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201709272

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UWHC,UWMF,

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

OP - Retina Surgery - Adult - Preoperative [2912]

OP - Retina Surgery - Adult - Preoperative [2912] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Ophthalmology


OP - Retina Surgery - Adult - Preoperative [2912]
for Adult Patients OnlyIntended
Pre-Day of Procedure
Medications - Prescriptions - RIGHT Eye [90417]
polymyxin-trimethoprim (POLYTRIM) ophthalmic
soln - 4x/d [46801]
1 drop, 10 mL, 1, starting 9/26/17 until 10/3/17,
Normal, Pre-Day of Procedure
prednisolone 1% ophthalmic susp - 4x/d [41271] 10 mL, 4, starting 9/26/17, Normal, Pre-Day of
Procedure
atropine 1% ophthalmic soln - 2x/d [34849] 1 drop, 5 mL, 1, starting 9/26/17, Normal, Pre-Day of
Procedure
Medications - Prescriptions - LEFT Eye [113322]
polymyxin-trimethoprim (POLYTRIM) ophthalmic
soln - 4x/d [46801]
1 drop, 10 mL, 1, starting 9/26/17 until 10/3/17,
Normal, Pre-Day of Procedure
prednisolone 1% ophthalmic susp - 4x/d [41271] 10 mL, 4, starting 9/26/17, Normal, Pre-Day of
Procedure
atropine 1% ophthalmic soln - 2x/d [34849] 1 drop, 5 mL, 1, starting 9/26/17, Normal, Pre-Day of
Procedure
Pre-Op 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 Drug Resistant
Organism (XDR) [ISO0320]
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
DVT Prophylactic Measures - DVT Risk [146122]
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
Page 1 of 4
Printed by WILLIAMS, HEATHER R [HRS0] at 9/26/2017 8:54:32 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Medications - RIGHT Eye [93467]
EyeRIGHT
tropicamide (MYDRIACYL) 1% ophthalmic soln
[43208]
1 drop, Eye (Right), EVERY 5 MINUTES For 3 Doses
Begin on call to OR
Pre-Op Day Of Procedure
phenylEPHRINE 2.5% ophthalmic soln [41006] 1 drop, Eye (Right), EVERY 5 MINUTES For 3 Doses
Begin on call to OR
Pre-Op Day Of Procedure
cyclopentolate (CYCLOGYL) 1% ophthalmic soln
[36271]
1 drop, Eye (Right), EVERY 5 MINUTES For 3 Doses
Begin on call to OR
Pre-Op Day Of Procedure
Medications - LEFT Eye [90414]
eyeLEFT
tropicamide (MYDRIACYL) 1% ophthalmic soln
[43208]
1 drop, Eye (Left), EVERY 5 MINUTES For 3 Doses
Begin on call to OR
Pre-Op Day Of Procedure
phenylEPHRINE 2.5% ophthalmic soln [41006] 1 drop, Eye (Left), EVERY 5 MINUTES For 3 Doses
Begin on call to OR
Pre-Op Day Of Procedure
cyclopentolate (CYCLOGYL) 1% ophthalmic soln
[36271]
1 drop, Eye (Left), EVERY 5 MINUTES For 3 Doses
Begin on call to OR
Pre-Op Day Of Procedure
Medications - Cataract - RIGHT Eye [93587]
EyeRIGHT
diclofenac (VOLTAREN) 0.1% ophthalmic soln
[44946]
1 drop, Eye (Right), EVERY 5 MINUTES For 3 Doses
Begin on call to OR
Pre-Op Day Of Procedure
apracloNIDINE (LOPIDINE) 0.5% ophthalmic soln
[44190]
1 drop, Eye (Right), EVERY 5 MINUTES For 3 Doses
Begin on call to OR
Pre-Op Day Of Procedure
apracloNIDINE (LOPIDINE) 1% ophthalmic soln
[44191]
1 drop, Eye (Right), EVERY 5 MINUTES For 3 Doses
Begin on call to OR
Pre-Op Day Of Procedure
Medications - Cataract - LEFT Eye [93586]
EyeLEFT
diclofenac (VOLTAREN) 0.1% ophthalmic soln
[44946]
1 drop, Eye (Left), EVERY 5 MINUTES For 3 Doses
Begin on call to OR
Pre-Op Day Of Procedure
apracloNIDINE (LOPIDINE) 0.5% ophthalmic soln
[44190]
1 drop, Eye (Left), EVERY 5 MINUTES For 3 Doses
Begin on call to OR
Pre-Op Day Of Procedure
apracloNIDINE (LOPIDINE) 1% ophthalmic soln
[44191]
1 drop, Eye (Left), EVERY 5 MINUTES For 3 Doses
Begin on call to OR
Pre-Op Day Of Procedure
Contingency Parameters [112487]
Page 2 of 4
Printed by WILLIAMS, HEATHER R [HRS0] at 9/26/2017 8:54:32 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Notify Anesthesiology [NURCOM0001] Provider to Notify: Other (Comment)
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
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
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
Page 3 of 4
Printed by WILLIAMS, HEATHER R [HRS0] at 9/26/2017 8:54:32 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

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 - New or Established [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 4 of 4
Printed by WILLIAMS, HEATHER R [HRS0] at 9/26/2017 8:54:32 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org