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/clinical/cckm-tools/content/order-sets/ambulatory/madison-surgery-center/name-98491-en.cckm

201611327

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100

UWHC,UWMF,

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

MSC – Surgery – Adult – Preoperative [4992]

MSC – Surgery – Adult – Preoperative [4992] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Madison Surgery Center


MSC - Surgery - Adult - Preoperative [4992]
Pre-op Day of Procedure
VTE Prophylaxis [137429]
• 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, Starting today, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral?
Type:
Pre-Op Day Of Procedure
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Starting today For 1 Occurrences, Routine
Reason Not Ordered: Other (Comment Required)
Pre-Op Day Of Procedure
Diet [133226]
Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Pre-Op Day Of Procedure
Non-categorized Patient Care Orders [133227]
Consent [NURCOM0022] ONCE, Starting today For 1 Occurrences, Consent to
read: ***, Pre-Op Day Of Procedure
Nursing Staff to Provide and Instruct Patient On
The Use Of Durable Medical Equipment
[NURACT0011]
ONCE, {UWIP MSC INSTRUCTIONS:30022695},
Pre-Op Day Of Procedure
Void On Call to OR [NURELM0022] CONTINUOUS, Routine, Pre-Op Day Of Procedure
No Pre-op Day of Surgery Orders Needed
[NURCOM0022]
ONCE, Pre-Op Day Of Procedure
Premedications for Needle Insertion [129449]
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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, 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
IV Fluids [133771]
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
sodium chloride 0.9 % infusion [64367] Intravenous, CONTINUOUS, Pre-Op Day Of
Procedure
sodium chloride 0.9% BOLUS [730003] Intravenous, Pre-Op Day Of Procedure
Medications [138058]
oxymetazoline (AFRIN) 0.05 % nasal spray
[40671]
1 spray, Nostril (Each), EVERY 10 MINUTES For 5
Doses, Pre-Op Day Of Procedure
Sedation [198648]
Block Sedation Medications [137269]
midazolam (VERSED) injection RANGE [750056] 1-4 mg, Intravenous, PRN, Sedation
IV Push Rate 1 mg/minute. Give every 1 minute as
needed.
Pre-Op Day Of Procedure
FENTanyl PF injection RANGE [750047] 25-50 mcg, Intravenous, PRN, pain
Give every 2-4 minutes as needed.
for 1 Minutes, Pre-Op Day Of Procedure
alfentanil (ALFENTA) injection [44052] 50-400 mcg, Intravenous, PRN For 3 Doses, pain
Give every 2 minutes as needed per
anesthesiologist instructions during regional block
only. May be repeated 1-3 times.
Pre-Op Day Of Procedure
Laboratory - Pregnancy Test [137635]
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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
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]
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]
Page 3 of 7
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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] 1,750 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 and Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies
(Single Response) [135233]
Clindamycin should only be used for ENT and other oropharyngeal procedures.
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
Page 4 of 7
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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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
Diagnosis
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
Page 5 of 7
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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
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]
Page 6 of 7
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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
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
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