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OP - Trabeculectomy - Adult - Pre/Postoperative [2827]

OP - Trabeculectomy - Adult - Pre/Postoperative [2827] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Ophthalmology


OP - Trabeculectomy - Adult - Pre/Postoperative [2827]
for Adult Patients OnlyIntended
Pre-Day of Procedure
Medications - Prescriptions [118098]
polymyxin-trimethoprim (POLYTRIM) ophthalmic
soln - 4x/d [46801]
1 drop, 10 mL, 1, starting 5/12/17 until 6/11/17,
Normal, Pre-Day of Procedure
Neomycin-Polymyxin-Dexameth 0.1 %
ophthalmic ointment [45860]
3.5 g, 3, starting 5/12/17 until 6/11/17, Normal
prednisolone 1% ophthalmic susp - q2h WA
DISPENSE GENERIC [41271]
1 drop, 10 mL, 5, starting 5/12/17, Normal, Pre-Day of
Procedure
prednisolone (PRED FORTE) 1 % ophthalmic
susp - q2h WA DISPENSE BRAND [41261]
1 drop, 10 mL, 5, DAW, starting 5/12/17, Normal, Pre-
Day of Procedure
atropine 1% ophthalmic soln - 2x/d-30d [34849] 1 drop, 5 mL, 1, starting 5/12/17 until 6/11/17,
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 - Bleeding Risk [88993]
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
Premedications for Needle Insertion [106313]
Page 1 of 5
Printed by WILLIAMS, HEATHER R S [HRS0] at 5/12/2017 10:26:22 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org

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.
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
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
Medications [88097]
pilocarpine (PILOCAR) 2% ophthalmic soln -
RIGHT [41044]
1 drop, Eye (Right), ON CALL For 1 Doses
Administer to operative eye 30 minutes preoperative
unless patient has already taken
Pre-Op Day Of Procedure
pilocarpine (PILOCAR) 2% ophthalmic soln -
LEFT [41044]
1 drop, Eye (Left), ON CALL For 1 Doses
Administer to operative eye 30 minutes preoperative
unless patient has already taken
Pre-Op Day Of Procedure
No eye drops needed [NURCOM0022] ONCE For 1 Occurrences, No eye drops needed,
Pre-Op Day Of Procedure
Contingency Parameters [91299]
Page 2 of 5
Printed by WILLIAMS, HEATHER R S [HRS0] at 5/12/2017 10:26:22 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org

Notify Anesthesiology [NURCOM0001] CONTINUOUS
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 - 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
IntraOp
Medications [88243]
mitomycin (MUTAMYCIN) in water (sterile) 1 mL
ophthalmic injection [700539]
0.5 mg, Other, ON CALL For 1 Doses, IntraOp
PACU
Contingency Parameters [91281]
Page 3 of 5
Printed by WILLIAMS, HEATHER R S [HRS0] at 5/12/2017 10:26:22 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org

Notify Anesthesiology [NURCOM0001] CONTINUOUS
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:
PACU
Post-Op/Phase II
Medications [118078]
acetaMINOPHEN (TYLENOL) tab RANGE
[750002]
500-1,000 mg, Oral, EVERY 4 HOURS PRN For 24
Hours, pain/fever, PRN mild-moderate pain,
multimodal therapy, or fever greater than 38.2C,
Post-Op/Phase II
Patient Discharge Orders
Activity/Return to Work [91287]
Activity [NURACT0011] Routine, No lifting, bending or straining for 3 weeks.
Return to work to be decided at postoperative visit.
Return to driving to be decided at postoperative visit.
Nutrition [91288]
Resume PreOp Diet [NURDIE0013] Routine, Resume PreOp diet.
Wound Care [91320]
Wound Care [NURWND0018] Routine, Wear eye patch and shield until seen in
clinic tomorrow
Contingency Parameters [117697]
Contingency Parameters [NURTRT0048] Routine, Call Surgeon at 608-263-7171 if increased
pain, nausea or vomiting.
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
Page 4 of 5
Printed by WILLIAMS, HEATHER R S [HRS0] at 5/12/2017 10:26:22 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org

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 - 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
Page 5 of 5
Printed by WILLIAMS, HEATHER R S [HRS0] at 5/12/2017 10:26:22 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org