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UWHC,UWMF,

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

OP - Gynecology - Benign - Adult - Preoperative [2933]

OP - Gynecology - Benign - Adult - Preoperative [2933] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Gynecology


OP - Gynecology - Benign - Adult - Preoperative [2933]
Intended for Adult Patients Only
Pre-Day of Procedure
Laboratory [91677]
ELECTROLYTES [LYTE] Status: Standing, Expires:3/4/16 MANUAL,Count:1, Normal,
Routine
CREATININE [CRET] Status: Standing, Expires:3/4/16 MANUAL,Count:1, Normal,
Routine
GLUCOSE [GLU] Status: Standing, Expires:3/4/16 MANUAL,Count:1, Normal,
Routine
CBC WITHOUT DIFFERENTIAL [HEMO] Status: Standing, Expires:3/4/16 MANUAL,Count:1, Normal,
Routine
URINALYSIS, NO MICROSCOPY [UACHEM] Status: Standing, Expires:3/4/16 MANUAL,Count:1, Normal,
Routine
URINALYSIS WITH MICROSCOPY AND CULTURE IF
>5 WBC/HPF [HCUACULT]
Status: Standing, Expires:3/4/16 MANUAL,Count:1, Normal,
Routine
Laboratory - Pregnancy Test [87226]
Obtain pregnancy test if female between menarche & menopause and any of: (1) surgery is pelvic, renal, or intra-
abdominal, (2) patient had unprotected intercourse, (3) patient missed menses, (4) patient says she "could" be pregnant.
Urine, Pregnancy Test [UPREG] Status: Standing, Expires:3/4/16 MANUAL,Count:1, Normal,
Routine
Labs - Blood Bank [91702]
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.
ANTIBODY SCREEN [ABSCR] Status: Standing, Expires:3/4/16 MANUAL,Count:1, Normal,
Routine
ABO AND RH TYPING [ABO] Status: Standing, Expires:3/4/16 MANUAL,Count:1, Normal,
Routine
Diagnostic Tests and Imaging [197911]
X-Ray Chest PA & LAT 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:1/19/16, Expires: 3/4/16, Normal,
Routine
X-RAY CHEST PA & LAT VIEWS [R71020] Status: Future, Expected:1/19/16, Expires: 3/4/16, Normal,
Routine
X-Ray Chest PA & LAT Views Dual Energy [R71020A] Status: Future, Expected:1/19/16, Expires: 3/4/16, Normal,
Routine
Pulmonary Lab Testing [999992] Routine
Reason for Exam: Preoperative evaluation
Specify Test: ABG on Room Air (Pulmonary Lab to draw)
Consults [91326]
CONSULT TO ANESTHESIOLOGY [1009009] What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Preoperative
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01/2016Lee Vermeulen, CCKM@uwhealth.org

evaluation
PreOp Day of Procedure
Isolation Status [97372]
Isolation - Enhanced Contact - Clostridium Difficile
[ISO0010]
CONTINUOUS, Separate order must be placed for isolation
cart., Pre-Op Day Of Procedure
Isolation - Contact - MRSA [ISO0039] CONTINUOUS, Separate order must be placed for isolation
cart., Pre-Op Day Of Procedure
Isolation - Contact - VRE [ISO0051] CONTINUOUS, Separate order must be placed for isolation
cart., Pre-Op Day Of Procedure
Isolation - Protective Precautions - Panel [116356]
Protective Precautions [ISO0001] CONTINUOUS
Reason for Protective Precautions:
Pre-Op Day Of Procedure
Protective - Positive Pressure Room [NURCOM0109] CONTINUOUS, Pre-Op Day Of Procedure
Isolation - Contact - Multidrug Resistant Organism -
Panel [116335]
Isolation - Contact - Multidrug Resistant Organism
(MDR) [ISO0006]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Isolation - Contact - Extensively Resistant Organism
(XDR) - Panel [193206]
Isolation - Contact - Extensively Resistant Organism
(XDR) [ISO0320]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
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 within 1 minute.
Choice of medication should be based on patient’s previous experience/preference, history of lidocaine allergy and ease
of access.
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
lidocaine (XYLOCAINE) 1% injection [39034] 0.1-0.4 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. Choice of medication should be
based on patient’s previous experience/preference, history of
lidocaine allergy and ease of access
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. Choice of medication should be
based on patient’s previous experience/preference, history of
lidocaine allergy and ease of access
Pre-Op Day Of Procedure
Page 2 of 5
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Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

Laboratory - Pregnancy Test [81397]
Obtain pregnancy test if female between menarche & menopause and any of: (1) surgery is pelvic, renal, or intra-
abdominal, (2) patient had unprotected intercourse, (3) patient missed menses, (4) patient says she "could" be pregnant.
Urine, Pregnancy Test [UPREG] STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
Tests [91574]
TYPE AND SCREEN [HCTS] STAT - RN COLLECT, Starting today For 1 Occurrences,
Routine, As good clinical practice and for patient safety, the
Transfusion Service will automatically crossmatch 2 packed
RBCs on all patients with antibodies to ensure blood would be
available in the event it is needed. If you would like to opt out
of this automatic order for this patient please contact the
UWHC Blood Bank at (608) 263-8367 or The American
Center Lab at (608) 234-6600 as appropriate., Pre-Op Day Of
Procedure
Surgical Prophylaxis
First Line (Single Response) [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 [199515]
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 [199518]
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
For Patients with MRSA and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [134595]
Patients who are 40-119 kg [199467]
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 120-159 kg [199470]
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 160 kg or greater [199473]
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 40-119 kg [197627]
Page 3 of 5
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Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@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 120 - 159 kg [197632]
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 [197630]
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
Diagnostic Tests and Imaging [144893]
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
Diagnosis
Diagnosis - Pre Op [711]
Pre-operative general physical examination [255759] Other specified pre-operative examination
Level of Service
Office Visit - Established Patients [30779]
99211 - Level I LOS Code
99212 - Level II LOS Code
99213 - Level III LOS Code
99214 - Level IV LOS Code
99215 - Level V LOS Code
99211 - w/ Resident (GC) - Level I LOS Code
99212 - w/ Resident (GC) - Level II LOS Code
99213 - w/ Resident (GC) - Level III LOS Code
99214 - w/ Resident (GC) - Level IV LOS Code
99215 - w/ Resident (GC) - Level V LOS Code
Office visit - New Patients [30778]
99201- Level I LOS Code
99202- Level II LOS Code
99203- Level III LOS Code
99204- Level IV LOS Code
99205 - Level V LOS Code
99201- w/ Resident (GC) - Level I LOS Code
99202- w/ Resident (GC) - Level II LOS Code
99203- w/ Resident (GC) - Level III LOS Code
99204- w/ Resident (GC) - Level IV LOS Code
99205- w/ Resident (GC) - Level V LOS Code
Consults [30780]
If Medicare patient, do not use Consult LOS. Choose an Established or New Patient LOS. Add the appropriate additional
E/M Code of 99354-99359 for prolonged office consultations in the LOS section of the Visit Navigator.
99241 - Level I LOS Code
99242 - Level II LOS Code
99243 - Level III LOS Code
Page 4 of 5
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Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

99244 - Level IV LOS Code
99245 - Level V LOS Code
99241- w/ Resident (GC) - Level I LOS Code
99242 - w/ Resident (GC)- Level II LOS Code
99243 - w/ Resident (GC) - Level III LOS Code
99244 - w/ Resident (GC) - Level IV LOS Code
99245 - w/ Resident (GC) - Level V LOS Code
Preoperative Exam (Global) [1265]
Preoperative H&P, No Charge, Surgical Package LOS Code
Page 5 of 5
Printed by LIND, JANNA S [JSL237] at 1/19/2016 10:10:31 AM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org