT [332964]
Internal referral
Breast Needle Localization Ultrasound Guided
LEFT [R76942TL]
Status: Future, Expires: 2/7/2019, Normal, Routine
X-Ray Breast Surgery Specimen LEFT
[R76098L]
Status: Future, Expires: 2/7/2019, Normal, Routine
Mammogram Diagnostic Digital Unilateral LEFT
[R77055AL]
Status: Future, Expires: 2/7/2019, Normal, Routine
Partial Mastectomy with Breast Needle
Localization Mammogram Guided RIGHT
[150258]
Partial Mastectomy with Breast Needle
Localization Mammogram Guided RIGHT
[332964]
Internal referral
Breast Needle Localization Mammogram Guided
RIGHT [R77032R]
Status: Future, Expires: 2/7/2019, Normal, Routine
X-Ray Breast Surgery Specimen RIGHT
[R76098R]
Status: Future, Expires: 2/7/2019, Normal, Routine
Partial Mastectomy with Breast Needle
Localization Ultrasound Guided RIGHT [153941]
Partial Mastectomy with Breast Needle
Localization Ultrasound Guided RIGHT [332964]
Internal referral
Breast Needle Localization Ultrasound Guided
RIGHT [R76942TR]
Status: Future, Expires: 2/7/2019, Normal, Routine
X-Ray Breast Surgery Specimen RIGHT
[R76098R]
Status: Future, Expires: 2/7/2019, Normal, Routine
Mammogram Diagnostic Digital Unilateral RIGHT
[R77055AR]
Status: Future, Expires: 2/7/2019, Normal, Routine
Partial Mastectomy, Seed Localization [207292]
Partial Mastectomy with Breast Seed Localization
Mammogram Guided LEFT [184717]
Partial Mastectomy with Breast Seed Localization
Mammogram Guided LEFT [332964]
Internal referral
Breast Seed Localization Mammogram Guided
LEFT [R77032M]
Status: Future, Expires: 2/7/2019, Normal, Routine
Breast Seed Localization Mammogram Guided,
each additional Lesion LEFT [R77032CL]
Status: Future, Expires: 2/7/2019, Normal, Routine
X-Ray Breast Surgery Specimen LEFT
[R76098L]
Status: Future, Expires: 2/7/2019, Normal, Routine
Partial Mastectomy with Breast Seed Localization
Ultrasound Guided LEFT [184724]
Partial Mastectomy with Breast Seed Localization
Ultrasound Guided LEFT [332964]
Internal referral
Breast Seed Localization Ultrasound Guided
LEFT [R76942UL]
Status: Future, Expires: 2/7/2019, Normal, Routine
Page 3 of 8
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:49:42 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Breast Seed Localization Ultrasound Guided,
each additional Lesion LEFT [R76942UAL]
Status: Future, Expires: 2/7/2019, Normal, Routine
X-Ray Breast Surgery Specimen LEFT
[R76098L]
Status: Future, Expires: 2/7/2019, Normal, Routine
Mammogram Diagnostic Digital Unilateral LEFT
[R77055AL]
Status: Future, Expires: 2/7/2019, Normal, Routine
Partial Mastectomy with Breast Seed Localization
Mammogram Guided RIGHT [184745]
Partial Mastectomy with Breast Seed Localization
Mammogram Guided RIGHT [332964]
Internal referral
Breast Seed Localization Mammogram Guided
RIGHT [R77032S]
Status: Future, Expires: 2/7/2019, Normal, Routine
Brest Seed Localization Mammogram Guided,
each additional Lesion RIGHT [R77032CR]
Status: Future, Expires: 2/7/2019, Normal, Routine
X-Ray Breast Surgery Specimen RIGHT
[R76098R]
Status: Future, Expires: 2/7/2019, Normal, Routine
Partial Mastectomy with Breast Seed Localization
Ultrasound Guided RIGHT [184746]
Partial Mastectomy with Breast Seed
Localization Ultrasound Guided RIGHT [332964]
Internal referral
Breast Seed Localization Ultrasound Guided
RIGHT [R76942UR]
Status: Future, Expires: 2/7/2019, Normal, Routine
Breast Seed Localization Ultrasound Guided,
each additional Lesion RIGHT [R76942UAR]
Status: Future, Expires: 2/7/2019, Normal, Routine
X-Ray Breast Surgery Specimen RIGHT
[R76098R]
Status: Future, Expires: 2/7/2019, Normal, Routine
Mammogram Diagnostic Digital Unilateral RIGHT
[R77055AR]
Status: Future, Expires: 2/7/2019, Normal, Routine
Mastectomy [208467]
Mastectomy [332964] Internal referral
Axillary Case Request
Sentinel Lymph Node Dissection [208470]
Sentinel Lymph Node Dissection - LEFT [208469]
Sentinel Lymph Node Dissection Case Request
[332964]
Internal referral
Sentinel Node Imaging Breast - LEFT [R78195E] Status: Future, Expires: 2/7/2019, Normal, Routine
Sentinel Node Injection Only Breast (in OR) -
LEFT [R38792A]
Status: Future, Expires: 2/7/2019, Normal, Routine
X-Ray Breast Surgery Specimen - LEFT
[R76098L]
Status: Future, Expires: 2/7/2019, Normal, Routine
Sentinel Lymph Node Dissection - RIGHT
[208471]
Sentinel Lymph Node Dissection Case Request
[332964]
Internal referral
Sentinel Node Imaging Breast - RIGHT
[R78195F]
Status: Future, Expires: 2/7/2019, Normal, Routine
Sentinel Node Injection Only Breast (in OR) -
RIGHT [R38792B]
Status: Future, Expires: 2/7/2019, Normal, Routine
X-Ray Breast Surgery Specimen - RIGHT
[R76098R]
Status: Future, Expires: 2/7/2019, Normal, Routine
Sentinel Lymph Node Dissection - BILATERAL
[208472]
Sentinel Lymph Node Dissection Case Request
[332964]
Internal referral
Sentinel Node Imaging Breast - BILATERAL
[R78195G]
Status: Future, Expires: 2/7/2019, Normal, Routine
Page 4 of 8
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:49:42 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Sentinel Node Injection Only Breast (in OR) -
BILATERAL [R38792C]
Status: Future, Expires: 2/7/2019, Normal, Routine
X-Ray Breast Surgery Specimen - RIGHT
[R76098R]
Status: Future, Expires: 2/7/2019, Normal, Routine
X-Ray Breast Surgery Specimen - LEFT
[R76098L]
Status: Future, Expires: 2/7/2019, Normal, Routine
Axillary Lymph Node Dissection [208473]
Axillary Lymph Node Dissection [196879]
Axillary Lymph Node Dissection [332964] Internal referral
X-Ray Breast Surgery Specimen - LEFT
[R76098L]
Status: Future, Expires: 2/7/2019, Normal, Routine
X-Ray Breast Surgery Specimen - RIGHT
[R76098R]
Status: Future, Expires: 2/7/2019, Normal, Routine
Pre-op Testing
Blood Lab Orders [208475]
CBC with Differential [CBC] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Hematocrit [HCT] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Hemoglobin [HGB] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
PT/INR [PT] Status: Standing, Expires:1/8/19 MANUAL,Count:1,
Normal, Routine
PTT [PTT] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
CMP Lab Orders [208464]
Creatinine [CRET] Status: Standing, Expires:1/8/19 MANUAL,Count:1,
Normal, Routine
Electrolytes [LYTE] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Glucose [GLU] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Albumin [ALB] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Protein, Total [TP] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Alkaline Phosphatase [ALKP] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
ALT [ALT] Status: Standing, Expires:1/8/19 MANUAL,Count:1,
Normal, Routine
AST [AST] Status: Standing, Expires:1/8/19 MANUAL,Count:1,
Normal, Routine
Bilirubin, Total [TBIL] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Calcium [CA] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Other Lab Orders [208477]
GGT [GGT] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Magnesium [MAG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Phosphate [PHOS] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Procedure Orders [208459]
Page 5 of 8
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:49:42 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

ECG - 12 Lead [EKG0008] Status: Future, Expires: 1/7/2019, Normal, Routine
Chest X-Ray PA & LAT Views [R71020] Status: Future, Expires: 2/7/2019, Normal, Routine
Transthoracic Resting Echocardiogram
[ECH0003]
Status: Future, Expires: 1/7/2019, Normal, Routine
Pre-Op Day of Procedure
Isolation Status [150229]
Enhanced Contact Isolation - CDIFF [ISO0348] What is the reason for isolation?
Separate order must be placed for isolation cart., Pre-
Op Day Of Procedure
Contact Isolation - MDRO (MRSA) [ISO0334] CONTINUOUS
What is the Reason for Isolation? MRSA
Separate order must be placed for isolation cart., Pre-
Op Day Of Procedure
Contact Isolation - MDRO (VRE) [ISO0334] CONTINUOUS
What is the Reason for Isolation? VRE
Separate order must be placed for isolation cart., Pre-
Op Day Of Procedure
Intravenous Therapy [150234]
IV running prior to needle localization/nuclear
medication injection [NURVAD0053]
ONCE For 1 Occurrences, Pre-Op Day Of Procedure
Premedications for Needle Insertion [153960]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is immediate.
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, peripheral line
insertion - see Admin Instructions
Do NOT apply to area greater than 200 square
centimeters (maximum 2.5 g/site; maximum 4 sites
per hour, 6 times per day). Do NOT leave on longer
than 2 hours. Use for stable patient, no allergies to
lidocaine, with at least 30 minutes time prior to IV use
Pre-Op Day Of Procedure
sodium chloride (bacteriostatic) 0.9 % injection
[50585]
0.05-0.1 mL, Intradermal, PRN, peripheral line
insertion - see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
Pre-Op Day Of Procedure
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Pre-Op Day Of Procedure
Lab Orders [208462]
PROTHROMBIN TIME/INR [PT] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
Page 6 of 8
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:49:42 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] STAT, Starting today For 1 Occurrences, Routine,
Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia management
and monitoring as indicated in the Hypoglycemia
Management (Adult) panel.
If Conditional, What Condition?
Pre-Op Day Of Procedure
CREATININE [CRET] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
Pregnancy Test [153597]
surgery is pelvic, renal, pregnancy test if female between menarche & menopause and any of: (1) Obtain
intercourse, (3) patient missed menses, (4) patient says abdominal, (2) patient had unprotected -or intra
pregnant. she "could" be
Urine, Pregnancy Test [UPREG] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
VTE Prophylaxis
VTE Prophylaxis [153965]
• If low risk for development of VTE - select VTE Prophylaxis - Reason Not Ordered
• If requires VTE prophylaxis AND
◦ LOW bleed risk - select pharmacologic agent only
◦ ABSOLUTE bleed risk - select mechanical agents only
◦ HIGH bleed risk - weigh risk of bleed vs risk of VTE development and select drug OR
mechanical agent
NOTE: Mechanical and pharmacologic agents should only be used together in patients
with a very high risk of VTE development
VTE Risk Factor Assessment Tool URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Sequential Compression Device (SCD) Panel
(TREATMENT AND SUPPLY) [206111]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
IntraOp
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
IntraOp
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Pre-Op Day Of Procedure
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, ON CALL For 1 Doses
If patient scheduled for block, give after block placed
IntraOp
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, ON CALL For 1 Doses, IntraOp
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE For 1 Occurrences, Routine
Reason Not Ordered:
Pre-Op Day Of Procedure
Page 7 of 8
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:49:42 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Surgical Prophylaxis
First Line (Single Response) [148038]
cefazolin (ANCEF) intravenous - NOTE: Order for
patient 40-120 kg [800000]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefazolin (ANCEF) intraVENOUS - NOTE: Order
for patient >120 kg [800000]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
Documented MRSA or history of MRSA or MRSE risk /Expander Reconstruction (Single Response)
[147993]
Patients who are 40-120 kg [228621]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are >120 kg [228623]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients with IgE-mediated or severe reaction to beta-lactam (Single Response) [154482]
vancomycin (VANCOCIN) intraVENOUS [800084] 20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients with IgE-mediated or severe reaction to beta-lactam AND MRSA or history of MRSA or MRSE
risk (Single Response) [231206]
vancomycin (VANCOCIN) intraVENOUS [800084] 20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Post-op Follow-up
Post-op Follow-up - INSIDE UW Health [208468]
Follow-up in Breast Center - 1 week [1009015] Details
Follow-up in Breast Center - 2 weeks [1009015] Details
Consult to Oncology - INSIDE UW Health - 1 to 3
weeks following surgery [1009075]
Details
Consult to Radiation Oncology - INSIDE UW
Health - 1 to 3 weeks following surgery [1009121]
What question regarding the patient's medical care
would you like the specialist to answer? (REQUIRED):
Consult to Plastic Surgery - INSIDE UW Health -
1 to 3 weeks following surgery [1009107]
What question regarding the patient's medical care
would you like the specialist to answer? (REQUIRED):
Consult to OCC Therapy - INSIDE UW Health -
with Postop Visit [9094]
Request Type: Consultation(opinion/advise) plus
procedure if needed
Reason for this request: Evaluate and Treat plus ROM
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
END OF SMARTSET [4852]
Other Chief Complaint
Page 8 of 8
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:49:42 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org