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/clinical/cckm-tools/content/order-sets/ambulatory/cardiologyct-surgery/name-98594-en.cckm

201606179

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Cardiology/CT Surgery

OP - Thoracic Surgery - Adult - Pre/Postoperative [2806]

OP - Thoracic Surgery - Adult - Pre/Postoperative [2806] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Cardiology/CT Surgery


OP - Thoracic Surgery - Adult - Pre/Postoperative [2806]
Intended for Adult Patients Only
Pre-Day of Procedure
Laboratory [146223]
CBC WITHOUT DIFFERENTIAL [HEMO] Status: Standing, Expires:8/5/16 MANUAL,Count:1, Normal,
Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:8/5/16 MANUAL,Count:1, Normal,
Routine
GLUCOSE [GLU] Status: Standing, Expires:8/5/16 MANUAL,Count:1, Normal,
Routine
BUN [BUN] Status: Standing, Expires:8/5/16 MANUAL,Count:1, Normal,
Routine
CREATININE [CRET] Status: Standing, Expires:8/5/16 MANUAL,Count:1, Normal,
Routine
CALCIUM [CA] Status: Standing, Expires:8/5/16 MANUAL,Count:1, Normal,
Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:8/5/16 MANUAL,Count:1, Normal,
Routine
PTT [PTT] Status: Standing, Expires:8/5/16 MANUAL,Count:1, Normal,
Routine
URINALYSIS WITH MICROSCOPY AND CULTURE IF
>5 WBC/HPF [HCUACULT]
Status: Standing, Expires:8/5/16 MANUAL,Count:1, Normal,
Routine
Labs - Blood Bank [91702]
Antibody Screen
Use to prescreen patient for alloantibodies to red blood cell components. Order if specimen collection will be greater than
72 hours prior to surgery. Blood products cannot be issued on the basis of this test.
ABO and Rh Typing
Use to determine patient blood type. Order if specimen collection will be greater than 72 hours prior to surgery. Blood
products cannot be issued on the basis of this test.
ANTIBODY SCREEN [ABSCR] Status: Standing, Expires:8/5/16 MANUAL,Count:1, Normal,
Routine
ABO AND RH TYPING [ABO] Status: Standing, Expires:8/5/16 MANUAL,Count:1, Normal,
Routine
Diagnostic Tests and Imaging [88554]
ECG - 12 Lead [EKG0008] Status: Future, Expires: 7/21/17, Normal, Routine
Pre-Op Day of Procedure
Isolation Status [97372]
Isolation - Enhanced Contact - Clostridium Difficile
[ISO0010]
CONTINUOUS, Separate order must be placed for isolation
cart., Pre-Op Day Of Procedure
Isolation - Contact - MRSA [ISO0039] CONTINUOUS, Separate order must be placed for isolation
cart., Pre-Op Day Of Procedure
Isolation - Contact - VRE [ISO0051] CONTINUOUS, Separate order must be placed for isolation
cart., Pre-Op Day Of Procedure
Isolation - Protective Precautions - Panel [116356]
Protective Precautions [ISO0001] CONTINUOUS
Reason for Protective Precautions:
Pre-Op Day Of Procedure
Protective - Positive Pressure Room [NURCOM0109] CONTINUOUS, Pre-Op Day Of Procedure
Isolation - Contact - Multidrug Resistant Organism -
Panel [116335]
Isolation - Contact - Multidrug Resistant Organism
(MDR) [ISO0006]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Isolation - Contact - Extensively Resistant Organism
(XDR) - Panel [193206]
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Isolation - Contact - Extensively Resistant Organism
(XDR) [ISO0320]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
VTE Prophylaxis [109260]
· If low risk for development of VTE - select VTE Prophylaxis - Reason Not Ordered
· If requires VTE prophylaxis AND
o LOW bleed risk - select pharmacologic agent only
o ABSOLUTE bleed risk - select mechanical agents only
o 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/references/medication-
use-manual/anticoagulation-resources/resources/name-
26461-en.file
Sequential Compression Device [EQP0023] CONTINUOUS, Routine
Left/Right/Bilateral? 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 PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, ON CALL For 1 Doses
If patient scheduled for block, give after block placed
IntraOp
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE For 1 Occurrences, Routine
Reason Not Ordered:
Pre-Op Day Of Procedure
Premedications for Needle Insertion [106313]
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 within 1 minute.
Choice of medication should be based on patient’s previous experience/preference, history of lidocaine allergy and ease
of access.
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
lidocaine (XYLOCAINE) 1% injection [39034] 0.1-0.4 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. Choice of medication should be
based on patient’s previous experience/preference, history of
lidocaine allergy and ease of access
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. Choice of medication should be
Page 2 of 10
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based on patient’s previous experience/preference, history of
lidocaine allergy and ease of access
Pre-Op Day Of Procedure
IV Fluids [114472]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: 18 Gauge
Does this need to be inserted/placed?
Pre-Op Day Of Procedure
dextrose 5%-NaCl 0.45% infusion [51613] at 75 mL/hr, Intravenous, CONTINUOUS
For 2nd and 3rd case
Pre-Op Day Of Procedure
Laboratory - If Not Obtained at Clinic Visit [94895]
CBC WITHOUT DIFFERENTIAL [HEMO] STAT - RN COLLECT, 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
ELECTROLYTES [LYTE] STAT - RN COLLECT, 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
BUN [BUN] STAT - RN COLLECT, 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
CREATININE [CRET] STAT - RN COLLECT, 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
GLUCOSE [GLU] STAT - RN COLLECT, 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
CALCIUM [CA] STAT - RN COLLECT, 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
MAGNESIUM [MAG] STAT - RN COLLECT, 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
PHOSPHATE [PHOS] STAT - RN COLLECT, 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?
Page 3 of 10
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

Pre-Op Day Of Procedure
PREALBUMIN [XPRALB] STAT - RN COLLECT, 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
PROTHROMBIN TIME/INR [PT] STAT - RN COLLECT, 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
URINALYSIS WITH MICROSCOPY AND CULTURE IF
>5 WBC/HPF [HCUACULT]
STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine
Indication:
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
Laboratory - Pregnancy Test [81397]
Obtain pregnancy test if female between menarche & menopause and any of: (1) surgery is pelvic, renal, or intra-
abdominal, (2) patient had unprotected intercourse, (3) patient missed menses, (4) patient says she "could" be pregnant.
Urine, Pregnancy Test [UPREG] STAT - RN COLLECT, 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
Tests [198872]
TYPE AND SCREEN [HCTS] STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine, As good clinical practice and for patient safety, the
Transfusion Service will automatically crossmatch 2 packed
RBCs on all patients with antibodies to ensure blood would be
available in the event it is needed. If you would like to opt out
of this automatic order for this patient please contact the
UWHC Blood Bank at (608) 263-8367 or The American
Center Lab at (608) 234-6600 as appropriate., Pre-Op Day Of
Procedure
Blood Products [83983]
Red Blood Cells (Adult) [BLB0006] 1 UNIT, Starting today For 1 Occurrences, Routine
Reason for Order: R1 Life-threatening hemorrhage or
anticipated/ongoing surgical blood loss
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products): SURGICAL USE
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD verifies that
the clinical situation is sufficiently urgent to require release of
blood before completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be pre-
selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates up to 4
Months Only) (May be pre-selected based on history):
Consent Status:
Patient Weight
No data found for Wt
Page 4 of 10
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

All cellular products are leukocyte-reduced (CMV safe)
1 Red Blood Cell Unit ~ 350 mL., Pre-Op Day Of Procedure
Plasma (Adult) [BLB0003] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products): SURGICAL USE
Date Product Needed:
Consent Status:
Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank at (608) 263-
8367 or The American Center Lab at (608) 234-6600 as
appropriate 30-60 minutes before transfusion to prepare
products.
Pre-Op Day Of Procedure
Platelets (Adult) [BLB0004] 1 SINGLE, Starting today For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products): SURGICAL USE
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be pre-
selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates up to 4
Months Only) (May be pre-selected based on history):
Consent Status:
Patient Weight
No data found for Wt
For refractory patients, call UWHC Blood Back at (608) 263-
8307 or The American Center Lab at (608) 234-6600 as
appropriate 30-60 minutes (at UWHC) or 2-3 hours (at The
American Center) before transfusion to prepare products.
1 Single Donor Unit ~ 200-250 mL.
All platelet products are leukocyte-reduced (CMV safe).
NURSING REMINDER: Call UWHC Blood Bank at (608) 263-
8367 or The American Center Lab at (608) 234-6600 as
appropriate 30-60 minutes (at UWHC) or 2-3 hours (at The
American Center) before transfusion to prepare products.,
Pre-Op Day Of Procedure
Cryoprecipitate (Adult) [BLB0005] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products): SURGICAL USE
Date Product Needed:
Consent Status:
Fibrin Glue, mLs Needed:
Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units (approx
120mL). Standard adult dose = 10 units. Suggested dose =
1 unit/10 kg.
Individual cryoprecipitate units are also available for fibrin
glue (approx 10-15 mL each).
Page 5 of 10
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

NURSING REMINDER: Call UWHC Blood Bank at (608) 263-
8367 or The American Center Lab at (608) 234-6600 as
appropriate 30-60 minutes before transfusion to prepare
products., Pre-Op Day Of Procedure
Blood Products [83984]
Red Blood Cells (Pediatric) [BLB0013] 1 UNIT, Starting today For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be transfused
(mL):
Reason for Order: PR5 Acute blood loss or anticipated
surgical blood loss
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products): SURGICAL USE
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD verifies that
the clinical situation is sufficiently urgent to require release of
blood before completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be pre-
selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates up to 4
Months Only) (May be pre-selected based on history):
Volume-Reduced (May be pre-selected based on history):
Consent Status:
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose: 10 mL/kg
body weight., Pre-Op Day Of Procedure
Plasma (Pediatric) [BLB0010] Starting today, Routine
If ordering < 1 unit specify the Total Volume to be transfused
(mL):
Reason for Order:
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products): SURGICAL USE
Date Product Needed:
Consent Status:
Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15 mL/kg body
weight.
NURSING REMINDER: Call UWHC Blood Bank at (608) 263-
8367 or The American Center Lab at (608) 234-6600 as
appropriate 30-60 minutes before transfusion to prepare
products., Pre-Op Day Of Procedure
Platelets (Pediatric) [BLB0011] Starting today, Routine
If ordering < 1 unit specify the Total Volume to be transfused
(mL):
Reason for Order:
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products): SURGICAL USE
Date Product Needed:
Page 6 of 10
Printed by LIND, JANNA S [JSL237] at 6/21/2016 12:38:21 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

Irradiated (See Blood Product Guidelines) (May be pre-
selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates up to 4
Months Only) (May be pre-selected based on history):
Volume-Reduced (May be pre-selected based on history):
Consent Status:
Patient Weight
No data found for Wt
For refractory patients, call UWHC Blood Back at (608) 263-
8307 or The American Center Lab at (608) 234-6600 as
appropriate 30-60 minutes (at UWHC) or 2-3 hours (at The
American Center) before transfusion to prepare products.
Suggested dose = 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 40 kg, suggested
dose is 1 Single Donor Unit. 1 Single Donor Unit = 200-250
mL. All platelet products are leukocyte-reduced (CMV safe).
NURSING REMINDER: Call UWHC Blood Bank at (608) 263-
8367 or The American Center Lab at (608) 234-6600 as
appropriate 30-60 minutes (at UWHC) or 2-3 hours (at The
American Center) before transfusion to prepare products.,
Pre-Op Day Of Procedure
Cryoprecipitate (Pediatric) [BLB0012] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products): SURGICAL USE
Date Product Needed:
Consent Status:
Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested dose: 1 Unit/10
kg body weight. If patient weighs less than 10 kg, give 1 Unit.
NURSING REMINDER: Call UWHC Blood Bank at (608) 263-
8367 or The American Center Lab at (608) 234-6600 as
appropriate 30-60 minutes before transfusion to prepare
products., Pre-Op Day Of Procedure
Diagnostic Tests and Imaging - If Not Performed at Clinic Visit [93678]
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: PRE-OPERATIVE
Pre-Op Day Of Procedure
X-RAY CHEST PA & LAT VIEWS [R71020] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by this
exam? Preoperative
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Pre-Op Day Of Procedure
Surgical Prophylaxis
First Line (Single Response) [87336]
cefazolin (ANCEF) intraVENOUS - NOTE: Patients who
are 41-80 kg [800000]
1 g, Intravenous, ON CALL For 1 Doses, IntraOp
Page 7 of 10
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

cefazolin (ANCEF) intraVENOUS - NOTE: Patients who
are 81-120 kg [800000]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefazolin (ANCEF) intraVENOUS - NOTE: Patients who
are 121 kg or greater [800000]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA/Documented MRSA History (Single Response) [146150]
Patients who are 40-120 kg [206102]
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 121 kg or greater [206105]
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
Immediate/Severe Reaction to Penicillin or Known Cephalosporin Allergies (Single Response) [146158]
vancomycin (VANCOCIN) intraVENOUS [800084] 20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-Op Day
Of Procedure
IntraOp
Diagnostic Tests and Imaging [113653]
Imaging in OR [R10000] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by this
exam?
Relevant recent/past history?
IntraOp
FLUOROSCOPY <= 1 HOUR [R76000] ONCE-RAD NEXT AVAILABLE, Routine
Which body area is to be imaged? Chest
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Dysphagia
What specific question(s) would you like answered by this
exam? Evaluate for changes intraoperatively
Relevant recent/past history?
Is patient pregnant? Unknown
If being performed remotely, where? OP OR
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
IntraOp
PACU
Diagnostics Tests and Imaging [206174]
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms? Status post thoracic surgery
What specific question(s) would you like answered by this
exam? Evaluate for changes
Relevant recent/past history?
Is patient pregnant? Unknown
If being performed remotely, where? OSC PACU
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done in outpatient PACU
PostOp/Phase II
Medications [92413]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, ONCE PRN For 1 Doses, pain, For mild to
Page 8 of 10
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

moderate pain or multi-modal therapy, Post-Op/Phase II
ibuprofen (MOTRIN) 600 mg tab [38356] 600 mg, Oral, ONCE PRN For 1 Doses, pain, For mild to
moderate pain or multi-modal therapy, Post-Op/Phase II
oxycodone tab RANGE [750032] 5-10 mg, Oral, ONCE PRN For 1 Doses, pain, For severe
pain, Post-Op/Phase II
oxycodone-acetaminophen (PERCOCET) 5-325 mg per
tab RANGE [750033]
1-2 tab, Oral, ONCE PRN For 1 Doses, pain, For severe pain,
Post-Op/Phase II
Patient Care Instructions [88737]
Discharge IV when Tolerating Oral Intake/Prior to
Discharge [NURTAD0046]
ONCE, Starting today For 1 Occurrences, Post-Op/Phase II
Prior to Discharge [113654]
Patient Must Be Seen by Attending Prior to Discharge
[NURMON0083]
ONCE, Starting today For 1 Occurrences, Routine, Post-
Op/Phase II
Patient Must Be Seen by Resident Prior to Discharge
[NURMON0082]
ONCE, Starting today For 1 Occurrences, Routine, Post-
Op/Phase II
Patient Must Void Prior to Discharge [NURMON0081] ONCE, Starting today For 1 Occurrences, Routine, Post-
Op/Phase II
Outpatient Discharge Orders
Medications - Analgesics - Opioid - Prescriptions [206145]
oxycodone 5 mg tab - 1-2t q4-6hp [45976] 5-10 mg, 0, starting 6/21/16, Normal, Phase II Discharge
oxycodone-acetaminophen (PERCOCET) 5-325 mg per
tab - 1-2t q4-6hp [40668]
1-2 tab, 0, starting 6/21/16, Normal, Phase II Discharge
Medications - Analgesics - Non-Opioid - Prescriptions [87345]
acetaMINOPHEN (TYLENOL) 325 mg tab - 2t q4-6hp
[34149]
650 mg, starting 6/21/16, Normal, Phase II Discharge
ibuprofen (MOTRIN) 600 mg tab - q6hp [38356] 600 mg, starting 6/21/16, Normal, Phase II Discharge
Discharge Instructions [88765]
Discharge Activity [NURACT0008] Routine
Discharge Activity:
May return to work/school in ***.
No lifting greater than *** pounds for ***.
No driving for *** or while taking pain pills.
Discharge - Suture Line Care [DC0021] Routine
Follow-Up Appointments [146242]
Schedule Follow Up Appointment [NURCOM0026] Routine
Purpose: Postop
With whom:
For when:
Follow-Up Diagnostic Tests and Imaging [146243]
X-RAY CHEST PA & LAT VIEWS [R71020] Status: Future, Expires: 8/21/17, Normal, Routine, TO BE
PERFORMED BEFORE FOLLOW-UP VISIT
Diagnosis
Diagnosis - Pre Op [711]
Pre-operative general physical examination [255759] Other specified pre-operative examination
Level of Service
Office Visit - Established Patients [30779]
99211 - Level I LOS Code
99212 - Level II LOS Code
99213 - Level III LOS Code
99214 - Level IV LOS Code
99215 - Level V LOS Code
99211 - w/ Resident (GC) - Level I LOS Code
Page 9 of 10
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

99212 - w/ Resident (GC) - Level II LOS Code
99213 - w/ Resident (GC) - Level III LOS Code
99214 - w/ Resident (GC) - Level IV LOS Code
99215 - w/ Resident (GC) - Level V LOS Code
Office visit - New Patients [30778]
99201- Level I LOS Code
99202- Level II LOS Code
99203- Level III LOS Code
99204- Level IV LOS Code
99205 - Level V LOS Code
99201- w/ Resident (GC) - Level I LOS Code
99202- w/ Resident (GC) - Level II LOS Code
99203- w/ Resident (GC) - Level III LOS Code
99204- w/ Resident (GC) - Level IV LOS Code
99205- w/ Resident (GC) - Level V LOS Code
Consults - New or Established [30780]
If Medicare patient, do not use Consult LOS. Choose an Established or New Patient LOS. Add the appropriate additional
E/M Code of 99354-99359 for prolonged office consultations in the LOS section of the Visit Navigator.
99241 - Level I LOS Code
99242 - Level II LOS Code
99243 - Level III LOS Code
99244 - Level IV LOS Code
99245 - Level V LOS Code
99241- w/ Resident (GC) - Level I LOS Code
99242 - w/ Resident (GC)- Level II LOS Code
99243 - w/ Resident (GC) - Level III LOS Code
99244 - w/ Resident (GC) - Level IV LOS Code
99245 - w/ Resident (GC) - Level V LOS Code
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org