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/clinical/cckm-tools/content/order-sets/ambulatory/orthopedicsrehab/name-98541-en.cckm

201711326

page

100

UWHC,UWMF,

Tools,

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

FDS - Spinal Surgery - Pediatric - Preoperative [2766]

FDS - Spinal Surgery - Pediatric - Preoperative [2766] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Orthopedics/Rehab


FDS - Spinal Surgery - Pediatric - Preoperative [2766]
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 11/22/17, Normal, Pre-Day of
Procedure
chlorhexidine gluconate (HIBICLENS) 4 % topical
soln [64730]
240 mL, 0, starting 11/22/17 until 11/27/17, Normal,
Pre-Day of Procedure
Labs - MRSA and MSSA Screening [113115]
CULTURE, MRSA/MSSA [HCSTAFCX] Status: Standing, Expires:3/24/18 MANUAL,Count:1,
Office collect, Routine
MRSA/MSSA BY PCR [HCMSSA] Status: Standing, Expires:1/6/18 MANUAL,Count:1,
Office collect, Routine
Laboratory [86463]
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:1/6/18 MANUAL,Count:1,
Normal, Routine
PTT [PTT] Status: Standing, Expires:1/6/18 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:1/6/18 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:1/6/18 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:1/6/18 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:1/6/18 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:1/6/18 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:1/6/18 MANUAL,Count:1,
Normal, Routine
URINALYSIS WITH MICROSCOPY AND
CULTURE IF >5 WBC/HPF [HCUACULT]
Status: Standing, Expires:1/6/18 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:1/6/18 MANUAL,Count:1,
Normal, Routine
Antibody Screen and ABO and Rh Typing
[192516]
ANTIBODY SCREEN [ABSCR] Status: Standing, Expires:3/24/18 MANUAL,Count:1,
Normal, Routine
ABO AND RH TYPING [ABO] Status: Standing, Expires:3/24/18 MANUAL,Count:1,
Normal, Routine
Diagnostic Tests and Imaging [86465]
Page 1 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 11/22/2017 9:16:44 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

X-RAY LUMBAR SPINE AP VIEW SUPINE
W/BEND [R72100]
Status: Future, Expires: 1/22/2019, Normal, Routine,
Maximum bending to the right and left (Acceptable to
miss top of T-spine).
X-RAY LUMBAR SPINE AP VIEW STANDING
W/BEND [R72100]
Status: Future, Expires: 1/22/2019, Normal, Routine,
Maximum bending to the right and left (Acceptable to
miss top of T-spine).
X-RAY ENTIRE SPINE 2-3 VIEW (E.G.
SCOLIOSIS) [R72082]
Status: Future, Expires: 1/22/2019, Normal, Routine,
One PA view bending left; one PA view bending right.
X-RAY ENTIRE SPINE 1 VIEW (E.G.
SCOLIOSIS) [R72081]
Status: Future, Expires: 1/22/2019, Normal, Routine,
PA view only.
X-RAY ENTIRE SPINE 1 VIEW (E.G.
SCOLIOSIS) [R72081]
Status: Future, Expires: 1/22/2019, Normal, Routine,
Traction AP view.
X-RAY ENTIRE SPINE 1 VIEW (E.G.
SCOLIOSIS) [R72081]
Status: Future, Expires: 1/22/2019, Normal, Routine,
AP view only.
Pre-Op Day of Procedure
Non-Categorized Patient Care Orders [127659]
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
Verify Bowel Prep Completed [NURELM0061] ONCE, Starting today For 1 Occurrences, Pre-Op Day
Of Procedure
Isolation Status [97372]
Enhanced Contact Isolation - CDIFF [ISO0348] What is the reason for isolation?
Separate order must be placed for isolation cart., Pre-
Op Day Of Procedure
Contact Isolation - MDRO (MRSA) [ISO0334] CONTINUOUS
What is the Reason for Isolation? MRSA
Separate order must be placed for isolation cart., Pre-
Op Day Of Procedure
Contact Isolation - MDRO (VRE) [ISO0334] CONTINUOUS
What is the Reason for Isolation? VRE
Separate order must be placed for isolation cart., Pre-
Op Day Of Procedure
Isolation - Protective Precautions [233556]
Protective Precautions [ISO0349] What is the Reason for Isolation?
Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Isolation - Contact - Multidrug Resistant
Organism (MDRO) [233557]
Contact Isolation - MDRO [ISO0334] CONTINUOUS
What is the Reason for Isolation? MDR
Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Isolation - Contact - Multidrug Resistant
Organism (XDR) [233558]
Contact Isolation - MDRO (XDR) [ISO0334] CONTINUOUS
What is the Reason for Isolation? XDR
Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Chlorhexidine Prep [113588]
Page 2 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 11/22/2017 9:16:44 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Chlorhexidine Gluconate Cloth 2% PADS
[NURCOM0022]
SEE COMMENTS, Starting today, Cleanse incision
site if patient has not bathed with Hibiclens morning of
Surgery. Note: Do not use on patients less than 2
months of age, Pre-Op Day Of Procedure
Analgesics - Acetaminophen - PRN (Single Response) [240098]
acetaMINOPHEN (TYLENOL) tab [34149] Oral, ONCE For 1 Doses, Pre-Op Day Of Procedure
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
15 mg/kg, Oral, ONCE For 1 Doses, Pre-Op Day Of
Procedure
Analgesics - Other (Single Response) [186682]
gabapentin (NEURONTIN) cap - NOTE -
Suggested dose 10 mg/kg - Round down to
nearest capsule size Maximum Dose = 300 mg
[54258]
Oral, ONCE For 1 Doses
NOTE - Suggested dose 10 mg/kg - Round down to
nearest capsule size
Pre-Op Day Of Procedure
gabapentin (NEURONTIN) soln - Maximum Dose
= 300 mg [65814]
10 mg/kg, Oral, ONCE For 1 Doses, 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
Tests [91574]
TYPE AND SCREEN [HCTS] STAT, 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 [83984]
Page 3 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 11/22/2017 9:16:44 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT, Starting today For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR5 Acute blood loss or anticipated
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):
Volume-Reduced (May be pre-selected based on
history):
Consent Status:
Pre-Op Day Of Procedure
Plasma (Pediatric) [BLB0010] Starting today, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
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 (Pediatric) [BLB0011] Starting today, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
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):
Volume-Reduced (May be pre-selected based on
history):
Consent Status:
Pre-Op Day Of Procedure
Page 4 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 11/22/2017 9:16:44 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Cryoprecipitate (Pediatric) [BLB0012] 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
Blood Products [83983]
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
Page 5 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 11/22/2017 9:16:44 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis [86272]
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? Yes
Left/Right/Bilateral? Bilateral
Type: Knee high
Pre-Op Day Of Procedure
Surgical Prophylaxis
First Line [146309]
Cefepime and Vancomycin [228574]
cefepime (MAXIPIME) intraVENOUS [800016] 50 mg/kg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Immediate/Severe Reaction to Penicillin or Known Cephalosporin Allergies [146315]
Vancomycin and Tobramycin [226786]
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
tobramycin (NEBCIN) intraVENOUS [800081] 4 mg/kg, Intravenous, ON CALL For 1 Doses,
IntraOp
IntraOp
Medications - Aminocaproic acid (AMICAR) [86616]
aminocaproic acid (AMICAR) 15 g in sodium
chloride 0.9 % 310 mL infusion - BOLUS DOSE
[700428]
100 mg/kg/hr, Intravenous, CONTINUOUS For 1
Hours
Administer as a bolus dose over 1 hour from the
continuous infusion bag
IntraOp
aminocaproic acid (AMICAR) 15 g/310mL infusion
[700428]
10 mg/kg/hr, Intravenous, CONTINUOUS For 24
Hours, IntraOp
Diagnostic Tests and Imaging [148805]
Page 6 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 11/22/2017 9:16:44 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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
FLUOROSCOPY <= 1 HOUR [R76000] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Which body area is to be imaged?
Radiology Specialty Area: GENERAL IMAGING
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?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
IntraOp
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
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]
Page 7 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 11/22/2017 9:16:44 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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 8 of 8
Printed by O'BRIEN, RYLEY P [RPO249] at 11/22/2017 9:16:44 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org