/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/orthopedicsrehab/,

/clinical/cckm-tools/content/order-sets/ambulatory/orthopedicsrehab/name-98540-en.cckm

20170127

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Orthopedics/Rehab

FDS - Orthopedics - Major Procedure - Adult - Preoperative [2789]

FDS - Orthopedics - Major Procedure - Adult - Preoperative [2789] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Orthopedics/Rehab


FDS - Orthopedics - Major Procedure - Adult - Preoperative [2789]
for Adult Patients OnlyIntended
Pre-Day of Procedure
Medications - MRSA/MSSA Positive - NOTE: Please select the orders below if your patient is MRSA or
MSSA positive [113083]
mupirocin (BACTROBAN) 2% ointment [45826] 1 Tube, 0, starting 1/17/17, Normal, Pre-Day of
Procedure
chlorhexidine gluconate (HIBICLENS) 4 % topical
soln [64730]
240 mL, 0, starting 1/17/17 until 1/22/17, Normal, Pre-
Day of Procedure
VTE Prophylaxis [152179]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, 1 X DAILY
Labs - MRSA and MSSA Screening [193749]
MRSA/MSSA BY PCR [HCMSSA] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Office collect, Routine
Laboratory [86943]
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine, Within 2 weeks prior to surgery.
CALCIUM [CA] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
HEMOGLOBIN A1C [HA1C] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
PROTEIN, TOTAL [TP] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
ALBUMIN [ALB] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
BILIRUBIN, TOTAL [TBIL] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
AST/SGOT [AST] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
ALT/SGPT [ALT] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
GGT [GGT] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
ALKALINE PHOSPHATASE [ALKP] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
HEPATITIS C AB [HCV] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
HIV AB/AG COMBO [HIVABAG] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
URINALYSIS WITH MICROSCOPY AND
CULTURE IF >5 WBC/HPF [HCUACULT]
Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
Page 1 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 1/17/2017 4:46:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

C REACTIVE PROTEIN [CRPN] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
VITAMIN D, 25-HYDROXY BY HPLC [HCLCD25] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
Labs - Blood Bank [91701]
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.
Antibody Screen should be ordered with the ABO and Rh Typing.
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. ABO and Rh Typing should be
ordered with the antibody screen.
Type and Screen
Order if specimen collection will be less than 72 hours prior to surgery. Patient is required to have an ID
band in place at the time of Type and Screen blood specimen collection and remain in place throughout
admission.
TYPE AND SCREEN [HCTS] Status: Standing, Expires:3/3/17 MANUAL,Count:1,
Normal, Routine
Antibody Screen and ABO and Rh Typing
[192516]
ANTIBODY SCREEN [ABSCR] Status: Standing, Expires:5/19/17
MANUAL,Count:1, Normal, Routine
ABO AND RH TYPING [ABO] Status: Standing, Expires:5/19/17
MANUAL,Count:1, Normal, Routine
Diagnostic Tests and Imaging [113230]
ECG - 12 Lead [EKG0008] Status: Future, Expires: 2/17/18, Normal, Routine
Transthoracic Resting Echocardiogram
[ECH0003]
Status: Future, Expires: 2/17/18, Normal, Routine
X-RAY CERVICAL SPINE (4 OR 5 VIEWS)
[R72050A]
Status: Future, Expires: 3/17/18, Normal, Routine
PreOp 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
Page 2 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 1/17/2017 4:46:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

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
Chlorhexidine Prep (Single Response) [113584]
Chlorhexidine Gluconate Cloth 2% PADS
[NURCOM0022]
SEE COMMENTS, Starting today, Cleanse incision
site if patient has not bathed with Hibiclens morning of
surgery., 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 within 1 minute. Choice of medication should be based on patient’s previous
experience/preference, history of lidocaine allergy and ease of access.
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
Analgesics - Acetaminophen - Scheduled [87315]
acetaMINOPHEN (TYLENOL) tab [34150] 1,000 mg, Oral, ON CALL For 1 Doses, Pre-Op Day
Of Procedure
Analgesics - Opioid - Oral - Scheduled (Single Response) [218566]
MORPHine (MS CONTIN, ORAMORPH) ER tab
- NOTE: Order for patients older than 60 years of
age [156572]
15 mg, Oral, ON CALL For 1 Doses
NOTE: Order for patients older than 60 years of age
Pre-Op Day Of Procedure
MORPHine (MS CONTIN, ORAMORPH) ER tab
- NOTE: Order for patients 60 years of age or
younger [156572]
30 mg, Oral, ON CALL For 1 Doses
NOTE: Order for patients 60 years of age or younger
Pre-Op Day Of Procedure
Page 3 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 1/17/2017 4:46:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Steriods [218567]
hydrocortisone sod suc in sodium chloride 0.9%
injection [800189]
100 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
Antiemetics [218568]
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
Laboratory [86970]
PROTHROMBIN TIME/INR [PT] 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
Glucose, POC [IPGLUCOSE] ONCE, Starting today For 1 Occurrences, Routine,
Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
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
she "could" be pregnant.
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
Tests [91574]
TYPE AND SCREEN [HCTS] STAT - RN COLLECT, 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
Blood Products [83983]
Page 4 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 1/17/2017 4:46:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT, Starting today For 1 Occurrences, Routine
Reason for Order: R1 Life-threatening hemorrhage or
anticipated/ongoing surgical blood loss
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Consent Status:
Pre-Op Day Of Procedure
Plasma (Adult) [BLB0003] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Consent Status:
Pre-Op Day Of Procedure
Platelets (Adult) [BLB0004] 1 SINGLE, Starting today For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Consent Status:
Pre-Op Day Of Procedure
Cryoprecipitate (Adult) [BLB0005] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): SURGICAL USE
Date Product Needed:
Consent Status:
Fibrin Glue, mLs Needed:
Pre-Op Day Of Procedure
VTE Prophylaxis
VTE Prophylaxis [109260]
Page 5 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 1/17/2017 4:46:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

• 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 PF 5000 UNIT/0.5ML injection [156571] 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) [151944]
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 40-120 kg [800000]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 121 kg and greater [800000]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
First Line with Implanted Device or on Antibiotic Greater Than 5 Days (Single Response) [151962]
cefuroxime (ZINACEF) intraVENOUS - NOTE:
Patients who are 40 - 120 kg [800030]
1.5 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefuroxime (ZINACEF) intraVENOUS - NOTE:
Patients who are 121 kg and greater [800030]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
MRSA / Documented MRSA History or High Risk for MRSA/MRSE (Implanted Device) (Single Response)
[151945]
Patients who are 40 - 120 kg - Cefazolin and
Vancomycin [206640]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Maximum Dose of 2000 mg
Maximum Concentration: Peripheral 5 mg/mL;
Central line 10 mg/mL
Pre-Op Day Of Procedure
Patients who are 121 kg and greater - Cefazolin
and Vancomycin [206641]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
Page 6 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 1/17/2017 4:46:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Maximum Dose of 2000 mg
Maximum Concentration: Peripheral 5 mg/mL;
Central line 10 mg/mL
Pre-Op Day Of Procedure
Patients who are 40-120 kg - Cefuroxime and
Vancomycin [210025]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Maximum Dose of 2000 mg
Maximum Concentration: Peripheral 5 mg/mL;
Central line 10 mg/mL
Pre-Op Day Of Procedure
Patients who are 121 kg and greater -
Cefuroxime and Vancomycin [210028]
cefuroxime (ZINACEF) intraVENOUS [800030] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Maximum Dose of 2000 mg
Maximum Concentration: Peripheral 5 mg/mL;
Central line 10 mg/mL
Pre-Op Day Of Procedure
Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies [151964]
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Maximum Dose of 2000 mg
Pre-Op Day Of Procedure
IntraOp
Patient Care Orders [86978]
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today, Routine, To
discontinue this order, enter a new order for
"Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes
in the new order.
Type: Indwelling Triple Lumen
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
IntraOp
Lateral Transfer Device - Hovermatt
[NURCOM0022]
ONCE, Starting today For 1 Occurrences, After
patient is transferred to the OR table place the
Hovermatt on the postoperative bed., IntraOp
Laboratory [86979]
URINALYSIS WITH MICROSCOPY AND
CULTURE IF >5 WBC/HPF [HCUACULT]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
IntraOp
Medications [135339]
dexamethasone (DECADRON) intraVENOUS
[800037]
4 mg, Intravenous, ON CALL For 1 Doses, IntraOp
Page 7 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 1/17/2017 4:46:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

tranexamic acid (CYKLOKAPRON) in sodium
chloride 0.9% 100 mL bag [700605]
1 g, Intravenous, ON CALL For 1 Doses, IntraOp
Diagnostic Tests and Imaging [87014]
Imaging in OR [R10000] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
IntraOp
X-RAY SPINE 1 VIEW [R72020] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
To be done IntraOp, IntraOp
X-RAY SHOULDER >= 2 VIEWS LEFT
[R73030L]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done IntraOp, IntraOp
X-RAY SHOULDER >= 2 VIEWS RIGHT
[R73030R]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done IntraOp, IntraOp
X-RAY ELBOW >= 3 VIEWS LEFT [R73080L] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done IntraOp, IntraOp
Page 8 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 1/17/2017 4:46:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

X-RAY ELBOW >= 3 VIEWS RIGHT [R73080R] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done IntraOp, IntraOp
X-RAY HIP UNILATERAL 1 VIEW LEFT
[R73500L]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done IntraOp, IntraOp
X-RAY HIP UNILATERAL 1 VIEW RIGHT
[R73500R]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done IntraOp, IntraOp
X-RAY CALCANEUS (HEEL) >=2 VIEWS LEFT
[R73650L]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done IntraOp, IntraOp
Page 9 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 1/17/2017 4:46:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

X-RAY CALCANEUS (HEEL) >=2 VIEWS
RIGHT [R73650R]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done IntraOp, IntraOp
PACU
Diagnostic Tests and Imaging [87019]
X-RAY SHOULDER >= 2 VIEWS LEFT
[R73030L]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done in PACU, PACU
X-RAY SHOULDER >= 2 VIEWS RIGHT
[R73030R]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done in PACU, PACU
X-RAY ELBOW >= 3 VIEWS LEFT [R73080L] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done in PACU, PACU
Page 10 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 1/17/2017 4:46:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

X-RAY ELBOW >= 3 VIEWS RIGHT [R73080R] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done in PACU, PACU
X-RAY ANKLE >= 3 VIEWS LEFT [R73610L] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done in PACU, PACU
X-RAY ANKLE >= 3 VIEWS RIGHT [R73610R] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done in PACU, PACU
X-RAY CALCANEUS (HEEL) >=2 VIEWS LEFT
[R73650L]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done in PACU, PACU
Page 11 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 1/17/2017 4:46:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

X-RAY CALCANEUS (HEEL) >=2 VIEWS
RIGHT [R73650R]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done in PACU, PACU
X-RAY FOOT >= 3 VIEWS LEFT [R73630L] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done in PACU, PACU
X-RAY FOOT >= 3 VIEWS RIGHT [R73630R] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done in PACU, PACU
Page 12 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 1/17/2017 4:46:58 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org