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

OP/FDS - Otolaryngologic Surgery - Adult - Preoperative [2913]

OP/FDS - Otolaryngologic Surgery - Adult - Preoperative [2913] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, ENT


OP/FDS - Otolaryngologic Surgery - Adult - Preoperative [2913]
for Adult Patients OnlyIntended
Pre-Day of Procedure
Laboratory [90371]
URINALYSIS WITH MICROSCOPY [UA] Status: Future Approximate, Expires: 3/9/18, Normal,
Routine
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
CBC WITHOUT DIFFERENTIAL [HEMO] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
PLATELET COUNT [PLT] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
ALBUMIN [ALB] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
PROTEIN, TOTAL [TP] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
BILIRUBIN, TOTAL [TBIL] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
AST/SGOT [AST] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
ALT/SGPT [ALT] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
ALKALINE PHOSPHATASE [ALKP] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
PTT [PTT] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
GGT [GGT] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
HEMOGLOBIN A1C [HA1C] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine, Only if not done in the last 90 days
TSH [TSH] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
T4, FREE [FT4] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
Laboratory - Pregnancy Test [87226]
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] Status: Standing, Expires:3/9/18 MANUAL,Count:1,
Normal, Routine
Labs - Blood Bank [91701]
Page 1 of 12
Printed by WILLIAMS, HEATHER R [HRS0] at 1/23/2018 10:47:43 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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:3/9/18 MANUAL,Count:1,
Normal, Routine
Antibody Screen and ABO and Rh Typing
[192516]
ANTIBODY SCREEN [ABSCR] Status: Standing, Expires:5/25/18 MANUAL,Count:1,
Normal, Routine
ABO AND RH TYPING [ABO] Status: Standing, Expires:5/25/18 MANUAL,Count:1,
Normal, Routine
Diagnostic Tests and Imaging [90413]
ECG - 12 Lead [EKG0008] Status: Future, Expires: 2/23/2019, Normal, Routine
X-RAY CHEST SINGLE VIEW [R71045] Status: Future, Expires: 3/23/2019, Normal, Routine, If
not already done prior to pre-op visit.
X-RAY CHEST 2 VIEWS [R71046] Status: Future, Expires: 3/23/2019, Normal, Routine, If
not already done prior to pre-op visit.
X-RAY CHEST 2 VIEWS DUAL ENERGY
[R71046A]
Status: Future, Expires: 3/23/2019, Normal, Routine, If
not already ordered or performed.
MRI HEAD W & W/O CONTRAST [R70553] Status: Future, Expires: 3/23/2019, Normal, Routine, If
not already ordered or performed.
CT SINUS W/O IV CONTRAST [R70486B] Status: Future, Expires: 3/23/2019, Normal, Routine, If
not already ordered or performed.
CT TEMPORAL BONE W IV CONTRAST
[R70481B]
Status: Future, Expires: 3/23/2019, Normal, Routine, If
not already ordered or performed.
CT NECK W IV CONTRAST [R70491] Status: Future, Expires: 3/23/2019, Normal, Routine, If
not already ordered or performed.
Consults [90415]
CONSULT TO SPEECH THERAPY [1009177] What question regarding the patient's medical care
would you like the specialist to answer? (REQUIRED):
Pre-operative Speech Evaluation
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]
Enhanced Contact Isolation - CDIFF [ISO0348] What is the reason for isolation?
Separate order must be placed for isolation cart., Pre-
Op Day Of Procedure
Page 2 of 12
Printed by WILLIAMS, HEATHER R [HRS0] at 1/23/2018 10:47:43 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
Isolation - Protective Precautions [240760]
Protective Precautions [ISO0349] What is the Reason for Isolation?
Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Protective - Positive Pressure Room
[NURCOM0109]
CONTINUOUS
Isolation - Contact - Multidrug Resistant
Organism (MDRO) [233557]
Contact Isolation - MDRO [ISO0334] CONTINUOUS
What is the Reason for Isolation? MDR
Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Isolation - Contact - Multidrug Resistant
Organism (XDR) [233558]
Contact Isolation - MDRO (XDR) [ISO0334] CONTINUOUS
What is the Reason for Isolation? XDR
Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Perioperative Normoglycemia Management - For First Day Surgery Patients Only (Single Response)
[230505]
equal to 6.4%diabetes history includes prediabetes and patients with A1C less than or No
Patients withOUT Diabetes [216834]
Glucose, POC [IPGLUCOSE] ONCE 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
Glucose, POC [IPGLUCOSE] EVERY 2 HOURS, 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?
Repeat POC glucose if previous reading greater
than or equal to 180 mg/dL. No recheck for reading
< 180 mg/dL, Pre-Op Day Of Procedure
Notify Provider [NURCOM0001] Provider to Notify: Other (Comment)
Notify based on: Blood Glucose
If blood glucose > (mg/dL): 179
If blood glucose < (mg/dL):
Pre-Op Day Of Procedure
Patients WITH Diabetes [216834]
Page 3 of 12
Printed by WILLIAMS, HEATHER R [HRS0] at 1/23/2018 10:47:43 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] ONCE 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
Glucose, POC [IPGLUCOSE] EVERY 2 HOURS, 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?
Repeat POC glucose if previous reading greater
than or equal to 180 mg/dL. No recheck for reading
< 180 mg/dL, Pre-Op Day Of Procedure
Notify Provider [NURCOM0001] Provider to Notify: Other (Comment)
Notify based on: Blood Glucose
If blood glucose > (mg/dL): 179
If blood glucose < (mg/dL):
Pre-Op Day Of Procedure
Does Not Apply - Outpatient Surgery [230506]
Does Not Apply - Outpatient Surgery
[NURCOM0022]
ONCE, Pre-Op Day Of Procedure
Medications - Hypoglycemia Treatment [212994]
URL:
Hypoglycemia Management (Adult) [191576]
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today For Until specified,
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
Page 4 of 12
Printed by WILLIAMS, HEATHER R [HRS0] at 1/23/2018 10:47:43 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA
TREATMENT, Starting today For Until specified,
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?
Per hypoglycemia treatment algorithm Recheck
glucose 15 minutes after providing treatment until
glucose is greater than or equal to 70 mg/dL. If
patient has been critically low (i.e., glucose less than
40 mg/dL), recheck glucose after 1 hour to ensure
glucose remains greater than or equal to 70mg/dL.
After resolution of mild hypoglycemia (i.e., glucose
40-69 mg/dL), consider rechecking after 1 hour if
patient has signs/symptoms of hypoglycemia or is at
risk for a subsequent hypoglycemic event (e.g.,
previously administered insulin still active, altered
renal status, altered mental status, NPO or
interrupted nutrition, or any other condition that
increases hypoglycemia risk), Pre-Op Day Of
Procedure
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Glucose,Other
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
Other: Nutritional status changes
Pre-Op Day Of Procedure
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If blood glucose less
than 40mg/dL and patient able to eat/swallow safely.
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., Pre-Op Day Of Procedure
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If glucose is 40-69
mg/dL and patient able to eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., Pre-Op Day Of Procedure
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose 40-
69 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
Pre-Op Day Of Procedure
glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
less than 40 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
Pre-Op Day Of Procedure
Page 5 of 12
Printed by WILLIAMS, HEATHER R [HRS0] at 1/23/2018 10:47:43 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, For blood glucose less
than 69 mg/dL and patient unable to eat/swallow
safely AND has NO IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Pre-Op Day Of Procedure
dextrose injection [800233] 12.5 g, Intravenous, PRN, For blood glucose 40-69
mg/dL and patient unable to eat/swallow safely AND
has IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Pre-Op Day Of Procedure
dextrose injection [800233] 25 g, Intravenous, PRN, For blood glucose less than
40 mg/dL and patient unable to eat/swallow safely
AND has IV access.
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Pre-Op Day Of Procedure
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Pre-Op Day Of Procedure
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting 1/31/18 For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Pre-Op Day Of Procedure
DVT Prophylactic Measures [86272]
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, Starting today, Routine
Does this need to be inserted/placed? Yes
Left/Right/Bilateral? Bilateral
Type: Knee high
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 immediate.
Page 6 of 12
Printed by WILLIAMS, HEATHER R [HRS0] at 1/23/2018 10:47:43 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
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
IV Therapy [149130]
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
Medications [90498]
oxymetazoline (AFRIN) 0.05% nasal spray
[40671]
2 spray, Nostril (Each), EVERY 15 MINUTES For 4
Doses
Start one hour prior to case
Pre-Op Day Of Procedure
Medications - Thyroplasty [91673]
dexamethasone (DECADRON) intraVENOUS
[800037]
10 mg, Intravenous, ON CALL For 1 Doses
Give 30 minutes prior to case
Pre-Op Day Of Procedure
Non-Categorized Patient Care Orders [90416]
Glucose, POC [IPGLUCOSE] ONCE, 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
Check O2 Saturation [NURMON0060] ONCE, Starting today For 1 Occurrences, Pre-Op Day
Of Procedure
No IV or Puncture [NURVAD0053] CONTINUOUS, Starting today, No IV or puncture on
*** arm., Pre-Op Day Of Procedure
Contingency Parameters [149139]
Page 7 of 12
Printed by WILLIAMS, HEATHER R [HRS0] at 1/23/2018 10:47:43 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Pre-Op Day Of Procedure
Laboratory [90418]
CBC WITH DIFFERENTIAL [CBC] 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
PLATELET COUNT [PLT] 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
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
PTT [PTT] 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
ELECTROLYTES, WHOLE BLOOD
[HCWBLYTS]
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
BUN [BUN] 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
GLUCOSE, WHOLE BLOOD [HCWBGLU] STAT, Starting today For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Anytime blood glucose monitoring (bedside) is less
than 40 or greater than 400 mg/dL., Pre-Op Day Of
Procedure
Laboratory - Pregnancy Test [81397]
Page 8 of 12
Printed by WILLIAMS, HEATHER R [HRS0] at 1/23/2018 10:47:43 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
Tests [91574]
TYPE AND SCREEN [HCTS] STAT, 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
Surgical Prophylaxis - Throat / Oral Cavity Procedures
First Line (Single Response) [223904]
ampicillin/sulbactam (UNASYN) intraVENOUS
[800010]
3 g, Intravenous, ON CALL For 1 Doses, Pre-Op Day
Of Procedure
MRSA/Documented MRSA History [223911]
Ampicillin/Sulbactam - Vancomycin (Maximum
Dose 2 grams) [228504]
ampicillin/sulbactam (UNASYN) intraVENOUS
[800010]
3 g, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
MRSA Negative and Immediate/Severe Reaction to Penicillin or Known Cephalosporin Allergies (Single
Response) [149387]
clindamycin (CLEOCIN) intraVENOUS - Patients
who are 40 - 80 kg [800033]
600 mg, Intravenous, ON CALL For 1 Doses, IntraOp
clindamycin (CLEOCIN) intraVENOUS - Patients
who are 81 - 120 kg [800033]
900 mg, Intravenous, ON CALL For 1 Doses, IntraOp
clindamycin (CLEOCIN) intraVENOUS - Patients
who are 121 kg or greater [800033]
1,200 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
MRSA and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [223914]
For patients 40-160kg [234190]
moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL bag [168649]
400 mg, Intravenous, ON CALL For 1 Doses, for 60
Minutes, Pre-Op Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
For patients over 160kg (800 mg total
moxifloxacin = TWO 400 mg bags) [234193]
moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL bag [168649]
400 mg, Intravenous, EVERY 1 HOUR For 2 Doses
On call to OR
for 60 Minutes, Pre-Op Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Surgical Prophylaxis - Other Procedures Needing Only Skin Coverage
First line [149386]
cefuroxime (ZINACEF) intraVENOUS - NOTE:
Patients who are 40 - 120 kg [800030]
1.5 g, Intravenous, ON CALL For 1 Doses, IntraOp
Page 9 of 12
Printed by WILLIAMS, HEATHER R [HRS0] at 1/23/2018 10:47:43 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

cefuroxime (ZINACEF) - NOTE: Patients who are
121 kg and greater [800030]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA/Documented MRSA History OR High Risk for MRSA (Implanted Device) (Single Response)
[145977]
Patients who are 40-120 kg [245211]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 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 greater than 121 kg [245214]
cefuroxime (ZINACEF) intraVENOUS [800030] 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
MRSA Negative and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [223982]
URL:
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Send to OR
Pre-Op Day Of Procedure
MRSA Positive and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [149373]
URL:
vancomycin (VANCOCIN) intraVENOUS [800084] 20 mg/kg, Intravenous, ON CALL For 1 Doses
Send to OR
Pre-Op Day Of Procedure
IntraOp
Medications - Vocal Cord [89281]
cidofovir (VISTIDE) in sodium chloride 0.9% inj
soln [700386]
15 mg, Other, ON CALL For 1 Doses
For vocal cord injection
IntraOp
dexamethasone (DECADRON) injection [36595] 10 mg, Other, ON CALL For 1 Doses
For vocal cord injection
IntraOp
mitomycin (MUTAMYCIN) injection [760168] 0.5 mg, Other, ON CALL For 1 Doses
For vocal cord application
for 5 Minutes, IntraOp
triamcinolone acetonide (KENALOG) 10 mg/mL
injection susp [46789]
Other, ON CALL For 1 Doses
For vocal card injection
IntraOp
triamcinolone acetonide (KENALOG) 40 mg/mL
injection susp [43072]
Other, ON CALL For 1 Doses
For vocal cord injection
IntraOp
onabotulinumtoxinA (BOTOX) 25 units/mL
injection [760265]
25 units, Other, ON CALL For 1 Doses
For vocal cord injection
Pharmacy send in luer lock syringe
IntraOp
Laboratory - For Patients Having Parathyroidectomy [92284]
PTH, Baseline [HCPTHIN] 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?
Baseline, IntraOp
Page 10 of 12
Printed by WILLIAMS, HEATHER R [HRS0] at 1/23/2018 10:47:43 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

PTH, 5 minutes [HCPTHIN] 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?
5 minutes, IntraOp
PTH, 10 minutes [HCPTHIN] 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?
10 minutes, IntraOp
PTH, 15 minutes [HCPTHIN] 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?
15 minutes, IntraOp
PTH [HCPTHIN] 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?
IntraOp
Patient Care Orders - Vocal Cord [113343]
Juvederm - Obtain from ENT Clinic
[NURCOM0022]
ONCE For 1 Occurrences, IntraOp
Radiesse - Obtain from ENT Clinic
[NURCOM0022]
ONCE For 1 Occurrences, IntraOp
Restylane - Obtain from ENT clinic
[NURCOM0022]
ONCE For 1 Occurrences, IntraOp
Dianosis
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
Page 11 of 12
Printed by WILLIAMS, HEATHER R [HRS0] at 1/23/2018 10:47:43 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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 12 of 12
Printed by WILLIAMS, HEATHER R [HRS0] at 1/23/2018 10:47:43 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org