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201611327

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100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Madison Surgery Center

MSC - Interventional Pain Management - Adult - Pre/Intraoperative [4994]

MSC - Interventional Pain Management - Adult - Pre/Intraoperative [4994] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Madison Surgery Center


MSC - Interventional Pain Management - Adult - Pre/Intraoperative [4994]
Pre-Op Day of Procedure
Vital Signs [133279]
Vital Signs [NURMON0013] ONCE For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Pre-Op Day Of Procedure
Patient Monitoring [133291]
Oxygen Therapy [RT0032] CONTINUOUS, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow: 2
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device:
Attempt to Wean Off Oxygen?
Pre-Op Day Of Procedure
Pulse Oximetry [NURMON0009] ONCE, Routine, Pre-Op Day Of Procedure
Suction Airway [NURTAD0017] PRN, Routine
Location:
Pre-Op Day Of Procedure
Non-Categorized Patient Care Orders [133298]
Consent [NURCOM0022] ONCE, Starting today For 1 Occurrences, Consent to
read:, Pre-Op Day Of Procedure
For contrast dye allergy premedication - ask
patient if they took the pre-medications
[NURCOM0022]
ONCE, Pre-Op Day Of Procedure
No Pre-op Day of Surgery Orders Needed
[NURCOM0022]
ONCE, Pre-Op Day Of Procedure
Premedications for Needle Insertion [137578]
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 1 % vial [39034] 0.1-0.4 mL, Intradermal, PRN, pain, 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 1 of 8
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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
IV Fluids [132703]
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
lactated ringers infusion [38890] at 75 mL/hr, Intravenous, CONTINUOUS, Pre-Op
Day Of Procedure
lactated ringers BOLUS [730001] 1,000 mL, Intravenous, ONCE For 1 Doses
At a rate to keep open
Pre-Op Day Of Procedure
lactated ringers BOLUS [730001] 500 mL, Intravenous, ONCE For 1 Doses
Prior to celiac plexus block
Pre-Op Day Of Procedure
dextrose 5 % BOLUS [730000] Intravenous, PRN, Systematic hypoglycemia, Pre-Op
Day Of Procedure
sodium chloride flush 0.9% 10 mL injection
[785055]
Flush, Pre-Op Day Of Procedure
Premedications [203269]
midazolam (VERSED) syrup [60487] 5 mg, Oral, ONCE For 1 Doses
Prior to procedure for relaxation
Pre-Op Day Of Procedure
Anti-emetics [132704]
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting, Pre-Op Day Of Procedure
diazepam (VALIUM) tab [36679] 5 mg, Oral, ONCE For 1 Doses, Pre-Op Day Of
Procedure
Non-categorized [185858]
diphenhydramine (BENADRYL) injection
[800106]
25 mg, Intravenous, ONCE PRN For 1 Doses,
Documented allergy to contrast
Documented hives or pruritus with contrast
Pre-Op Day Of Procedure
Laboratory [132400]
ACCUCHECK GLUCOSE [HCMGLUC] ONCE For 1 Occurrences, Routine
If Conditional, What Condition?
Pre-Op Day Of Procedure
Laboratory - Pregnancy Test [137635]
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
she "could" be pregnant.
HCG, QUAL, URINE, POC [HCPREGPOC] ONCE For 1 Occurrences, Routine
If Conditional, What Condition?
Pre-Op Day Of Procedure
Diagnostic Tests and Imaging [133304]
Page 2 of 8
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SPINE DISCOGRAM LUMBAR [R72295] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
What level(s) and which side (if appropriate) do you
wish injected?
Current signs and symptoms?
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.
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Pre-Op Day Of Procedure
Surgical Prophylaxis
First line (Single Response) [132701]
Cefazolin (Single Response) [214619]
cefazolin (ANCEF) - Patients who are 40-119 kg
[35637]
2 g, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
cefazolin (ANCEF) - Patients who are 120 kg or
greater [35637]
3 g, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
Cefuroxime (Single Response) [214620]
cefuroxime (ZINACEF) - Patients who are 40-119
kg [67822]
1.5 g, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
cefuroxime (ZINACEF) - Patients who are 120 kg
or greater [67822]
3 g, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
MRSA Positive (Single Response) [135177]
Patients who are 40-43 kg [194201]
cefazolin (ANCEF) [35637] 2 g, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) [46836] 750 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
Patients who are 44-56 kg [194202]
cefazolin (ANCEF) [35637] 2 g, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) [46836] 1,000 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
Patients who are 57-68 kg [194203]
Page 3 of 8
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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cefazolin (ANCEF) [35637] 2 g, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) [46836] 1,250 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
Patients who are 69-81 kg [194204]
cefazolin (ANCEF) [35637] 2 g, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) [46836] 1,500 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
Patients who are 82-93 kg [194205]
cefazolin (ANCEF) [35637] 2 g, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) [46836] 1,750 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
Patients who are 94-120 kg [194206]
cefazolin (ANCEF) [35637] 2 g, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) [46836] 2,000 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
Patients who are greater than 120 kg [194207]
cefazolin (ANCEF) [35637] 3 g, Intravenous, ONCE For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) [46836] 2,000 mg, Intravenous, ONCE For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
MRSA POSITIVE with Immediate/Severe Reactions to PCN/cephalosporin (Single Response) [135232]
vancomycin (VANCOCIN) - Patients who are 40-
43 kg [46836]
750 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) - Patients who are 44-
56 kg [46836]
1,000 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) - Patients who are 57-
68 kg [46836]
1,250 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) - Patients who are 69-
81 kg [46836]
1,500 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) - Patients who are 82-
93 kg [46836]
1,750 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) - Patients who are
greater than 93 kg [46836]
2,000 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
MRSA NEGATIVE With Immediate/Severe Reactions to PCN/cephalosporin (Single Response) [135233]
Clindamycin should only be used for ENT and other oropharyngeal procedures.
Page 4 of 8
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

clindamycin (CLEOCIN) - Patients who are 40-79
kg [144945]
600 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
clindamycin (CLEOCIN) - Patients who are 80-
159 kg [144945]
900 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
clindamycin (CLEOCIN) - Patients who are 160
kg or greater [144945]
1,200 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) - Patients who are 40-
43 kg [46836]
750 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) - Patients who are 44-
56 kg [46836]
1,000 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) - Patients who are 57-
68 kg [46836]
1,250 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) - Patients who are 69-
81 kg [46836]
1,500 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) - Patients who are 82-
93 kg [46836]
1,750 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
vancomycin (VANCOCIN) - Patients who are
greater than 93 kg [46836]
2,000 mg, Intravenous, ON CALL For 1 Doses
See infusion guidelines
Pre-Op Day Of Procedure
IntraOp
Non-categorized [132706]
FENTanyl PF injection RANGE [750047] 25-50 mcg, Intravenous, PRN, pain, for 1 Minutes,
IntraOp
midazolam (VERSED) injection RANGE [750056] 0.5-1 mg, Intravenous, PRN, pain
If ordered IV: push rate 1 mg/minute.
Give every 1-2 minutes as needed
IntraOp
flumazenil (ROMAZICON) injection - Maximum
Dose - 1 mg [760105]
0.2 mg, Intravenous, PRN, Reversal of sedation
IV push over 15-30 seconds
IntraOp
naloxone (NARCAN) 2 MG/2ML soln prefilled
syringe [172355]
0.1 mg, Intravenous, PRN, opioid overdose,
Symptomatic respiratory depression.
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
lactated ringers infusion [38890] Intravenous, CONTINUOUS
PRN History of vasovago, or Systolic Blood
Pressure , <100. ALWAYS order if having the
following procedures: radio frequency, spinal cord
stimulating trial or implant, discogram
IntraOp
atropine injection [34843] 0.5 mg, Intravenous, PRN, bradycardia, for 1 Minutes,
IntraOp
Diagnosis
Page 5 of 8
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Diagnosis - Preoperative [2472]
Preoperative general physical examination
[255757]
Other specified pre-operative examination
Follow-Up
Follow-up [33406]
Follow-up Follow Up
Level of Service
Office Visit - Established Patient (Single Response) [573]
99211, Level 1 (5 min) LOS Code
99212, Level 2 (10 min) LOS Code
99213, Level 3 (15 min) LOS Code
99214, Level 4 (25 min) LOS Code
99215, Level 5 (40 min) LOS Code
Office Visit - Established Patient - Additional E & M (Single Response) [1104]
99211, Level 1, Modifier 25 (5 min) LOS Code
99212, Level 2, Modifier 25 (10 min) LOS Code
99213, Level 3, Modifier 25 (15 min) LOS Code
99214, Level 4, Modifier 25 (25 min) LOS Code
99215, Level 5, Modifier 25 (40 min) LOS Code
Office Visit - Established Patient, Resident with Faculty (Single Response) [11788]
99211, Level 1 - Modifier GC (5 min) LOS Code
99212, Level 2 - Modifier GC (10 min) LOS Code
99213, Level 3 - Modifier GC (15 min) LOS Code
99214, Level 4 - Modifier GC (25 min) LOS Code
99215, Level 5 - Modifier GC (40 min) LOS Code
Office Visit - Established Patient - Additional E & M, Resident with Faculty (Single Response) [19509]
99211, Level 1, Modifiers 25 & GC (5 min) LOS Code
99212, Level 2, Modifiers 25 & GC (10 min) LOS Code
99213, Level 3, Modifiers 25 & GC (15 min) LOS Code
99214, Level 4, Modifiers 25 & GC (25 min) LOS Code
99215, Level 5, Modifiers 25 & GC (40 min) LOS Code
Office Visit - Established Patient, Resident Alone (Single Response) [11789]
99211, Level 1 - Modifier GE (5 min) LOS Code
99212, Level 2 - Modifier GE (10 min) LOS Code
99213, Level 3 - Modifier GE (15 min) LOS Code
Office Visit - Established Patient - Additional E & M, Resident Alone (Single Response) [19518]
99211, Level 1, Modifiers 25 & GE (5 min) LOS Code
99212, Level 2, Modifiers 25 & GE (10 min) LOS Code
99213, Level 3, Modifiers 25 & GE (15 min) LOS Code
Office Visit - New Patient (Single Response) [574]
99201, Level 1 (10 min) LOS Code
99202, Level 2 (20 min) LOS Code
99203, Level 3 (30 min) LOS Code
99204, Level 4 (45 min) LOS Code
99205, Level 5 (60 min) LOS Code
Office Visit - New Patient - Additional E & M (Single Response) [1105]
99201, Level 1, Modifier 25 (10 min) LOS Code
99202, Level 2, Modifier 25 (20 min) LOS Code
Page 6 of 8
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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99203, Level 3, Modifier 25 (30 min) LOS Code
99204, Level 4, Modifier 25 (45 min) LOS Code
99205, Level 5, Modifier 25 (60 min) LOS Code
Office Visit - New Patient, Resident with Faculty (Single Response) [11791]
99201, Level 1 - Modifier GC (10 min) LOS Code
99202, Level 2 - Modifier GC (20 min) LOS Code
99203, Level 3 - Modifier GC (30 min) LOS Code
99204, Level 4 - Modifier GC (45 min) LOS Code
99205, Level 5 - Modifier GC (60 min) LOS Code
Office Visit - New Patient - Additional E & M, Resident with Faculty (Single Response) [19519]
99201, Level 1, Modifiers 25 & GC (10 min) LOS Code
99202, Level 2, Modifiers 25 & GC (20 min) LOS Code
99203, Level 3, Modifiers 25 & GC (30 min) LOS Code
99204, Level 4, Modifiers 25 & GC (45 min) LOS Code
99205, Level 5, Modifiers 25 & GC (60 min) LOS Code
Office Visit - New Patient, Resident Alone (Single Response) [11790]
99201, Level 1 - Modifier GE (10 min) LOS Code
99202, Level 2 - Modifier GE (20 min) LOS Code
99203, Level 3 - Modifier GE (30 min) LOS Code
Office Visit - New Patient - Additional E & M, Resident Alone (Single Response) [19520]
99201, Level 1, Modifiers 25 & GE (10 min) LOS Code
99202, Level 2, Modifiers 25 & GE (20 min) LOS Code
99203, Level 3, Modifiers 25 & GE (30 min) LOS Code
Office Consult (Single Response) [722]
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 1 (15 min) LOS Code
99242, Level 2 (30 min) LOS Code
99243, Level 3 (40 min) LOS Code
99244, Level 4 (60 min) LOS Code
99245, Level 5 (80 min) LOS Code
Office Visit - Consult - Visit w/Procedure (Single Response) [103123]
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 1, Modifier 25 (15 min) LOS Code
99242, Level 2, Modifier 25 (30 min) LOS Code
99243, Level 3, Modifier 25 (40 min) LOS Code
99244, Level 4, Modifier 25 (60 min) LOS Code
99245, Level 5, Modifier 25 (80 min) LOS Code
Office Consult - Modifier 25 & GC (Single Response) [34450]
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 1, Modifier 25 & GC (15 min) LOS Code
99242, Level 2, Modifier 25 & GC (30 min) LOS Code
99243, Level 3, Modifier 25 & GC (40 min) LOS Code
99244, Level 4, Modifier 25 & GC (60 min) LOS Code
Page 7 of 8
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

99245, Level 5, Modifier 25 & GC (80 min) LOS Code
No E&M with Procedure (Single Response) [721]
No Evaluation and Management Charge with
Procedure (Procedure Only)
LOS Code
Page 8 of 8
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org