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/clinical/cckm-tools/content/order-sets/ambulatory/orthopedicsrehab/name-98546-en.cckm

201711326

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100

UWHC,UWMF,

Tools,

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

OP - Orthopedics - Minor Procedure - Pediatric - Postoperative [2979]

OP - Orthopedics - Minor Procedure - Pediatric - Postoperative [2979] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Orthopedics/Rehab


OP - Orthopedics - Minor Procedure - Pediatric - Postoperative [2979]
PACU
Consults [92148]
Consult Cast Room Technician - Pediatric
[CON0152]
For the pediatric cast room technician, please call
890-8151., PACU
Post-Op/Phase II
Non-Categorized Patient Care Orders [240073]
Give Patient HFFY:Pain Medicine Safety
[NURCOM0025]
ONCE, Routine, Give patient HFFY #7971: Pain
Medicine Safety, Post-Op/Phase II
Analgesics - Acetaminophen - Scheduled (Single Response) [131815]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, EVERY 6 HOURS For 72 Hours,
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) tab [34149] Oral, EVERY 6 HOURS For 72 Hours, Post-Op/Phase
II
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 20 mg/kg. Must order in
whole suppository size (maximum 650 mg/dose)
[43994]
Rectal
Use if unable to tolerate oral medications
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
Analgesics - Acetaminophen - PRN (Starting in 72 hours) (Single Response) [187907]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, EVERY 4 HOURS PRN Starting
11/25/17, pain, Mild pain or multimodal therapy., Post-
Op/Phase II
acetaMINOPHEN (TYLENOL) tab - NOTE:
Suggested dose 15 mg/kg (maximum 650
mg/dose) [34149]
Oral, EVERY 4 HOURS PRN Starting 11/25/17, pain,
Mild pain or multimodal therapy, Post-Op/Phase II
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 20 mg/kg. Must order in
whole suppository size (Maximum 650 mg/dose)
[43994]
Rectal, EVERY 6 HOURS PRN Starting 11/25/17,
pain, Mild pain or multimodal therapy
Use if unable to tolerate oral medications
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Post-Op/Phase II
Analgesics - NSAID - Scheduled (Single Response) [187906]
ketOROLAC (TORADOL) injection - NOTE:
Suggested dose 0.5 mg/kg (Maximum 15
mg/dose) [800050]
0.5 mg/kg, Intravenous, EVERY 6 HOURS For 72
Hours, Post-Op/Phase II
ibuprofen (MOTRIN) susp - NOTE: Suggested
dose 10 mg/kg (Maximum 600 mg/dose) [45376]
10 mg/kg, Oral, EVERY 6 HOURS For 72 Hours,
Post-Op/Phase II
Analgesics - NSAID - PRN (Starting in 72 hours) [187870]
ibuprofen (MOTRIN) susp - NOTE: Suggested
dose 10 mg/kg (Maximum 600 mg/dose) [45376]
10 mg/kg, Oral, EVERY 6 HOURS PRN Starting
11/25/17, pain, Mild to Moderate Pain or Multimodal
therapy, Post-Op/Phase II
Analgesics - Opioids (Oral) - PRN (Single Response) [187909]
oxycodone 5 MG/5ML soln RANGE – (Maximum
20 mg/dose) [750031]
0.1-0.2 mg/kg, Oral, EVERY 4 HOURS PRN, pain,
Moderate/Severe Pain, Post-Op/Phase II
oxycodone tab RANGE – NOTE: Suggested dose
0.1-0.2 mg/kg (Maximum 20mg/dose) [750032]
Oral, EVERY 4 HOURS PRN, pain, Moderate/Severe
Pain, Post-Op/Phase II
Analgesics - Opioids (Intravenous) - PRN (Single Response) [187910]
Page 1 of 6
Printed by O'BRIEN, RYLEY P [RPO249] at 11/22/2017 9:13:59 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2017CCKM@uwhealth.org

morphine PF injection – NOTE: suggested dose
0.05 – 0.1 mg/kg (Maximum 2 mg/dose) [800122]
0.05-0.1 mg/kg, Intravenous, EVERY 2 HOURS PRN,
pain, Moderate/Severe Pain and unable to take oral
opioid
Use if unable to tolerate oral medications
Post-Op/Phase II
HYDROmorphone PF (DILAUDID) injection -
NOTE: suggested dose 0.01-0.02 mg/kg
(Maximum 0.4 mg/dose) [800120]
0.01-0.02 mg/kg, Intravenous, EVERY 2 HOURS
PRN, pain, Moderate/Severe Pain and unable to take
oral opioid
Use if unable to tolerate oral medications
Post-Op/Phase II
Bowel Management (Single Response) [131817]
docusate sodium (COLACE) cap [36859] 100 mg, Oral, 2 X DAILY, Post-Op/Phase II
polyethylene glycol (MIRALAX) oral packet -
NOTE: for patients less than 10 kg [61829]
3.4 g, Oral, 1 X DAILY, Post-Op/Phase II
polyethylene glycol (MIRALAX) oral packet -
NOTE: For patients 10 - 25 kg [61829]
8.5 g, Oral, 1 X DAILY
Dissolve in 4 ounces of water
NOTE: For patients less than 25 kg
Post-Op/Phase II
polyethylene glycol (MIRALAX) oral packet -
NOTE: For patients 25 kg or greater [61829]
17 g, Oral, 1 X DAILY
Dissolve in 8 ounces of water
NOTE: For patients 25 kg or greater
Post-Op/Phase II
Anti-emetics [88788]
ondansetron (ZOFRAN) injection - NOTE:
Suggested dose 0.1 mg/kg (Maximum 4 mg/dose)
[800202]
0.1 mg/kg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
NOTE: Suggested dose 0.1 mg/kg (Maximum 4
mg/dose)
Post-Op/Phase II
Non-categorized Medications [202767]
nalbuphine (NUBAIN) injection - Maximum Dose
= 2.5 mg [39994]
0.05 mg/kg, Intravenous, EVERY 6 HOURS PRN,
pain, 1st Line Pruritus, for 3 Minutes
Other Patient Care Instructions [145606]
Give Patient HFFY: Cast Care [NURCOM0025] ONCE For 1 Occurrences, Routine, Give patient
HFFY #4332 - Cast Care, Post-Op/Phase II
Give Patient HFFY: Hip Spica Cast Care
[NURCOM0025]
ONCE For 1 Occurrences, Routine, Give patient
HFFY #6622 - Hip Spica Cast Care, Post-Op/Phase II
Give Patient HFFY: Preparation guide for a
successful pin removal appointment
[NURCOM0025]
ONCE For 1 Occurrences, Routine, Give patient
HFFY #7313 - Preparation guide for a successful pin
removal appointment, Post-Op/Phase II
Consults [92323]
Consult Cast Room Technician - Pediatric
[CON0152]
For the pediatric cast room technician, please call
890-8151., Post-Op/Phase II
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult:
Post-Op/Phase II
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult:
Post-Op/Phase II
Prior to Discharge [127892]
Patient Must Be Seen by Attending Prior to
Discharge [NURMON0083]
ONCE, Starting today For 1 Occurrences, Routine,
Post-Op/Phase II
Patient Must Be Seen by Resident Prior to
Discharge [NURMON0082]
ONCE, Starting today For 1 Occurrences, Routine,
Post-Op/Phase II
Outpatient Discharge Orders
Medications - Prescriptions - Acetaminophen - PRN (Single Response) [185001]
Page 2 of 6
Printed by O'BRIEN, RYLEY P [RPO249] at 11/22/2017 9:13:59 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) 80 mg chew tab -
q6h prn - NOTE: Suggested dose 10-15 mg/kg
(Maximum 650 mg/dose) [34147]
0, starting 11/22/17, Normal, Phase II Discharge
acetaMINOPHEN (TYLENOL) 325 mg tab - q6h
prn - NOTE: Suggested dose 10-15 mg/kg
(Maximum 650 mg/dose) [34149]
0, starting 11/22/17, Normal, Phase II Discharge
acetaMINOPHEN alcohol free (TYLENOL) 160
mg/5 mL susp - q6h prn - NOTE: Suggested dose
10-15 mg/kg (Maximum 650 mg/dose) [43991]
1 Bottle, 0, starting 11/22/17, Normal, Phase II
Discharge
Medications - Prescriptions - Ibuprofen/Naproxen (Single Response) [185002]
ibuprofen (MOTRIN) 200 mg tab - q8h prn -
NOTE: Suggested dose 5-10 mg/kg (Maximum
800 mg/dose) [38353]
0, starting 11/22/17, Normal, Phase II Discharge
ibuprofen (MOTRIN) 100 mg/5 mL susp - q8h prn
- NOTE: Suggested dose 5-10 mg/kg (Maximum
800 mg/dose) [45376]
0, starting 11/22/17, Normal, Phase II Discharge
naproxen (NAPROSYN) 250 mg tab [40050] starting 11/22/17, Normal, Phase II Discharge
naproxen 125 MG/5ML susp [45844] starting 11/22/17, Normal, Phase II Discharge
Medications - Prescriptions - Oxycodone (Single Response) [185003]
oxycodone 5 mg tab - q4h prn - NOTE:
Suggested dose 0.1-0.2 mg/kg (Maximum 5
mg/dose) [45976]
0, starting 11/22/17, Normal, Phase II Discharge
oxycodone 5 mg/5mL soln - q4h prn - NOTE:
Suggested dose 0.1-0.2 mg/kg (Maximum 5
mg/dose) [45975]
0, starting 11/22/17, Normal, Phase II Discharge
Medication - Prescriptions - Diazepam (Single Response) [185004]
diazepam (VALIUM) soln - NOTE: Order for
patients less than or equal to 40 kg [36676]
0.1 mg/kg, starting 11/22/17, Normal
Max dose of 2 mg
diazepam (VALIUM) soln - NOTE: Order for
patients greater than 40 kg [36676]
0.1 mg/kg, starting 11/22/17, Normal
Max dose of 5 mg
diazepam (VALIUM) 5 MG tab - NOTE: Order for
patients greater than 40 kg [36679]
starting 11/22/17, Normal
Max dose of 5 mg
Phase II Discharge
Medications - Prescriptions - Bowel Management [145347]
polyethylene glycol (MIRALAX) oral powder
[61353]
starting 11/22/17, Normal, Phase II Discharge
Activity [92149]
Activity [NURACT0008] Routine
Discharge Activity:
May return to school when no longer taking narcotics.,
Phase II Discharge
Elevate Extremity [NURACT0010] Routine, Elevate effected extremity as much as
possible for 3-5 days postoperatively or until swelling
and pain decreases.
Do Not Drive for 48 Hours or While on Narcotic
Pain Medications [NURACT0011]
Routine
Return to School [92150]
Return to School [NURACT0011] Routine, Patient may return to school in *** days.
Return to School [NURACT0011] Routine, Patient may not return to school before
postoperative follow-up clinic visit.
Orthopedic Device [92151]
Arm Brace [NURACT0011] Routine, Wear at all times, even sleeping. Keep brace
locked until follow-up visit.
Sling [NURACT0011] Routine, Keep arm in sling until follow-up appointment.
Patient to wear sling *** hours per day.
Page 3 of 6
Printed by O'BRIEN, RYLEY P [RPO249] at 11/22/2017 9:13:59 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Walking Boot [NURACT0011] Routine, Patient to wear walking boot at all times
when ambulating and at least *** hours per day.
Crutches [NURACT0011] Routine, Use crutches when walking
Walker [NURACT0011] Routine, Use walker when walking.
Leg Brace [NURACT0011] Routine, Keep leg brace in full locked position until
follow-up appointment. Patient to wear brace ***
hours per day.
Short Leg Splint [NURACT0011] Routine, Patient to wear splint *** hours per day.
Nutrition [92152]
General Diet [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
Resume normal diet as tolerated. Low fat initially is
best.
Wound Care [92153]
Wound Care - Dressing Change [NURWND0018] Routine, ***
Wound Care - Bathing Instructions
[NURWND0018]
Routine, ***
Contingency Parameters [92154]
Call Doctor For: [NURCOM0001] Routine, Nausea or vomiting lasting more than 24
hours; if you have not had a bowel movement in 3
days; temperature above 100.4 degrees F by mouth
for 2 readings taken 4 hours apart; shortness of breath
or cough; cramping or excess swelling to extremity not
relieved by elevation; dark colored urine; loss of
movement. Excess bleeding, redness and/or warmth
at the incision site, pus like drainage, rapid or
excessive bruising. Cast tightness, irritation,
increasing numbness or tingling, coolness, extreme
paleness, or blue color to fingers or toes. Increased
pain not relieved by prescribed pain medication.
Any other questions or concerns, please contact the
clinic at 608-263-6420. After hours, nights, weekends,
or holidays call 608-262-0486.
Follow-Up Appointments [92155]
Patient to Schedule Appointment (Orthopedics)
[NURCOM0056]
Routine
Purpose: Postoperative follow-up clinic visit
With whom:
For when:
Schedule Appointment [NURCOM0026] Routine
Reason for Hospital Follow Up Appointment:
Which Provider:
Which Clinic or Specialty:
Please indicate what X-Rays are needed: ***
Dissolvable sutures: {Yes / No:28723}
Schedule Appointment - 2 weeks [NURCOM0026] Routine
Reason for Hospital Follow Up Appointment: Post op
follow up
Which Provider: Other Provider or Specialist
When do you want appointment: Other (Enter
comments)
Which Clinic or Specialty:
Please indicate what X-Rays are needed: ***
Dissolvable sutures: {Yes / No:28723}
Page 4 of 6
Printed by O'BRIEN, RYLEY P [RPO249] at 11/22/2017 9:13:59 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Schedule Appointment - 4 weeks [NURCOM0026] Routine
Reason for Hospital Follow Up Appointment: Post op
follow up
Which Provider: Other Provider or Specialist
When do you want appointment: 1 month
Which Clinic or Specialty:
Please indicate what X-Rays are needed: ***
Dissolvable sutures: {Yes / No:28723}
Schedule Appointment - 6 weeks [NURCOM0026] Routine
Reason for Hospital Follow Up Appointment: Post op
follow up
Which Provider: Other Provider or Specialist
When do you want appointment: Other (Enter
comments)
Which Clinic or Specialty:
Please indicate what X-Rays are needed: ***
Dissolvable sutures: {Yes / No:28723}
Discharge Scripts [142620]
Discharge - Outpatient Therapy [DC0002] Routine
Type(Each Agency Requires a Separate Order): PT -
Evaluate and Treat
Diagnosis:
Facility:
Facility City:
Facility Phone:
Facility Fax:
Discharge - Outpatient Therapy [DC0002] Routine
Type(Each Agency Requires a Separate Order): OT -
Evaluate and Treat
Diagnosis:
Facility:
Facility City:
Facility Phone:
Facility Fax:
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]
Page 5 of 6
Printed by O'BRIEN, RYLEY P [RPO249] at 11/22/2017 9:13:59 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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 [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 6 of 6
Printed by O'BRIEN, RYLEY P [RPO249] at 11/22/2017 9:13:59 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org