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/clinical/cckm-tools/content/order-sets/ambulatory/orthopedicsrehab/name-98549-en.cckm

201704117

page

100

UWHC,UWMF,

Tools,

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

OP - Sport Medicine - Pre/Postoperative [2802]

OP - Sport Medicine - Pre/Postoperative [2802] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Orthopedics/Rehab


OP - Sport Medicine - Pre/Postoperative [2802]
Pre-Day of Procedure
Medications - Prescriptions-Adults [87416]
hydrocodone-acetaMINOPHEN (NORCO) 5-325
mg per tab - 1-2t q4hp [71425]
1-2 tab, 0, starting 4/27/17, Normal, Pre-Day of
Procedure
oxycodone-acetaminophen (PERCOCET) 5-325
mg per tab - 1-2t q4hp [40668]
1-2 tab, starting 4/27/17, Normal, Pre-Day of
Procedure
MORPHine 15 mg tab - 1-2t q4h prn [39807] 15-30 mg, starting 4/27/17, Normal, Pre-Day of
Procedure
senna-docusate (SENOKOT S) 8.6-50 MG per
tab [60530]
2 tab, starting 4/27/17, Normal
oxycodone 5 mg tab - 1-2t q4hp [45976] 5-10 mg, starting 4/27/17, Normal, Pre-Day of
Procedure
celecoxib (CELEBREX) 200 mg cap - qd prn
[60835]
200 mg, starting 4/27/17, Normal, Pre-Day of
Procedure
ibuprofen (MOTRIN) 800 mg tab - q8h prn
[38357]
800 mg, starting 4/27/17 until 5/27/17, Normal, Pre-
Day of Procedure
ketOROLAC (TORADOL) 10 mg tab - q6h prn
[45509]
10 mg, 0, starting 4/27/17, Normal, Pre-Day of
Procedure
nabumetone (RELAFEN) 750 mg tab - 2x/d
[45829]
750 mg, starting 4/27/17, Normal, Pre-Day of
Procedure
naproxen (NAPROSYN) 500 mg tab - 2x/d prn
[40052]
500 mg, starting 4/27/17, Normal, Pre-Day of
Procedure
traMADOL (ULTRAM) 50 mg tab - 1-2t q4hp
[50258]
50-100 mg, starting 4/27/17, Normal, Pre-Day of
Procedure
promethazine (PHENERGAN) 25 mg tab - q6h
prn [41417]
25 mg, starting 4/27/17, Normal, Pre-Day of
Procedure
ondansetron (ZOFRAN) 4 MG tab [45939] 4 mg, starting 4/27/17, Normal
prochlorperazine (COMPAZINE) 10 MG tab
[41371]
10 mg, starting 4/27/17, Normal
enoxaparin (LOVENOX) 40 MG/0.4ML injection
[142049]
40 mg, starting 4/27/17, Normal
Medications-Prescriptions-Liquids [127575]
hydrocodone-acetaMINOPHEN 7.5/325
MG/15ML soln [74885]
starting 4/27/17, Normal
oxycodone 5 MG/5ML soln [45975] starting 4/27/17, Normal
Laboratory [87277]
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:6/11/17 MANUAL,Count:1,
Normal, Routine
PLATELET COUNT [PLT] Status: Standing, Expires:6/11/17 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:6/11/17 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:6/11/17 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:6/11/17 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:6/11/17 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:6/11/17 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:6/11/17 MANUAL,Count:1,
Normal, Routine
Page 1 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 4/27/2017 3:05:13 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

HEMOGLOBIN A1C [HA1C] Status: Standing, Expires:6/11/17 MANUAL,Count:1,
Normal, Routine
TSH REFLEX FREE T4 [TSHT4] Status: Standing, Expires:6/11/17 MANUAL,Count:1,
Normal, Routine
Diagnostic Tests and Imaging [87279]
ECG - 12 Lead [EKG0008] Status: Future, Expires: 5/27/18, Normal, Routine
Consults [93211]
CONSULT TO PHYSICAL THERAPY [9095] Request Type:
Reason for this request:
CONSULT TO SPORTS MEDICINE [1009133] What question regarding the patient's medical care
would you like the specialist to answer?
(REQUIRED):
Follow-Up Appointments [87325]
Patient Needs X-Rays at Follow-Up Clinic Visit
[NURCOM0022]
Routine, Order surgery-specific X-Ray to be
performed at follow-up clinic visit
Patient Needs MRI at Follow-Up Clinic Visit
[NURCOM0022]
Routine, Order surgery-specific MRI to be performed
at follow-up clinic visit
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
Non-Categorized Patient Care Orders [91706]
Glucose, POC - For Diabetic Patients
[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
Contingency Parameters [87292]
Page 2 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 4/27/2017 3:05:13 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Notify [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
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: Skin lesions are present,Signs and symptoms
of infection
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.
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
Page 3 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 4/27/2017 3:05:13 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

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
Laboratory [87301]
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
ELECTROLYTES [LYTE] 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
CREATININE [CRET] 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
PLATELET COUNT [PLT] 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
HEMOGLOBIN [HGB] 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
HEMATOCRIT [HCT] 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
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
Page 4 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 4/27/2017 3:05:13 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

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
Diagnostic Tests and Imaging [87304]
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
Pre-Op Day Of Procedure
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?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Prior to surgery., Pre-Op Day Of Procedure
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?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Prior to surgery., Pre-Op Day Of Procedure
X-RAY KNEE 3 VIEWS LEFT [R73562L] 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?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Prior to surgery., Pre-Op Day Of Procedure
Page 5 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 4/27/2017 3:05:13 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

X-RAY KNEE 3 VIEWS RIGHT [R73562R] 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?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Prior to surgery., Pre-Op Day Of Procedure
VTE Prophylaxis
VTE Prophylaxis [86969]
Sequential Compression Device (SCD) Panel
(TREATMENT AND SUPPLY) [206111]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral?
Pre-Op Day Of Procedure
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type:
Pre-Op Day Of Procedure
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Starting today, Routine
Does this need to be inserted/placed? Yes
Left/Right/Bilateral? Bilateral
Type: Thigh high
Pre-Op Day Of Procedure
Use Venous Foot Pumps [EQP0023] CONTINUOUS, Starting today, Routine
Left/Right/Bilateral? Bilateral
Pre-Op Day Of Procedure
Surgical Prophylaxis - Adult
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 4/27/2017 3:05:13 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@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
Surgical Prophylaxis - Pediatrics
First Line [128280]
cefuroxime (ZINACEF) intraVENOUS - NOTE:
Suggested dose 50 mg/kg (Maximum 1.5 g/dose)
[800030]
50 mg/kg, Intravenous, ON CALL For 1 Doses
Maximum dose 1.5g
IntraOp
MRSA / Documented MRSA History or high risk for MRSA/MRSE (Implanted Device) [146300]
Cefuroxime (Maximum 1.5 grams) - Vancomycin
(Maximum Dose 2 grams) [216828]
cefuroxime (ZINACEF) intraVENOUS [800030] 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 [212581]
vancomycin (VANCOCIN) intraVENOUS -
Maximum of 2 grams [800084]
15 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
IntraOp
Diagnostic Tests and Imaging [127578]
Imaging in OR [R10000] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
STAT
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
IntraOp
PACU
Page 7 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 4/27/2017 3:05:13 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Diagnostic Tests and Imaging [87314]
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
PACU
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?
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?
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 CHEST AP VIEW [R71010] 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 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?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done in PACU, PACU
Page 8 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 4/27/2017 3:05:13 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

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?
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 2 VIEWS LEFT [R73070L] 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?
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 2 VIEWS RIGHT [R73070R] 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?
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 KNEE 1-2 VIEWS LEFT [R73560L] 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?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done in PACU, PACU
Page 9 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 4/27/2017 3:05:13 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

X-RAY KNEE 1-2 VIEWS RIGHT [R73560R] 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?
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 HIP UNILATERAL W/PELV WHEN
PERFMD 2-3 VIEWS LEFT [R73502L]
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?
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 HIP UNILATERAL W/PELV WHEN
PERFMD 2-3 VIEWS RIGHT [R73502R]
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?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
To be done in PACU, PACU
PostOp/Phase II
Analgisics - NSAID - Oral - PRN (Single Response) [216823]
celecoxib (CELEBREX) cap [60835] 200 mg, Oral, ONCE PRN For 1 Doses, pain
Administer for mild to moderate pain or multi-modal
therapy
Post-Op/Phase II
naproxen (NAPROSYN) tab [40052] 500 mg, Oral, ONCE PRN For 1 Doses, pain
Administer for mild to moderate pain or multi-modal
therapy
Post-Op/Phase II
nabumetone (RELAFEN) tab [45829] 750 mg, Oral, ONCE PRN For 1 Doses, pain
Administer for mild to moderate pain or multi-modal
therapy
Post-Op/Phase II
Page 10 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 4/27/2017 3:05:13 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab RANGE
[750000]
325-650 mg, Oral, EVERY 4 HOURS PRN, pain/fever
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Administer for mild to moderate pain or multi-modal
therapy
Post-Op/Phase II
Analgesics - Opioid - Oral - PRN (Single Response) [92440]
oxycodone tab RANGE [750032] 5-10 mg, Oral, EVERY 4 HOURS PRN For 24 Hours,
pain
Administer for severe pain
Post-Op/Phase II
MORPHine tab [39807] 15 mg, Oral, EVERY 4 HOURS PRN For 24 Hours,
pain
Administer for severe pain
Post-Op/Phase II
oxycodone-acetaminophen (PERCOCET) 5-325
mg per tab RANGE [750033]
1-2 tab, Oral, EVERY 4 HOURS PRN For 24 Hours,
pain
Administer for severe pain
Post-Op/Phase II
traMADOL (ULTRAM) tab [50258] 50 mg, Oral, EVERY 4 HOURS PRN For 8 Doses,
pain
Administer for severe pain
Post-Op/Phase II
hydrocodone-acetaMINOPHEN (NORCO) 5-325
mg per tab RANGE [750021]
1-2 tab, Oral, EVERY 4 HOURS PRN For 24 Hours,
pain, Post-Op/Phase II
Prior to Discharge [92767]
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
Activity/Return to Work [87317]
Activity [NURACT0008] Routine
Discharge Activity:
No lifting greater than 10 pounds for 5 days after
surgery.
No driving while on pain medication or {while in
sling/while in brace/while on crutches:21974}.
Phase II Discharge
Leg Brace [NURACT0011] Routine, Keep leg brace in full locked position until
follow-up appointment
Sling [NURACT0011] Routine, Keep arm in sling until follow-up appointment
Walking Boot (Bledsoe) [NURACT0011] Routine, Wear boot at all times and when walking.
Continue to wear until next follow up appointment.
Crutches [NURACT0008] Routine
Discharge Activity:
Use crutches while walking., Phase II Discharge
Nutrition [87319]
General Diet Without Restrictions [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
Page 11 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 4/27/2017 3:05:13 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Clear Liquid Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid: Clear Liquid
Esophagectomy:
Fat Controlled:
Fiber:
Fluid Restriction:
Heart Healthy:
Metabolic:
Renal:
Sodium Controlled:
NPO:
Advance diet as tolerated.
Wound Care [87320]
Do Not Shower [NURWND0018] Routine, Patient may shower in *** days with incision
site covered.
Patient May Shower [NURWND0018] Routine, May shower with wound uncovered starting
3 days postoperatively.
Change Dressing [NURWND0018] Routine, Change dressing *** days postoperatively.
Ice Unit [NURWND0018] Routine, Use ice unit as tolerated for first 24 hours,
then not more than 1 hour ON followed by at least 1
hour OFF.
Contingency Parameters [87323]
Notify Provider [NURCOM0022] Routine, Call Sports Medicine for nausea or vomiting
lasting more than 24 hours; if you have not had a
bowel movement in 3 days; temperature above 100.4
F by mouth, for 2 readings taken 4 hours apart;
excess swelling or bleeding; increased redness
and/or warmth at the incision site; pus-like drainage;
excessive drainage (greater than 200mL's every 4
hours); pain not relieved by pain pills; rapid or excess
bruising (some bruising is normal); sudden shortness
of breath or cough; cramping/swelling to leg; and/or
dark urine. Phone: 608-263-8850 After Hours
Phone: 608-262-2122
Consults [91683]
CONSULT TO PHYSICAL THERAPY [9095] Request Type:
Reason for this request:
Page 12 of 12
Printed by O'BRIEN, RYLEY P [RPO249] at 4/27/2017 3:05:13 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org