/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-98574-en.cckm

20180112

page

100

UWHC,UWMF,

Tools,

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

OP - Gynecology - Oncology - Preoperative [2934]

OP - Gynecology - Oncology - Preoperative [2934] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Gynecology


OP - Gynecology - Oncology - Preoperative [2934]
for Adult Patients OnlyIntended
Pre-Day of Procedure
Laboratory [91323]
CBC WITHOUT DIFFERENTIAL [HEMO] Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
ELECTROLYTES [LYTE] Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
GLUCOSE [GLU] Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
BUN [BUN] Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
CREATININE [CRET] Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
CALCIUM [CA] Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
CA 19-9 [XCA199] Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
CARCINOEMBRYONIC ANTIGEN [CEA] Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
INHIBIN B [HCINHBNB] Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
AFP, TUMOR MARKER, SERUM [XAFPTM] Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
LD, TOTAL [LDH] Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
HCG, QUANTITATIVE [BHCG] Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
URINALYSIS WITH MICROSCOPY AND
CULTURE IF >5 WBC/HPF [HCUACULT]
Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
Antibody Screening [205946]
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: 1/10/2018 Approximate,
Expires: 5/12/2018, Normal, Routine
ABO AND RH TYPING [ABO] Status: Standing, Expires:2/24/18 MANUAL,Count:1,
Normal, Routine
Diagnostic Tests and Imaging [99712]
Page 1 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 11:42:09 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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: 1/10/2018, Expires: 2/24/18,
Normal, Routine
X-RAY CHEST 2 VIEWS [R71046] Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
X-RAY CHEST 2 VIEWS DUAL ENERGY
[R71046A]
Status: Future, Expected: 1/10/2018, Expires: 2/24/18,
Normal, Routine
Pulmonary Lab Testing [999992] Routine
Reason for Exam: Preoperative evaluation
Specify Test: ABG on Room Air (Pulmonary Lab to
draw)
Consults [219287]
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):
Medications - Prescriptions - Bowel Prep [92220]
G.I. lavage (NULYTELY) soln [103972] 4 L, 0, starting 1/10/18, Local Printer, Pre-Day of
Procedure
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
Page 2 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 11:42:09 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
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
Laboratory [214370]
Obtain a Prothrombin Time/INR [PT] on all patients with a recent history of anticoagulation
(within one month).
PROTHROMBIN TIME/INR [PT] 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
Page 3 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 11:42:09 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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 [205945]
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
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 [109260]
• 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
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
Page 4 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 11:42:09 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
For Patients with MRSA and Immediate/Severe Reactions 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]
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]
Page 5 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 11:42:09 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
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
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
Page 6 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 11:42:09 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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 7 of 7
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 11:42:09 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org