/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/ambulatory/,/clinical/cckm-tools/content/order-sets/ambulatory/gynecology/,

/clinical/cckm-tools/content/order-sets/ambulatory/gynecology/name-98570-en.cckm

20180122

page

100

UWHC,UWMF,

Tools,

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

FDS - Gynecology - Oncology - Preoperative [2936]

FDS - Gynecology - Oncology - Preoperative [2936] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Gynecology


FDS - Gynecology - Oncology - Preoperative [2936]
for Adult Patients OnlyIntended
Pre-Day of Procedure
Laboratory [92227]
Prothrombin Time/INR
Please order for any of the following reasons:
1. Patient on warfarin
2. Patient with conditions causing poor coagulation - malnutrition, advanced cancer, chronic
antibiotic treatment, liver disease, renal dysfuction
3. Patient with history of clotting/bleeding disorders.
ALBUMIN [ALB] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
CBC WITHOUT DIFFERENTIAL [HEMO] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
CREATININE [CRET] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
ELECTROLYTES [LYTE] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
GLUCOSE [GLU] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
URINALYSIS WITH MICROSCOPY AND
CULTURE IF >5 WBC/HPF [HCUACULT]
Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
PTT [PTT] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
ALKALINE PHOSPHATASE [ALKP] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
ALT/SGPT [ALT] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
AST/SGOT [AST] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
BILIRUBIN, TOTAL [TBIL] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
BUN [BUN] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
CALCIUM [CA] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
MAGNESIUM [MAG] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
PROTEIN, TOTAL [TP] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
CA 125 [XCA125] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
CA 19-9 [XCA199] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
CARCINOEMBRYONIC ANTIGEN [CEA] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
INHIBIN B [HCINHBNB] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
AFP, TUMOR MARKER, SERUM [XAFPTM] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
Page 1 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

LD, TOTAL [LDH] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
HCG, QUANTITATIVE [BHCG] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
Laboratory - Blood Bank [109051]
Antibody Screen
Use to prescreen patient for alloantibodies to red blood cell components. Order if specimen collection will
be greater than 72 hours prior to surgery. Blood products cannot be issued on the basis of this test.
ABO and Rh Typing
Use to determine patient blood type. Order if specimen collection will be greater than 72 hours prior to
surgery. Blood products cannot be issued on the basis of this test.
Type and Screen
Order if specimen collection will be less than 72 hours prior to surgery.
ANTIBODY SCREEN [ABSCR] Status: Future, Expected: 1/22/2018 Approximate,
Expires: 5/24/2018, Normal, Routine
ABO AND RH TYPING [ABO] Status: Standing, Expires:3/8/18 MANUAL,Count:1,
Normal, Routine
Diagnostic Tests and Imaging [197911]
X-RAY CHEST 2 VIEWS
Please ONLY order for any of the following reasons:
1. Current cardio/pulmonary signs or symptoms or exam findings
2. Recent significant respiratory infection
3. Chronic lung disease > age 70
4. Heavy smoking
5. Aortic aneurysm
6. Cardiomegaly
7. Risk for pulmonary metastasis
ECG - 12 Lead [EKG0008] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
X-RAY CHEST 2 VIEWS [R71046] Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
X-RAY CHEST 2 VIEWS DUAL ENERGY
[R71046A]
Status: Future, Expected: 1/22/2018, Expires: 3/8/18,
Normal, Routine
Pulmonary Lab Testing [999992] Routine
Reason for Exam: Preoperative evaluation
Specify Test: ABG on Room Air (Pulmonary Lab to
draw)
Consults [243913]
Page 2 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

CONSULT TO UWH ANESTHESIA PASS
PREOP SERVICE [1009482]
Please indicate Surgical/Procedural Service (if not in
case request):
Who is Surgeon or Proceduralist? (if not in case
request):
Service contact + Pager/Phone. Essential for follow-
up!!:
If you want patient to be seen IN-PERSON at the
PASS Clinic, please select the reason:
CARDIOVASCULAR, chart review only:
PULMONARY OR AIRWAY, chart review only:
MEDICATION, chart review only:
OTHER REASONS, chart review only:
Who will complete the H&P?
If H&P to be done by non-UWH provider, what facility?
Approximately when will H&P be completed, from
today? (Reminder - H&Ps are required by CMS to be
done within 30 days):
Pre-op Device Check [CARD0017] Status: Future, Expires: 2/22/2019, Normal, Routine,
Qty-1
Medications - Prescriptions - Bowel Prep [92352]
G.I. lavage (NULYTELY) soln [103972] 4 L, 0, starting 1/22/18, Local Printer, Pre-Day of
Procedure
metRONIDazole (FLAGYL) 250 MG tab [39639] 9 tab, 0, starting 1/22/18, Normal, Pre-Day of
Procedure
neomycin 500 MG tab [40142] 6 tab, 0, starting 1/22/18, Normal, Pre-Day of
Procedure
RA SALINE ENEMA 19-7 GM/118ML ENEM
[150473]
starting 1/22/18, Normal, Pre-Day of Procedure
magnesium citrate 1.745 GM/30ML soln [39309] 296 mL, 0, starting 1/22/18, Normal, Pre-Day of
Procedure
Nutrition Before Surgery [241994]
Page 3 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Nourishments & Supplements - Impact AR
[NUT0005]
Click here to view supplements and nourishments
available at TAC.
Please note: TAC carries only the following items:
Medical Food/Oral Supplements:
Ensure Muscle Health, Vanilla (Cans)
Ensure Plus, Chocolate (Cans)
Ensure Plus, Strawberry (Cans)
Ensure Plus, Vanilla (Cans)
Gelatein Fruit Punch High Protein
Gelatein Orange High Protein
Gelatein Plus Tropical Lime High Protein
Glucerna Shake Butter Pecan
Magic Cup, Chocolate
Magic Cup, Orange
Magic Cup, Vanilla
Magic Cup, Wild Berry
Nepro (Cans)
Nourishments/Snack Items:
Angel Food Cake
Applesauce
Bread, Wheat
Bread, White
Cheese, Cheddar
Cheese, Low Fat/Low Salt
Cookie, Sugar
Cookie, Sugar-Free
Cottage Cheese
Fruit, Canned
Fruit, Fresh
Gelatin, Clear Liquid
Gelatin, Clear Liquid - Diabetic
Hard Candy
Hard Candy, Diabetic
Instant Breakfast, Sugar Free, Skim, Van illa
Instant Breakfast, No Sugar Added, Choco late
Instant Breakfast, Vanilla
Juice, Apple
Juice, Cranberry
Juice, Cranberry - Diabetic
Juice, Grape
Juice, Orange
Juice, Prune
Milk, 2%
Milk, Chocolate
Milk, Skim
Milk, Whole
Peanut Butter
Peanut Butter, Low-Sodium
Pop, Cola
Pop, Diet Cola
Pop, Diet Lemon Lime
Pop, Lemon Lime
Popsicle
Popsicle, Sugar-Free
Page 4 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Pudding
Pudding - Diabetic
Sandwich, Beef
Sandwich, Cheese
Sandwich, Chicken Salad
Sandwich, Ham & Cheese
Sandwich, Turkey
Sherbet
Yogurt, Routine
Medical Food / Oral Supplement(s): Other Products
(Comment)
Nourishment / Snack Item(s):
Schedule:
Medical Food / Oral Supplement = Impact AR
1 Box= 15 Cartons
Page 5 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Nourishments & Supplements [NUT0005] Click here to view supplements and nourishments
available at TAC.
Please note: TAC carries only the following items:
Medical Food/Oral Supplements:
Ensure Muscle Health, Vanilla (Cans)
Ensure Plus, Chocolate (Cans)
Ensure Plus, Strawberry (Cans)
Ensure Plus, Vanilla (Cans)
Gelatein Fruit Punch High Protein
Gelatein Orange High Protein
Gelatein Plus Tropical Lime High Protein
Glucerna Shake Butter Pecan
Magic Cup, Chocolate
Magic Cup, Orange
Magic Cup, Vanilla
Magic Cup, Wild Berry
Nepro (Cans)
Nourishments/Snack Items:
Angel Food Cake
Applesauce
Bread, Wheat
Bread, White
Cheese, Cheddar
Cheese, Low Fat/Low Salt
Cookie, Sugar
Cookie, Sugar-Free
Cottage Cheese
Fruit, Canned
Fruit, Fresh
Gelatin, Clear Liquid
Gelatin, Clear Liquid - Diabetic
Hard Candy
Hard Candy, Diabetic
Instant Breakfast, Sugar Free, Skim, Van illa
Instant Breakfast, No Sugar Added, Choco late
Instant Breakfast, Vanilla
Juice, Apple
Juice, Cranberry
Juice, Cranberry - Diabetic
Juice, Grape
Juice, Orange
Juice, Prune
Milk, 2%
Milk, Chocolate
Milk, Skim
Milk, Whole
Peanut Butter
Peanut Butter, Low-Sodium
Pop, Cola
Pop, Diet Cola
Pop, Diet Lemon Lime
Pop, Lemon Lime
Popsicle
Popsicle, Sugar-Free
Page 6 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Pudding
Pudding - Diabetic
Sandwich, Beef
Sandwich, Cheese
Sandwich, Chicken Salad
Sandwich, Ham & Cheese
Sandwich, Turkey
Sherbet
Yogurt, Routine
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
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 Normogyclemia Management - For First Day Surgery Patients Only (Single Response)
[216835]
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
Page 7 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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]
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
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 8 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
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 9 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
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 1/30/18 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
Medications [240892]
phenazopyridine (PYRIDIUM) tab [40946] 200 mg, Oral, ONCE For 1 Doses, Pre-Op Day Of
Procedure
celecoxib (CELEBREX) cap [60834] 400 mg, Oral, ON CALL For 1 Doses, Pre-Op Day Of
Procedure
acetaMINOPHEN (TYLENOL) tab [34150] 1,000 mg, Oral, ON CALL For 1 Doses, Pre-Op Day
Of Procedure
gabapentin (NEURONTIN) cap - NOTE give for
patients less than 60 years of age [54258]
600 mg, Oral, ON CALL For 1 Doses, Pre-Op Day Of
Procedure
gabapentin (NEURONTIN) cap - NOTE: give for
patients 60 years of age or greater [54258]
300 mg, Oral, ON CALL For 1 Doses, Pre-Op Day Of
Procedure
dexamethasone (DECADRON) intraVENOUS
[800037]
4 mg, Intravenous, ON CALL For 1 Doses
Postoperative Nausea/Vomiting Prophylaxis. Give
medication +/- 30 minute before incision
Pre-Op Day Of Procedure
haloperidol lactate (HALDOL) injection [800108] 1 mg, Intravenous, ON CALL For 1 Doses
Postoperative Nausea/Vomiting prophylaxis. Give
medication +/- 30 minute before incision
Pre-Op Day Of Procedure
scopolamine (TRANSDERM-SCOP) 1
MG/3DAYS 72hr patch [166671]
1 patch, Transdermal, ON CALL For 1 Doses
Premedications for Needle Insertion [106313]
Page 10 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
Laboratory [91448]
Obtain a Prothrombin Time/INR (PT/INR) on all patients with a recent history of anticoagulation
(within one month).
CBC WITHOUT DIFFERENTIAL [HEMO] 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
CREATININE, WHOLE BLOOD [HCWBCRET] 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?
Pre-Op Day Of Procedure
HEMOGLOBIN, WHOLE BLOOD [HCWBHGB] 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?
Pre-Op Day Of Procedure
POTASSIUM, WHOLE BLOOD [HCWBK] 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?
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
Page 11 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

URINALYSIS WITH MICROSCOPY [UA] 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 [83980]
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]
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
Page 12 of 17
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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]
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
Page 13 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
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
Non-categorized Patient Care Orders [198409]
May use foot pumps if patient is not tolerating
sequential compression devices. [NURCOM0022]
CONTINUOUS, Pre-Op Day Of Procedure
VTE Prophylaxis
VTE Prophylaxis [153965]
• 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
Page 14 of 17
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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) subcutaneous 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
First Line (Single Response) [134547]
cefoxitin (MEFOXIN) intraVENOUS - NOTE:
Patient who is 40-120 kg [800022]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefoxitin (MEFOXIN) intraVENOUS - NOTE:
Patient who is 121 kg or greater [800022]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA/Documented MRSA History (Single Response) [145991]
Patients who are 40-120 kg [228419]
cefoxitin (MEFOXIN) intraVENOUS [800022] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 121 kg or greater [228421]
cefoxitin (MEFOXIN) intraVENOUS [800022] 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 and Immediate/Severe Reaction to Penicillin or Known Cephalosporin Allergies (Single
Response) [134595]
Patients who are 40-120 kg [243640]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
metRONIDazole (FLAGYL) intraVENOUS
[800062]
500 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 121-160 kg [243643]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses,
IntraOp
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 [243646]
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, 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 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]
Page 15 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
IntraOp
Medications [198408]
levonorgestrel (KYLENNA) intrauterine device
[173314]
19.5 mg, Intrauterine, ONCE For 1 Doses
Insert once intrauterine
IntraOp
levonorgestrel (52 MG) (LILETTA) intrauterine
device [167526]
52 mg, Intrauterine, ONCE For 1 Doses
Insert once intrauterine
IntraOp
Medications [240891]
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, ONCE For 1 Doses
Give medication +/- 30 minute before closure
IntraOp
Diagnostic Tests and Imaging [101693]
BIOPSY ULTRASOUND GUIDED [R76942] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Site/ organ to biopsy?
Is this a Fine Needle Aspiration or Core Biopsy?
Radiology Specialty Area: ULTRASOUND
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.
For Scheduling purposes, is the patient claustrophobic
or require any form of sedation? Note: ordering
provider is responsible for prescribing oral anxiolytic or
ordering sedation services.
Is patient on anticoagulation therapy? If yes, specify
coagulation disorder and current medications in
comments box at bottom.
Transport Method: Floor Determined/Entered
For ultrasound done bedside in the OR, the radiology
specialty area is Ultrasound., IntraOp
Diagnosis
Diagnosis - Pre Op [711]
Pre-operative general physical examination
[255759]
Other specified pre-operative examination
Level of Service
Office Visit - Established Patients [30779]
99211 - Level I LOS Code
Page 16 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

99212 - Level II LOS Code
99213 - Level III LOS Code
99214 - Level IV LOS Code
99215 - Level V LOS Code
99211 - w/ Resident (GC) - Level I LOS Code
99212 - w/ Resident (GC) - Level II LOS Code
99213 - w/ Resident (GC) - Level III LOS Code
99214 - w/ Resident (GC) - Level IV LOS Code
99215 - w/ Resident (GC) - Level V LOS Code
Office visit - New Patients [30778]
99201- Level I LOS Code
99202- Level II LOS Code
99203- Level III LOS Code
99204- Level IV LOS Code
99205 - Level V LOS Code
99201- w/ Resident (GC) - Level I LOS Code
99202- w/ Resident (GC) - Level II LOS Code
99203- w/ Resident (GC) - Level III LOS Code
99204- w/ Resident (GC) - Level IV LOS Code
99205- w/ Resident (GC) - Level V LOS Code
Consults [30780]
If Medicare patient, do not use Consult LOS. Choose an Established or New Patient LOS. Add the
appropriate additional E/M Code of 99354-99359 for prolonged office consultations in the LOS
section of the Visit Navigator.
99241 - Level I LOS Code
99242 - Level II LOS Code
99243 - Level III LOS Code
99244 - Level IV LOS Code
99245 - Level V LOS Code
99241- w/ Resident (GC) - Level I LOS Code
99242 - w/ Resident (GC)- Level II LOS Code
99243 - w/ Resident (GC) - Level III LOS Code
99244 - w/ Resident (GC) - Level IV LOS Code
99245 - w/ Resident (GC) - Level V LOS Code
Preoperative Exam (Global) [1265]
Preoperative H&P, No Charge, Surgical Package LOS Code
Page 17 of 17
Printed by WILLIAMS, HEATHER R [HRS0] at 1/22/2018 1:54:36 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org