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/clinical/cckm-tools/content/order-sets/ambulatory/ent/name-98585-en.cckm

201606170

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UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,ENT

OP/FDS - Otolaryngologic Surgery - Pediatric - Preoperative [2915]

OP/FDS - Otolaryngologic Surgery - Pediatric - Preoperative [2915] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, ENT


OP/FDS - Otolaryngologic Surgery - Pediatric - Preoperative [2915]
Pre-Day of Procedure
Laboratory [90428]
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
PLATELET COUNT [PLT] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
PTT [PTT] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
BUN [BUN] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
GLUCOSE [GLU] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
CREATININE [CRET] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
CALCIUM [CA] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
C REACTIVE PROTEIN [CRPN] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
HEMOGLOBIN A1C [HA1C] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine, if not done in last 90 days
MAGNESIUM [MAG] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
T4, FREE [FT4] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
TSH [TSH] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
LEAD [XLEAD] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
LEAD, CAPILLARY [XLEDC] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
Laboratory - Pregnancy Test [87226]
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] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
Labs - Blood Bank [91701]
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. Antibody Screen should be ordered
with the ABO and Rh Typing.
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. ABO and Rh Typing should be ordered with the antibody screen.
Type and Screen
Order if specimen collection will be less than 72 hours prior to surgery. Patient is required to have an ID band in place at
the time of Type and Screen blood specimen collection and remain in place throughout admission.
TYPE AND SCREEN [HCTS] Status: Standing, Expires:7/11/16 MANUAL,Count:1, Normal,
Routine
Antibody Screen and ABO and Rh Typing [192516]
ANTIBODY SCREEN [ABSCR] Status: Standing, Expires:9/26/16 MANUAL,Count:1,
Page 1 of 5
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

Normal, Routine
ABO AND RH TYPING [ABO] Status: Standing, Expires:9/26/16 MANUAL,Count:1,
Normal, Routine
Diagnostic Tests and Imaging [90484]
X-RAY CHEST PA & LAT VIEWS [R71020] Status: Future, Expires: 7/27/17, Normal, Routine
X-RAY CERVICAL SPINE AP/ LAT/ OBL/ FL/ EXT (>=6
V XR) [R72052A]
Status: Future, Expires: 7/27/17, Normal, Routine, For flexion
extension to check for cervical instability or subfluxation.
Consults [90497]
CONSULT TO AUDIOLOGY [1009013] What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Pre-operative
audiogram
Pre-Op Day of Procedure
Nursing Communication [105629]
No Pre-op Day of Surgery Orders Needed
[NURCOM0059]
CONTINUOUS, Starting today, 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]
Isolation - Contact - Extensively Resistant Organism
(XDR) [ISO0320]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Medications [89116]
oxymetazoline (AFRIN) 0.05% nasal spray [40671] 2 spray, Nostril (Each), EVERY 15 MINUTES For 2 Doses
Begin 30 minutes prior to procedure
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 [91574]
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
Page 2 of 5
Printed by LIND, JANNA S [JSL237] at 5/27/2016 2:25:02 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

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
Surgical Prophylaxis
First Line (Single Response) [123143]
If incision is only through the skin, choose cefuroxime.
cefuroxime (ZINACEF) injection - NOTE: Patients who
are less than 40 kg [800030]
50 mg/kg, Intravenous, ON CALL For 1 Doses, IntraOp
cefuroxime (ZINACEF) intraVENOUS - NOTE: Patients
who are 40 - 80 kg [800030]
1.5 g, Intravenous, ON CALL For 1 Doses, IntraOp
ampicillin/sulbactam (UNASYN) intraVENOUS - NOTE:
Patients who are less than 40 kg [800010]
50 mg/kg, Intravenous, ON CALL For 1 Doses, IntraOp
ampicillin/sulbactam (UNASYN) intraVENOUS - NOTE:
Patients who are 40 - 80 kg [800010]
3 g, Intravenous, ON CALL For 1 Doses
NOTE: Patients who are 40 - 80 kg
IntraOp
MRSA/Documented MRSA History (Single Response) [149250]
Patients who are less than 40 kg [204584]
cefuroxime (ZINACEF) intraVENOUS [800030] 50 mg/kg, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, ON CALL For 1 Doses, IntraOp
Patients who are 40 - 80 kg [204585]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA Negative and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single Response)
[149253]
clindamycin (CLEOCIN) intraVENOUS - Patients who
are less than 40 kg [800033]
10 mg/kg, Intravenous, ON CALL For 1 Doses, IntraOp
clindamycin (CLEOCIN) intraVENOUS - NOTE: Patients
who are 40 - 80 kg [800033]
600 mg, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single Response) [149255]
Patients who are less than 40 kg [202870]
clindamycin (CLEOCIN) intraVENOUS [800033] 10 mg/kg, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
Patients who are 40 - 80 kg [202872]
clindamycin (CLEOCIN) intraVENOUS [800033] 600 mg, 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
IntraOp
Medications [123142]
onabotulinumtoxinA (BOTOX) 25 units/mL injection
[760265]
ON CALL For 1 Doses
Syringe type: Luer Lock
IntraOp
Cidofovir 15 mg in 3 ml of Normal Saline [960005] Other
MD to administer
IntraOp
dexamethasone (DECADRON) intraVENOUS [800037] 0.15 mg/kg, Intravenous, ONCE For 1 Doses, IntraOp
mitomycin (MUTAMYCIN) injection [760168] 0.5 mg, Other, ON CALL For 1 Doses, for 5 Minutes, IntraOp
ciprofloxacin-dexamethasone (CIPRODEX) 0.3-0.1%
otic susp [73602]
4 drop, Ears (Each), ON CALL For 1 Doses, IntraOp
ofloxacin (OCUFLOX) 0.3 % ophthalmic soln [55774] 5 drop, Ears (Each), ON CALL For 1 Doses
Give ophthalmic soln via otic route
IntraOp
Page 3 of 5
Printed by LIND, JANNA S [JSL237] at 5/27/2016 2:25:02 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

ciprofloxacin (CETRAXAL) 0.2 % otic soln [136381] 5 drop, Ears (Each), 2 X DAILY For 3 Days, Post-Op/Phase II
Laboratory [93823]
Intra-operative labs to be drawn by the Anesthesiologist during anesthesia (if not previously collected)
CBC WITH DIFFERENTIAL [CBC] 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?
IntraOp
C REACTIVE PROTEIN [CRPN] 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?
IntraOp
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?
IntraOp
PTT [PTT] 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?
IntraOp
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?
IntraOp
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?
IntraOp
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?
IntraOp
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?
IntraOp
TSH [TSH] 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?
IntraOp
LEAD [XLEAD] STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine
Page 4 of 5
Printed by LIND, JANNA S [JSL237] at 5/27/2016 2:25:02 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
IntraOp
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
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 [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
Preoperative Exam (Global) [1265]
Preoperative H&P, No Charge, Surgical Package LOS Code
Page 5 of 5
Printed by LIND, JANNA S [JSL237] at 5/27/2016 2:25:02 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org