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/clinical/cckm-tools/content/order-sets/ambulatory/girenal/name-98575-en.cckm

201712341

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,GI/Renal

OP - GI - Adult - Pre/Postprocedure [2678]

OP - GI - Adult - Pre/Postprocedure [2678] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, GI/Renal


OP - GI - Adult - Pre/Postprocedure [2678]
Intended for Adult Patients Only
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
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
Diagnostic Tests and Imaging [86228]
GI ENDOSCOPIC CATHETERIZATION OF
BILIARY DUCTS [R74328]
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
Contingency Parameters [86229]
Page 1 of 14
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Notify Attending [NURCOM0001] Provider to Notify: Attending
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): 120
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 < (%): 90
If urine output < (mL):
Other: International normalized ratio (INR) is greater
than 1.4,Platelet count less than 50,000/microliter,If
patient has taken clopidogrel (PLAVIX) within the last
7 days, unfractionated heparin within the last 8 hours,
low molecular weight heparin within the last 12 hours,
or warfarin (COUMADIN) within the last 5 days
Laboratory [127456]
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
HEMATOCRIT [HCT] STAT 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 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
BILIRUBIN, TOTAL [TBIL] STAT 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
AMYLASE [AMYL] STAT 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
LIPASE [LIPS] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
Page 2 of 14
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12/2017CCKM@uwhealth.org

ALBUMIN [ALB] STAT 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
ALKALINE PHOSPHATASE [ALKP] STAT 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
ALT/SGPT [ALT] STAT 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
AST/SGOT [AST] STAT 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
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
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
Intravenous Therapy [92820]
Page 3 of 14
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Pre-Op Day Of Procedure
sodium chloride 0.9% BOLUS [730003] 500 mL, Intravenous, ONCE For 1 Doses
Run at 125 mL/hr
Pre-Op Day Of Procedure
lactated ringers infusion [38890] Intravenous, CONTINUOUS, Pre-Op Day Of
Procedure
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS, Pre-Op Day Of
Procedure
Medications-Preprocedure Enema (Single Response) [93824]
phosphate (FLEET) enema [37517] 1 enema, Rectal, ONCE For 1 Doses, Pre-Op Day Of
Procedure
phosphate (FLEET) enema [37517] 2 enema, Rectal, ONCE For 1 Doses, Pre-Op Day Of
Procedure
Hypoglycemia Management - Preprocedure
Hypoglycemia Management [210984]
BOTH orders when ordering Select
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, 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
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 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:02:39 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@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 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:02:39 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@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 12/15/17 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
Surgical Prophylaxis
First Line - ERCP (Single Response) [146848]
ceftriaxone (ROCEPHIN) intraVENOUS - NOTE:
Patients who are 40-120 kg [800027]
1 g, Intravenous, ONCE For 1 Doses, IntraOp
ceftriaxone (ROCEPHIN) intraVENOUS - Patients
who are 121 kg or greater [800027]
2 g, Intravenous, ONCE For 1 Doses, IntraOp
Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single Response) [146849]
and gentamicin.Order ciprofloxacin only for patients who cannot tolerate both ceftriaxone NOTE:
gentamicin (GARAMYCIN) intraVENOUS -
Patients who are 40 kg and greater [800049]
5 mg/kg, Intravenous, ONCE For 1 Doses, Pre-Op
Day Of Procedure
ciprofloxacin (CIPRO) intraVENOUS - Patients
who are 40-120 kg [800031]
400 mg, Intravenous, ONCE For 1 Doses, Pre-Op Day
Of Procedure
ciprofloxacin (CIPRO) intraVENOUS - Patients
who are 121-160 kg [800031]
600 mg, Intravenous, ONCE For 1 Doses, Pre-Op Day
Of Procedure
ciprofloxacin (CIPRO) intraVENOUS - Patients
who are 161 kg and greater [800031]
800 mg, Intravenous, ONCE For 1 Doses, Pre-Op Day
Of Procedure
First Line - PEG (Single Response) [211094]
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are less than 40 kg [800000]
30 mg/kg, Intravenous, ONCE For 1 Doses, Pre-Op
Day Of Procedure
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 40 - 120 kg [800000]
2 g, Intravenous, ONCE For 1 Doses, Pre-Op Day Of
Procedure
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are greater than 121 kg [800000]
3 g, Intravenous, ONCE For 1 Doses, Pre-Op Day Of
Procedure
MRSA Postive/Documented History of MRSA - PEG (Single Response) [211098]
Page 6 of 14
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12/2017CCKM@uwhealth.org

Patients who are less than 40 kg - Cefazolin +
Vancomycin (Maximum 2000 mg) [228878]
cefazolin (ANCEF) intraVENOUS [800000] 30 mg/kg, Intravenous, ONCE For 1 Doses, Pre-Op
Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, ONCE For 1 Doses, Pre-Op
Day Of Procedure
Patients who are 40 - 120 kg - Cefazolin -
Vancomycin (Maximum 2000 mg) [228879]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ONCE For 1 Doses, Pre-Op Day
Of Procedure
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, Pre-Op Day Of Procedure
Patients who are greater than 121 kg - Cefazolin
+ Vancomycin (Maximum 2000 mg) [228880]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ONCE For 1 Doses, Pre-Op Day
Of Procedure
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ONCE For 1 Doses, Pre-Op
Day Of Procedure
Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies - PEG (Single Response)
[211108]
vancomycin (VANCOCIN) intraVENOUS -
Patients who are less than 40 kg (Maximum 2000
mg) [800084]
15 mg/kg, Intravenous, ONCE For 1 Doses, Pre-Op
Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS -
Patients who are greater than 40 kg (Maximum
2000 mg) [800084]
20 mg/kg, Intravenous, ONCE For 1 Doses, Pre-Op
Day Of Procedure
IntraOp
Sedation Medications (ED Only) [205515]
FENTanyl PF injection [800187] 50 mcg, Intravenous, ONCE For 1 Doses
Doses to be directed by provider
Administer initial dose concurrently with Midazolam
IntraOp
midazolam (VERSED) injection [800197] 2 mg, Intravenous, ONCE For 1 Doses
Doses to be directed by provider
Administer initial dose concurrently with Fentanyl
IntraOp
FENTanyl PF injection RANGE [750047] 12.5-50 mcg, Intravenous, PRN For 24 Hours,
Sedation for endoscopy procedure.
Doses to be directed by provider
Administer dose as needed every 2 minutes for
moderate sedation. After the initial dose, fentanyl and
midazolam should NOT be administered together.
Titrate to an appropriate level of sedation.
for 1 Minutes, IntraOp
midazolam (VERSED) injection RANGE [750056] 0.5-2 mg, Intravenous, PRN For 24 Hours, sedation,
Sedation for endoscopy procedure.
Doses to be directed by provider
Administer dose as needed every 2 minutes for
moderate sedation. After the initial dose, fentanyl and
midazolam should NOT be administered together.
Titrate to an appropriate level of sedation.
IntraOp
Page 7 of 14
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12/2017CCKM@uwhealth.org

diphenhydramine (BENADRYL) injection RANGE
[750044]
12.5-50 mg, Intravenous, PRN For 24 Hours, Sedation
for endoscopy procedure
Doses to be directed by provider
Once prn for moderate sedation. Do not repeat
administration.
for 1 Minutes, IntraOp
promethazine (PHENERGAN) injection RANGE
[750060]
12.5-25 mg, Intravenous, PRN For 24 Hours,
nausea/vomiting
Doses to be directed by provider
Second line or adjunct agent if diphenhydramine is not
patient preferred or if diphenhydramine is not
completely effective. Once prn for moderate sedation.
Do not repeat administration.
Extravasation Risk: CENTRAL or LARGE VEIN
required. No hand, foot, wrist, or antecubital veins or
areas of flexion
Requires further dilution in 10 to 20 mL NS or
preparation in a minibag. Administer over 10 to 15
minutes through a running IV line at a port furthest
from the patient's vein.
Discontinue immediately if burning or pain occurs with
administration.
IntraOp
Sedation Medications [148628]
FENTanyl PF injection RANGE [750047] 12.5-50 mcg, Intravenous, PRN For 24 Hours,
Sedation for endoscopy procedure
Initial dose of 50 mcg (consider lower doses for
patients older than 70 years old or less than 50 kg);
subsequent doses of 12.5-50 mcg every 2 minutes as
needed for moderate sedation. Titrate to maintain an
Adult Sedation Score between 3-4.
Doses to be directed by provider.
for 1 Minutes, APC/GI Sedation
midazolam (VERSED) injection RANGE [750056] 0.5-2 mg, Intravenous, PRN For 24 Hours, sedation,
Sedation for endoscopy procedure.
Initial dose of 2 mg (consider lower doses for patients
older than 70 years old or less than 50 kg).
Subsequent doses of 0.5-2 mg every 2 minutes as
needed for moderate sedation. Titrate to maintain an
Adult Sedation Score between 3-4.
If ordered IV: push rate 1 mg/minute.
Doses to be directed by provider.
APC/GI Sedation
diphenhydramine (BENADRYL) injection RANGE
[750044]
12.5-50 mg, Intravenous, PRN For 24 Hours, Sedation
for endoscopy procedure
Once prn for moderate sedation. Do not repeat
administration.
Doses to be directed by provider.
for 1 Minutes, APC/GI Sedation
Page 8 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:02:39 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

promethazine (PHENERGAN) injection RANGE
[750060]
12.5-25 mg, Intravenous, PRN For 24 Hours,
nausea/vomiting
Second line or adjunct agent if diphenhydramine is not
patient preferred or if diphenhydramine is not
completely effective. Once prn for moderate sedation.
Do not repeat administration.
Extravasation Risk: CENTRAL or LARGE VEIN
required. No hand, foot, wrist, or antecubital veins or
areas of flexion
Requires further dilution in 10 to 20 mL NS or
preparation in a minibag. Administer over 10 to 15
minutes through a running IV line at a port furthest
from the patient's vein.
Discontinue immediately if burning or pain occurs with
administration.
Doses to be directed by provider.
IntraOp
Sedation Reversal [210988]
naloxone (NARCAN) injection [800199] 0.1 mg, Intravenous, PRN For 24 Hours, opioid
overdose, Sedation reversal
Doses to be directed by provider
Administer every 3 minutes times 4 doses as needed
for respiratory rate less than 8 breaths/minute or
sedation score of 5 or greater. Notify MD if naloxone
administered.
IntraOp
flumazenil (ROMAZICON) injection [104460] 0.1-1 mg, Intravenous, PRN For 24 Hours, Sedation
reversal
Doses to be directed by provider
Give 0.1-0.2 mg IV over 15 seconds; repeat dose after
45 seconds (1 minute intervals) as needed for
sedation reversal up to a maximum dose of 1 mg.
IntraOp
GI Medications [148873]
epINEPHrine (CARDIAC 1:10,000) 0.1 MG/ML
soln prefilled syringe [177443]
0.1-0.4 mg, Subcutaneous, ONCE PRN For 24 Hours,
Gastrointestinal bleeding
Give via scope
If ordered IV: push over 15-30 seconds.
Doses to be directed by provider
IntraOp
glucagon injection kit [107799] 0.25-1 mg, Intravenous, ONCE PRN For 24 Hours,
Gastrointestinal motility
Doses to be directed by provider
IntraOp
methylene blue (PROVAYBLUE) injection
[172272]
0.5-2 mg, Subcutaneous, ONCE PRN For 24 Hours
Dilute in 5 mL normal saline. Give via scope
If ordered IV: push 1 mL over 1-2 minutes.
Doses to be directed by provider
IntraOp
sodium tetradecyl (SOTRADECOL) 3 % vial
[46605]
2-8 mL, Subcutaneous, ONCE PRN For 24 Hours,
Sclerosing agent
Give via scope
Doses to be directed by provider
RN to document total dose given in treatment session
IntraOp
Page 9 of 14
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lidocaine (XYLOCAINE JELLY) 2 % gel [39030] Topical, ONCE PRN For 24 Hours, pain
Apply to rectum
Doses to be directed by provider
IntraOp
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN For 24
Hours, nausea/vomiting
Doses to be directed by provider
IntraOp
PostOp/Phase II
Medications- PostOp [146881]
indomethacin (INDOCIN) rectal suppository
[38416]
50 mg, Rectal, ONCE Starting today For 1 Doses
Administer during or at termination of Endoscopic
Retrograde Cholangiopancreatography (ERCP)
Post-Op/Phase II
pantoprazole (PROTONIX) intraVENOUS
[800119]
40 mg, Intravenous, ONCE For 1 Doses, Post-
Op/Phase II
Contingency Parameters [90161]
Notify Attending [NURCOM0001] Provider to Notify: Attending
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): 120
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 < (%): 90
If urine output < (mL):
Other: New abdominal pain,New chest pain
Post-Op/Phase II
Laboratory [127457]
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?
Post-Op/Phase II
TROPONIN [GM2447] EVERY 6 HOURS, Starting today For 3 Occurrences,
Routine
If Conditional, What Condition? Draw if patient
experiences a cardiac event such as chest pain.
Draw immediately postprocedure and then every 6
hours times 3 or until peak., Post-Op/Phase II
HEMATOCRIT [HCT] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
Page 10 of 14
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12/2017CCKM@uwhealth.org

PLATELET COUNT [PLT] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
BUN [BUN] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
CALCIUM [CA] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
CREATININE [CRET] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
ELECTROLYTES [LYTE] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
MAGNESIUM [MAG] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
PHOSPHATE [PHOS] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
Diagnostic Tests and Imaging [86264]
X-RAY CHEST AP VIEW [R71010] 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?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Post-Op/Phase II
Page 11 of 14
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12/2017CCKM@uwhealth.org

X-RAY ABDOMEN AP VIEW (KUB) [R74000] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Post-Op/Phase II
GI ESOPHAGRAM [R74220] 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
Post-Op/Phase II
Diagnostic Tests and Imaging - Virtual Colonoscopy [89264]
CT VIRTUAL COLONOSCOPY DIAGNOSTIC
[R0067T]
ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history.
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Post-Op/Phase II
diatrizoate meglumine and sodium
(GASTROGRAFIN) 66-10 % soln [44937]
30 mL, Oral, ONCE For 1 Doses
Take with 2-3 glasses of liquid or water
Post-Op/Phase II
Outpatient Discharge Orders
Nutrition [86265]
Page 12 of 14
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12/2017CCKM@uwhealth.org

Clear Liquid Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid: Clear Liquid
Esophagectomy:
Fat Controlled:
Fiber:
Fluid Restriction:
Heart Healthy:
Metabolic:
Renal:
Sodium Controlled:
NPO:
Clear liquids until tomorrow morning.
Soft Solids [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid:
Esophagectomy:
Fat Controlled:
Fiber:
Fluid Restriction:
Heart Healthy:
Metabolic:
Renal:
Sodium Controlled:
NPO:
Soft food for *** days, then advance as tolerated.
Medication Instructions [86458]
Resume clopidogrel (PLAVIX) [NURTRT0048] ONCE, Starting today For 1 Occurrences, Resume
clopidogrel (PLAVIX) in *** days, Post-Op/Phase II
Resume warfarin (COUMADIN) [NURTRT0048] ONCE, Starting today For 1 Occurrences, Resume
warfarin (COUMADIN) in *** days, Post-Op/Phase II
Resume low molecular weight heparin
[NURTRT0048]
ONCE, Starting today For 1 Occurrences, Resume
low molecular weight heparin at previous schedule for
*** days, Post-Op/Phase II
Resume aspirin and non-steroidal anti-
inflammatories [NURTRT0048]
ONCE For 1 Occurrences, Resume aspirin and non-
steroidal anti-inflammatories in *** days, Post-
Op/Phase II
Medications - Discharge [148705]
diphenhydramine-lidocaine-al&mag-simethicone
(FIRST-MOUTHWASH BLM) susp [104894]
10 mL, 1 Bottle, , starting 12/7/17, Normal
Follow-Up Appointments [86266]
Schedule Appointment [NURCOM0026] Routine
Reason for Hospital Follow Up Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
Diagnosis
Page 13 of 14
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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 - New or Established Patients [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
Page 14 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:02:39 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org