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/clinical/cckm-tools/content/order-sets/ambulatory/general-surgery/name-98584-en.cckm

201712341

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,General Surgery

OP/FDS - General Surgery - Adult - Preoperative [4584]

OP/FDS - General Surgery - Adult - Preoperative [4584] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, General Surgery


OP/FDS - General Surgery - Adult - Preoperative [4584]
for Adult Patients OnlyIntended
Pre-Day of Procedure
Medications - Prescriptions - Bowel Prep [183963]
bisacodyl EC (DULCOLAX) 5 mg delayed release
tab [49076]
4 tab, 0, starting 12/7/17, Normal, Pre-Day of
Procedure
G.I. lavage (GOLYTELY) soln [103976] 4000 mL, 0, starting 12/7/17, Normal, Pre-Day of
Procedure
metRONIDazole (FLAGYL) 250 mg tab [39639] 9 tab, 0, starting 12/7/17, Normal, Pre-Day of
Procedure
neomycin 500 mg tab [40142] 6 tab, 0, starting 12/7/17, Normal, Pre-Day of
Procedure
phosphate (FLEET) enema - (1 Enema Prep)
[37517]
1 enema, 0, starting 12/7/17, Normal, Pre-Day of
Procedure
phosphate (FLEET) enema - (2 Enema Prep)
[37517]
2 enema, , starting 12/7/17, Normal, Pre-Day of
Procedure
Na Sulfate-K Sulfate-Mg Sulf (SUPREP BOWEL
PREP) Soln [142595]
177 mL, 2, starting 12/7/17, Normal, Pre-Day of
Procedure
PEG-KCl-NaCl-NaSulf-Na Asc-C 100 G soln
[114374]
2000 mL, , starting 12/7/17, Normal, Pre-Day of
Procedure
polyethylene glycol (MIRALAX) oral powder
[61353]
250 g, , starting 12/7/17, Normal, Pre-Day of
Procedure
Medications - Prescriptions - Modified Bowel Prep [91919]
magnesium citrate soln - 10 oz x1 [39309] 300 mL, 0, starting 12/7/17, Normal, Pre-Day of
Procedure
magnesium citrate soln - 20 oz x1 [39309] 600 mL, 0, starting 12/7/17, Normal, Pre-Day of
Procedure
Anti-infectives [184322]
mupirocin (BACTROBAN) 2 % ointment [45826] starting 12/7/17, Normal, Pre-Day of Procedure
chlorhexidine gluconate (HIBICLENS) 4 % topical
liquid [64730]
5 package, , starting 12/7/17, Normal, Pre-Day of
Procedure
Immunizations - Order if Splenectomy/Distal Pancreatectomy Surgery is Scheduled After 14 Days
[150001]
Pneumococcal Polysaccharide 23 Valent (PPV-
23) Vaccine (> 2 Yrs) [90732]
Normal, Routine
meningococcal conjugate vaccine (MENVEO)
injection [139839]
starting 12/7/17, Normal, Pre-Day of Procedure
Influenza Immunizations - Order if Splenectomy/Distal Pancreatectomy Surgery is Scheduled After 14
Days (Single Response) [151740]
Influenza, Quadrivalent, PRESERVATIVE FREE,
ages 3 years and older, UNIT-DOSE [90686]
Normal, Routine
Influenza, Quadrivalent, ages 3 years and older,
MULTI-DOSE [90688]
Normal, Routine
Laboratory [86269]
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:1/21/18 MANUAL,Count:1,
Normal, Routine
CBC WITHOUT DIFFERENTIAL [HEMO] Status: Standing, Expires:1/21/18 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:1/21/18 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:1/21/18 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:1/21/18 MANUAL,Count:1,
Normal, Routine
Page 1 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CREATININE [CRET] Status: Standing, Expires:1/21/18 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:1/21/18 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:1/21/18 MANUAL,Count:1,
Normal, Routine
ALBUMIN [ALB] Status: Standing, Expires:1/21/18 MANUAL,Count:1,
Normal, Routine
ALT/SGPT [ALT] Status: Standing, Expires:1/21/18 MANUAL,Count:1,
Normal, Routine
AST/SGOT [AST] Status: Standing, Expires:1/21/18 MANUAL,Count:1,
Normal, Routine
BILIRUBIN, TOTAL [TBIL] Status: Standing, Expires:1/21/18 MANUAL,Count:1,
Normal, Routine
ALKALINE PHOSPHATASE [ALKP] Status: Standing, Expires:1/21/18 MANUAL,Count:1,
Normal, Routine
LD, TOTAL [LDH] Status: Standing, Expires:1/21/18 MANUAL,Count:1,
Normal, Routine
URINALYSIS WITH MICROSCOPY AND
CULTURE IF >5 WBC/HPF [HCUACULT]
Status: Standing, Expires:1/21/18 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:1/21/18 MANUAL,Count:1,
Normal, Routine
Antibody Screen and ABO and Rh Typing
[192516]
ANTIBODY SCREEN [ABSCR] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
ABO AND RH TYPING [ABO] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Diagnostic Tests and Imaging [86271]
ECG - 12 Lead [EKG0008] Status: Future, Expires: 1/7/2019, Normal, Routine,
Pre-Operative, General Anesthesia
X-RAY CHEST PA & LAT VIEWS [R71020] Status: Future, Expires: 2/7/2019, Normal, Routine
X-RAY CHEST PA & LAT VIEWS DUAL
ENERGY [R71020A]
Status: Future, Expires: 2/7/2019, Normal, Routine
PreOp 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 18
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:18:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@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 18
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:18:56 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] 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
Non-Categorized Patient Care Orders [86273]
Mattress Air Transfer Hovermat - Order for
Bariatric Patients [NURCOM0022]
ONCE, Pre-Op Day Of Procedure
Bariatric Bed-Mighty Air Sizewise (Specialty Bed)
[EQP0034]
CONTINUOUS, Routine
Trapeze Needed:
Time Needed:
Last patient height? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
Send Request to CS?
Deliver Equipment To:
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
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.
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
Page 4 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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
Steroid Dosing (Single Response) [153487]
hydrocortisone sodium succinate injection
[800189]
25 mg, Intravenous, ON CALL For 1 Doses
Administer 1 hour prior to incision
Pre-Op Day Of Procedure
hydrocortisone sodium succinate injection
[800189]
35 mg, Intravenous, ON CALL For 1 Doses
Administer 1 hour prior to incision
Pre-Op Day Of Procedure
hydrocortisone sodium succinate injection
[800189]
50 mg, Intravenous, ON CALL For 1 Doses
Administer 1 hour prior to incision
Pre-Op Day Of Procedure
Laboratory [86275]
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
POTASSIUM [K] 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
Laboratory - Pregnancy Test [81397]
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
Blood Products [83983]
Page 5 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

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:
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:
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:
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:
Pre-Op Day Of Procedure
Blood Products [83984]
Page 6 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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:
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:
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:
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:
Pre-Op Day Of Procedure
Page 7 of 18
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:18:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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:
Pre-Op Day Of Procedure
Diagnostic Tests and Imaging [113348]
ECG - 12 Lead [EKG0008] ONCE For 1 Occurrences, Routine
Reason for exam: Pre-operative
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
Pre-Operative, General Anesthesia
VTE Prophylaxis
VTE Prophylaxis [105649]
• 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) subcutanoeus 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
Surgical Prophylaxis - Appendectomy
Page 8 of 18
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12/2017CCKM@uwhealth.org

procedures may not need surgical prophylaxis Clean
appendicitis) (Uncomplicated
First Line (Single Response) [219009]
cefoxitin (MEFOXIN) intraVENOUS - Patients
who are 40 - 120 kg [800022]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefoxitin (MEFOXIN) intraVENOUS - Patients
who are 121 kg or greater [800022]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
Patients who are 40 - 120 kg - Cefazolin +
Metronidazole [227820]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are greater than 121 kg - Cefazolin
+ Metronidazole [227821]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
MRSA/Documented MRSA History (Single Response) [219101]
Patients who are 40-120 kg - Cefoxitin +
Vancomycin [228406]
cefoxitin (MEFOXIN) intraVENOUS [800022] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 121 kg or greater - Cefoxtin +
Vancomycin [228408]
cefoxitin (MEFOXIN) intraVENOUS [800022] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 40 - 120 kg - Cefazolin +
Metronidazole + Vancomycin [228407]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 121 kg - Cefazolin
+ Metronidazole + Vancomycin [228410]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
MRSA and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [154515]
Patients who are 40-120 kg [228494]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 121 - 160 kg [228497]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
Page 9 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum of 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 160 kg [228496]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum 2000 mg/dose [800084]
2 g, 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) [154514]
Patients who are 40-120 kg [227826]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are 121 - 160 kg [227828]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are greater than 160 kg [227827]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Surgical Prophylaxis - Biliary Tract
of common procedures may not need surgical prophylaxis (cholecystectomy, exploration Clean
bile duct, and choledochoenterostomy)
First Line (Single Response) [154693]
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 40 - 120 kg [800000]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 121 kg and greater [800000]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
ampicillin/sulbactam (UNASYN) intraVENOUS -
NOTE: Patients who are 40 kg and greater
[800010]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA/Documented MRSA History (Single Response) [154516]
Patients who are 40 - 120 kg - Cefazolin +
Vancomycin [228788]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 120 kg - Cefazolin
+ Vancomycin [228790]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 40 kg and greater - Ampicillin /
Sulbactam + Vancomycin [228789]
ampicillin/sulbactam (UNASYN) intraVENOUS
[800010]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
Page 10 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [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) [154517]
Patients who are 40 - 120 kg - Ciprofloxacin +
Metronidazole [227829]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are 121-160 kg - Ciprofloxacin -
Metronidazole [227831]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are greater than 160 kg -
Ciprofloxacin + Metronidazole [227830]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who 40 -120 kg - Metronidazole and
Gentamicin [227832]
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
gentamicin (GARAMYCIN) intraVENOUS
[800049]
5 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who 121 kg and greater - Metronidazole
and Gentamicin [227833]
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
gentamicin (GARAMYCIN) intraVENOUS
[800049]
5 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
MRSA and Immediate/Severe Reactions to Pencillin or Known Cephalosporin Allergies (Single
Response) [154534]
Patients who are 40-120 kg - Ciprofloxacin -
MetRONIDazole - Vancomycin [228590]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 121 - 160 kg - Ciprofloxacin -
Metronidazole - Vancomycin [228592]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 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
Patients who are greater than 160 kg -
Ciprofloxacin - MetRONIDazole - Vancomycin
[228591]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
Page 11 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Surgical Prophylaxis - Clean Procedure, Skin Coverage Only
First Line (Single Response) [147677]
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 40-120 kg [800000]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are greater than 120 kg [800000]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA/Documented History of MRSA (Single Response) [147679]
Patients who are 40 - 120 kg [228793]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 120 kg [228795]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [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
[145187]
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Send on call to OR
Pre-Op Day Of Procedure
Surgical Prophylaxis - Colorectal Surgery
First Line (Single Response) [154510]
Patients who are 40 - 120 kg - Cefazolin +
Metronidazole [227835]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are greater than 120 kg - Cefazolin
+ Metronidazole [227838]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
MRSA/Documented MRSA History (Single Response) [154511]
Patients who are 40 - 120 kg - Cefazolin +
Metronidazole + Vancomycin [227839]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 120 kg - Cefazolin
+ Metronidazole + Vancomycin [227840]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients with IgE-mediated or Severe Reaction to Beta Lactams (Single Response) [146896]
Patients who are 40 - 120 kg [236149]
Page 12 of 18
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:18:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are 121 - 160 kg [236151]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are greater than 160 kg [236150]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients with IgE-mediated or severe reaction to Beta-lactam AND MRSA or history of MRSA or MRSE
Risk (Single Response) [146275]
Patients who are 40 - 120 kg [236152]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose - 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 120 kg [236153]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose - 2000 mg/dose [800084]
2 g, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
Surgical Prophylaxis - Gastroduodenal
Clean procedures may not need surgical prophylaxis (Resection with or without vagotomy for
gastric or duodenal ulcers, resection for gastric carcinoma, revision required to repair strictures of
the gastric outlet, PEG insertion, perforated ulcer procedures, pancreaticduodenectomy, and
bariatric surgical prophylaxis)
First Line (Single Response) [154704]
cefazolin (ANCEF) intraVENOUS - Patients who
are 40 - 120 kg [800000]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefazolin (ANCEF) intraVENOUS - Patients who
are 121 kg or greater [800000]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA/Documented MRSA History (Single Response) [154543]
Patients who are 40 - 120 kg [228839]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 121 kg or greater [228840]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [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) [153523]
moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL bag - NOTE: Patients who
are 40 - 160 kg [168649]
400 mg, Intravenous, ON CALL For 1 Doses, for 60
Minutes, Pre-Op Day Of Procedure
Page 13 of 18
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:18:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL - NOTE: Patients who are
greater than 160 kg [168649]
400 mg, Intravenous, EVERY 1 HOUR For 2 Doses,
for 60 Minutes, Pre-Op Day Of Procedure
MRSA and Immediate Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [154544]
URL:
Patients who are 40-160 kg [234184]
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 -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 160 kg [234187]
moxifloxacin (AVELOX) 400 mg in sodium
chloride 0.8% 250 mL bag [168649]
400 mg, Intravenous, EVERY 1 HOUR For 2 Doses,
for 60 Minutes, Pre-Op Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
2 g, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
Surgical Prophylaxis - Hernia Repair
herniorrhaphy) procedures may not need surgical prophylaxis (Hernioplasty and Clean
First Line (Single Response) [154704]
cefazolin (ANCEF) intraVENOUS - Patients who
are 40 - 120 kg [800000]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefazolin (ANCEF) intraVENOUS - Patients who
are 121 kg or greater [800000]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA/Documented MRSA History (Single Response) [154543]
Patients who are 40 - 120 kg [228839]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 121 kg or greater [228840]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Immediate/Severe Reactions to Pencillin or Known Cephalosporin Allergies (Single Response) [154713]
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Surgical Prophylaxis - Small Intestine (Non-obstructed)
small intestine, procedures may not need surgical prophylaxis (Incision or resection of the Clean
enterostomy, intestinal bypass, and enterectomy, with or without intestinal anastomosis or
strictureoplasty)
First Line (Single Response) [154704]
cefazolin (ANCEF) intraVENOUS - Patients who
are 40 - 120 kg [800000]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefazolin (ANCEF) intraVENOUS - Patients who
are 121 kg or greater [800000]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA/Documented History of MRSA (Single Response) [147679]
Patients who are 40 - 120 kg [228793]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 120 kg [228795]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Page 14 of 18
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:18:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

MRSA Negative and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [154514]
Patients who are 40-120 kg [227826]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are 121 - 160 kg [227828]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are greater than 160 kg [227827]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
MRSA and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [154515]
Patients who are 40-120 kg [228494]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 121 - 160 kg [228497]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum of 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 160 kg [228496]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum 2000 mg/dose [800084]
2 g, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
Surgical Prophylaxis - Small Intestine (Obstructed)
Clean procedures may not need surgical prophylaxis (Incision or resection of the small intestine,
enterectomy, with or without intestinal anastomosis or enterostomy, intestinal bypass, and
strictureoplasty)
First Line (Single Response) [154510]
Patients who are 40 - 120 kg - Cefazolin +
Metronidazole [227835]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are greater than 120 kg - Cefazolin
+ Metronidazole [227838]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Page 15 of 18
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:18:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

MRSA/Documented MRSA History (Single Response) [154511]
Patients who are 40 - 120 kg - Cefazolin +
Metronidazole + Vancomycin [227839]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 120 kg - Cefazolin
+ Metronidazole + Vancomycin [227840]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [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) [154514]
Patients who are 40-120 kg [227826]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are 121 - 160 kg [227828]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
Patients who are greater than 160 kg [227827]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
MRSA and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [154515]
Patients who are 40-120 kg [228494]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 121 - 160 kg [228497]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum of 2000 mg/dose [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 160 kg [228496]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
metRONIDazole (FLAGYL) intraVENOUS
[800062]
750 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS -
Maximum 2000 mg/dose [800084]
2 g, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
Page 16 of 18
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:18:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

IntraOp
Diagnostic Tests and Imaging [185813]
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
US ABDOMEN COMPLETE [R76700] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: ULTRASOUND
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
If being performed remotely, where?
Transport Method: Floor Determined/Entered
IntraOp
GI CHOLANGIOGRAM OPERATIVE [R74300] 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?
Is patient pregnant?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
IntraOp
ULTRASOUND GUIDANCE, INTRAOPERATIVE
0-2 HOURS [R76998A]
ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
If being performed remotely, where?
Transport Method: Floor Determined/Entered
IntraOp
Diagnosis
Page 17 of 18
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:18:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Diagnosis - Pre Op [711]
Pre-operative general physical examination
[255759]
Other specified pre-operative examination
Diagnosis - Immunizations [101181]
Need for prophylactic vaccination against
Haemophilus influenzae type B [992472]
Diagnosis
Anthrax exposure [323600] Contact with or exposure to anthrax
Need for prophylactic vaccination against
Streptococcus pneumoniae (pneumococcus)
[V03.82.ICD-9-CM]
Need for prophylactic vaccination against
streptococcus pneumoniae(pneumococcus)
Need for prophylactic vaccination and inoculation
against influenza [V04.81.ICD-9-CM]
Need for prophylactic vaccination and inoculation
against influenza
Need for vaccination for meningococcus
[253964]
Need for other specified prophylactic vaccination
against single bacterialdisease
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
Preoperative Exam (Global) [1265]
Preoperative H&P, No Charge, Surgical Package LOS Code
Page 18 of 18
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:18:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org