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201712349

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Pulmonary

OP - Pulmonary - Adult - Preprocedure [4600]

OP - Pulmonary - Adult - Preprocedure [4600] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Pulmonary


OP - Pulmonary - Adult - Preprocedure [4600]
Intended for Adult Patients Only
PreOp 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 [240760]
Protective Precautions [ISO0349] What is the Reason for Isolation?
Pre-Op Day Of Procedure
Isolation Cart [EQP0016] CONTINUOUS, Routine, Pre-Op Day Of Procedure
Protective - Positive Pressure Room
[NURCOM0109]
CONTINUOUS
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
Non-Categorized Patient Care Orders [86227]
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today, 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
Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA TREATMENT,
Starting today, 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
Diagnostic Tests and Imaging [124121]
Page 1 of 5
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:14:09 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

ECG - 12 Lead Without Rhythm [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: Other (enter comments)
Comment:
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
Evaluate QT - going to be given droperidol., Pre-Op
Day Of Procedure
FLUOROSCOPY <= 1 HOUR [R76000] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Which body area is to be imaged? chest
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? guide procedure
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
Pre-Op Day Of Procedure
Contingency Parameters (Single Response) [128068]
Notify Fellow [NURCOM0001] Provider to Notify: Other (Comment)
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): 120
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 < (%): 90
If urine output < (mL):
Other: International normalized ratio (INR) is greater
than 1.4,Platelet count less than 50,000/microliter,If
patient has taken clopidogrel (PLAVIX) within the last
7 days, unfractionated heparin within the last 8 hours,
low molecular weight heparin within the last 12 hours,
or warfarin (COUMADIN) within the last 5 days
Laboratory [86230]
HEMOGLOBIN [HGB] 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
Page 2 of 5
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:14:09 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

PLATELET COUNT [PLT] 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
PROTHROMBIN TIME/INR [PT] 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
Premedications for Needle Insertion [241915]
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 immediate.
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
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.
Pre-Op Day Of Procedure
Intravenous Therapy [124157]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Pre-Op Day Of Procedure
lactated ringers infusion [38890] Intravenous, CONTINUOUS, Pre-Op Day Of
Procedure
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS, Pre-Op Day Of
Procedure
sodium chloride 0.9 % infusion [64367] at 125 mL/hr, Intravenous, CONTINUOUS, Pre-Op
Day Of Procedure
IntraOp
Sedation Medications [193514]
FENTanyl PF injection RANGE [750047] 12.5-50 mcg, Intravenous, PRN For 24 Hours,
Sedation for endoscopy procedure
Initial dose of 50 mcg (consider lower doses for
patients older than 70 years old or less than 50 kg);
subsequent doses of 12.5-50 mcg every 2 minutes as
needed for moderate sedation. Titrate to maintain an
Adult Sedation Score between 3-4.
Doses to be directed by the provider.
for 1 Minutes, APC/GI Sedation
Page 3 of 5
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:14:09 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

midazolam (VERSED) injection RANGE [750056] 0.5-2 mg, Intravenous, PRN For 24 Hours, sedation,
Sedation for endoscopy procedure.
Initial dose of 2 mg (consider lower doses for patients
older than 70 years old or less than 50 kg).
Subsequent doses of 0.5-2 mg every 2 minutes as
needed for moderate sedation. Titrate to maintain an
Adult Sedation Score between 3-4.
Doses to be directed by the provider.
APC/GI Sedation
Anti-emetics [191355]
diphenhydramine (BENADRYL) injection RANGE
[750044]
12.5-50 mg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting, For first line therapy. Use second
line therapy if ineffective
Doses to be directed by the provider.
for 1 Minutes
promethazine (PHENERGAN) injection RANGE
[750060]
12.5-25 mg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting, Second line therapy when
unresponsive to first line therapy within 30 minutes.
Do not repeat
Doses to be directed by the provider.
Opioid/Benzodiazepine Reversal [193516]
naloxone (NARCAN) injection - NOTE: Order for
opioid reversal [800199]
0.2-0.8 mg, Intravenous, PRN For 24 Hours, opioid
overdose, Sedation reversal
Administer every 3 minutes times 4 doses as needed
for respiratory rate less than 8 breaths/minute or
sedation score of 5 or greater
Administer over 2 minutes
Doses to be directed by the provider.
IntraOp
flumazenil (ROMAZICON) injection - NOTE:
Order for benzodiazepine reversal [104460]
0.1-1 mg, Intravenous, PRN For 24 Hours, Sedation
reversal
Give 0.1-0.2 mg IV over 15 seconds; repeat dose after
45 seconds (1 minute intervals) as needed for
sedation reversal up to a maximum dose of 1 mg.
Doses to be directed by the provider.
IntraOp
Medications [124158]
lidocaine 1 % vial [39034] 20-40 mL, Other, ONCE For 1 Doses
Route: Topical into lungs
IntraOp
lidocaine (XYLOCAINE JELLY) 2 % gel [39030] Topical, ONCE For 1 Doses
Apply to nares
IntraOp
Diagnosis
Diagnosis - Pre Op [124138]
Pre-operative general physical examination
[255759]
Other specified pre-operative examination
Level of Service
Office Visit - Established Patients [124139]
99211 - Level I LOS Code
99212 - Level II LOS Code
99213 - Level III LOS Code
Page 4 of 5
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:14:09 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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 [124140]
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 [124141]
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 BENNETT, SARA J [SJB008] at 12/15/2017 7:14:09 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org