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/clinical/cckm-tools/content/order-sets/ambulatory/urology/name-98514-en.cckm

20180119

page

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UWHC,UWMF,

Tools,

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

FDS - Urologic Surgery - Adult - Preoperative [2891]

FDS - Urologic Surgery - Adult - Preoperative [2891] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Urology


FDS - Urologic Surgery - Adult - Preoperative [2891]
for Adult Patients OnlyIntended
Pre-Day of Procedure
Medications - Prescriptions - Bowel Prep [90698]
metoclopramide (REGLAN) 10 mg tab [39629] 2 tab, 0, starting 1/16/18, Normal, Pre-Day of
Procedure
phosphate (FLEET) ADULT enema [37517] 1 enema, 1 Bottle, 0, starting 1/16/18 until 1/16/18,
Normal, Pre-Day of Procedure
erythromycin base (E-MYCIN) 500 mg tab
[37230]
6 tab, 0, starting 1/16/18 until 2/15/18, Normal, Pre-
Day of Procedure
neomycin 500 mg tab [40142] 6 tab, 0, starting 1/16/18 until 2/15/18, Normal, Pre-
Day of Procedure
magnesium citrate soln [39309] 300 mL, 300 mL, 0, starting 1/16/18 until 1/16/18,
Normal, Pre-Day of Procedure
G.I. lavage (GOLYTELY) 236 GM SOLR [103976] 0, starting 1/16/18, Normal, Pre-Day of Procedure
G.I. lavage (GOLYTELY) 236 GM SOLR [103976] 0, starting 1/16/18, Normal, Pre-Op Day Of Procedure
Laboratory [91286]
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
CBC WITHOUT DIFFERENTIAL [HEMO] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
HEMATOCRIT [HCT] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
PLATELET COUNT [PLT] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
PTT [PTT] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
HEMOGLOBIN A1C [HA1C] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
ALT/SGPT [ALT] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
AST/SGOT [AST] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
ALBUMIN [ALB] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
ALKALINE PHOSPHATASE [ALKP] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
BILIRUBIN, TOTAL [TBIL] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
MAGNESIUM [MAG] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
Page 1 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/16/2018 3:33:15 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

PHOSPHATE [PHOS] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
PSA TOTAL, DIAGNOSTIC [PSA] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
PSA TOTAL, SCREEN [PSAM] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
PSA TOTAL, DIAGNOSTIC WITH REFLEX TO
FREE PSA [HCPSADRF]
Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
CULTURE, URINE [URC] Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
URINALYSIS WITH MICROSCOPY AND
CULTURE IF >5 WBC/HPF [HCUACULT]
Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
TESTOSTERONE, TOTAL, ADULT MALE
[XTTEST]
Status: Standing, Expires:3/2/18 MANUAL,Count:1,
Normal, Routine
Laboratory - Pregnancy Test [87226]
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] Status: Standing, Expires:3/2/18 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:3/2/18 MANUAL,Count:1,
Normal, Routine
Antibody Screen and ABO and Rh Typing
[192516]
ANTIBODY SCREEN [ABSCR] Status: Standing, Expires:5/18/18 MANUAL,Count:1,
Normal, Routine
ABO AND RH TYPING [ABO] Status: Standing, Expires:5/18/18 MANUAL,Count:1,
Normal, Routine
Diagnostic Tests and Imaging [91289]
ECG - 12 Lead [EKG0008] Status: Future, Expires: 2/16/2019, Normal, Routine
CT ABDOMEN W IV CONTRAST [R74160] Status: Future, Expires: 3/16/2019, Normal, Routine, If
patient has not had one within the past 2 months.
CT CHEST WO & CT ABD/PELVIS W [218169]
CT CHEST W/ O IV CONTRAST [R71250] Status: Future, Expires: 3/16/2019, Normal, Routine,
CT Chest W/O & CT Abd/Pelvis W to be scheduled
together
CT ABDOMEN PELVIS W IV CONTRAST
[R07416]
Status: Future, Expires: 3/16/2019, Normal, Routine,
CT Chest W/O & CT Abd/Pelvis W to be scheduled
together
CT ABDOMEN PELVIS W IV CONTRAST
[R07416]
Status: Future, Expires: 3/16/2019, Normal, Routine
Page 2 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/16/2018 3:33:15 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

CT UROGRAPHY W & W/O IV CONTRAST
[R07417]
Status: Future, Expires: 3/16/2019, Normal, Routine
CT FLANK PAIN [R99992] Status: Future, Expires: 3/16/2019, Normal, Routine
US KIDNEY & AORTA [R76770] Status: Future, Expires: 3/16/2019, Normal, Routine
NM KIDNEY SCAN W FLOW & FUNCTION W
RX [R78708]
Status: Future, Expires: 3/16/2019, Normal, Routine
MRI ABDOMEN PELVIS W & W/O CONTRAST
[R07020]
Status: Future, Expires: 3/16/2019, Normal, Routine
Consults [198900]
CONSULT TO CSC PRE-ANESTHESIA
[1009482]
Please indicate Surgical/Procedural Service (if not in
case request):
Who is Surgeon or Proceduralist? (if not in case
request):
Service contact + Pager/Phone. Essential for follow-
up!!:
If you want patient to be seen IN-PERSON at the
PASS Clinic, please select the reason:
CARDIOVASCULAR, chart review only:
PULMONARY OR AIRWAY, chart review only:
MEDICATION, chart review only:
OTHER REASONS, chart review only:
Who will complete the H&P?
If H&P to be done by non-UWH provider, what facility?
Approximately when will H&P be completed, from
today? (Reminder - H&Ps are required by CMS to be
done within 30 days):
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 [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]
Page 3 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/16/2018 3:33:15 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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
Perioperative Normogyclemia Management - For First Day Surgery Patients Only (Single Response)
[216835]
equal to 6.4%diabetes history includes prediabetes and patients with A1C less than or No
Patients withOUT Diabetes [216834]
Glucose, POC [IPGLUCOSE] ONCE 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
Glucose, POC [IPGLUCOSE] EVERY 2 HOURS, 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?
Repeat POC glucose if previous reading greater
than or equal to 180 mg/dL. No recheck for reading
< 180 mg/dL, Pre-Op Day Of Procedure
Notify Provider [NURCOM0001] Provider to Notify: Other (Comment)
Notify based on: Blood Glucose
If blood glucose > (mg/dL): 179
If blood glucose < (mg/dL):
Pre-Op Day Of Procedure
Patients WITH Diabetes [216834]
Glucose, POC [IPGLUCOSE] ONCE 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
Glucose, POC [IPGLUCOSE] EVERY 2 HOURS, 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?
Repeat POC glucose if previous reading greater
than or equal to 180 mg/dL. No recheck for reading
< 180 mg/dL, Pre-Op Day Of Procedure
Notify Provider [NURCOM0001] Provider to Notify: Other (Comment)
Notify based on: Blood Glucose
If blood glucose > (mg/dL): 179
If blood glucose < (mg/dL):
Pre-Op Day Of Procedure
Medications - Hypoglycemia Treatment [212994]
URL:
Hypoglycemia Management (Adult) [191576]
Page 4 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/16/2018 3:33:15 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today For Until specified,
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 For Until specified,
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?
Per hypoglycemia treatment algorithm Recheck
glucose 15 minutes after providing treatment until
glucose is greater than or equal to 70 mg/dL. If
patient has been critically low (i.e., glucose less than
40 mg/dL), recheck glucose after 1 hour to ensure
glucose remains greater than or equal to 70mg/dL.
After resolution of mild hypoglycemia (i.e., glucose
40-69 mg/dL), consider rechecking after 1 hour if
patient has signs/symptoms of hypoglycemia or is at
risk for a subsequent hypoglycemic event (e.g.,
previously administered insulin still active, altered
renal status, altered mental status, NPO or
interrupted nutrition, or any other condition that
increases hypoglycemia risk), Pre-Op Day Of
Procedure
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Glucose,Other
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
Other: Nutritional status changes
Pre-Op Day Of Procedure
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If blood glucose less
than 40mg/dL and patient able to eat/swallow safely.
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., Pre-Op Day Of Procedure
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If glucose is 40-69
mg/dL and patient able to eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater., Pre-Op Day Of Procedure
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose 40-
69 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
Pre-Op Day Of Procedure
Page 5 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/16/2018 3:33:15 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
less than 40 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
Pre-Op Day Of Procedure
glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, For blood glucose less
than 69 mg/dL and patient unable to eat/swallow
safely AND has NO IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Pre-Op Day Of Procedure
dextrose injection [800233] 12.5 g, Intravenous, PRN, For blood glucose 40-69
mg/dL and patient unable to eat/swallow safely AND
has IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Pre-Op Day Of Procedure
dextrose injection [800233] 25 g, Intravenous, PRN, For blood glucose less than
40 mg/dL and patient unable to eat/swallow safely
AND has IV access.
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
Pre-Op Day Of Procedure
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Pre-Op Day Of Procedure
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting 1/24/18 For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Pre-Op Day Of Procedure
Non-Categorized Patient Care Orders [91291]
Ostomy Nurse to Mark Site [NURWND0018] ONCE, Starting today For 1 Occurrences, 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?
As Needed for Signs and Symptoms of Hypoglycemia,
Pre-Op Day Of Procedure
Premedications for Needle Insertion [153960]
Page 6 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/16/2018 3:33:15 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Pre-Op Day Of Procedure
GI Promotility - Opioid Antagonist [238828]
alvimopan (ENTEREG) cap [130251] 12 mg, Oral, ONCE For 1 Doses
Preoperative dose administer 30 minutes to 5 hours
before surgery.
Pre-Op Day Of Procedure
Medications - Non-categorized [113809]
diphenhydramine (BENADRYL) injection [800106] 50 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
Laboratory [91292]
CBC WITHOUT DIFFERENTIAL [HEMO] 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
POTASSIUM [K] 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
Research Kit (A) [7700066] STAT, Starting tomorrow For 1 Occurrences, Routine
Will this research kit be processed (or shipped) by a
UW Health Lab?
Pre-Op Day Of Procedure
Page 7 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/16/2018 3:33:15 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

URINALYSIS WITH MICROSCOPY AND
CULTURE IF >5 WBC/HPF [HCUACULT]
STAT, 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?
Pre-Op Day Of Procedure
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if blood glucose
< 40 mg/dL or > 400 mg/dL
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 [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
Page 8 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/16/2018 3:33:15 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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
Blood Products [83984]
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
Page 9 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/16/2018 3:33:15 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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
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
Diagnostic Tests and Imaging [91294]
X-RAY ABDOMEN SINGLE VIEW [R74018] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: AMBULATORY
PROCEDURE CENTER
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
Pre-Op Day Of Procedure
VTE Prophylaxis
VTE Prophylaxis [153965]
Page 10 of 14
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01/2018CCKM@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 subcutaneous injection [800290] 5,000 units, Subcutaneous, ON CALL For 1 Doses
If patient scheduled for block, give after block placed
IntraOp
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, ON CALL For 1 Doses, 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) [137337]
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 or greater [800000]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefoxitin (MEFOXIN) intraVENOUS - Note:
Patients who are 40-120 kg [800022]
2 g, Intravenous, ON CALL For 1 Doses, IntraOp
cefoxitin (MEFOXIN) intraVENOUS - Note:
Patients who are 121 kg or greater [800022]
3 g, Intravenous, ON CALL For 1 Doses, IntraOp
ciprofloxacin (CIPRO) intraVENOUS - Note:
Patients who are 40-120 kg [800031]
400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
ciprofloxacin (CIPRO) intraVENOUS - Note:
Patients who are 120-160 kg [800031]
600 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
ciprofloxacin (CIPRO) intraVENOUS - Note:
Patients who are greater than 160 kg [800031]
800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
MRSA/Documented MRSA History (Single Response) [150951]
Patient who is 40-120 kg [243274]
cefoxitin (MEFOXIN) intraVENOUS [800022] 2 g, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patient who is greater than 120 kg [243277]
Page 11 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/16/2018 3:33:15 PM
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01/2018CCKM@uwhealth.org

cefoxitin (MEFOXIN) intraVENOUS [800022] 3 g, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 40-120 kg - ciprofloxacin
therapy [243280]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 120-160 kg - ciprofloxacin
therapy [243283]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 160 kg -
ciprofloxacin therapy [243286]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Immediate/Severe Reaction to Penicillin or Known Cephalosporin Allergies (Single Response) [150958]
Patients who are 40-120 kg [243289]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are 121-160 kg [243295]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Patients who are greater than 160 kg [243292]
ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Artificial Urinary Sphincter / Penile Inflatable Prosthesis / Penile Implant [219189]
Gentamicin - Vancomycin (Maximum Dose = 2
grams) [243298]
gentamicin (GARAMYCIN) intraVENOUS
[800049]
5 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
IntraOp
Medications [89864]
incobotulinumtoxinA (XEOMIN) 50 UNIT/ML
injection [760375]
100 units, Other, ON CALL For 1 Doses
To be injected into sphincter. Pharmacy to send in
Luer lock syringe
IntraOp
incobotulinumtoxinA (XEOMIN) 100 UNIT/ML
injection [760372]
300 units, Other, ON CALL For 1 Doses
To be injected into sphincter. Pharmacy to send in
Luer lock syringe
Page 12 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/16/2018 3:33:15 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

hexaminolevulinate (CYSVIEW) bladder kit
[142596]
1 Kit, Intravesical, ON CALL For 1 Doses
To be administered 1 hour prior to OR time and
instilled by the RN in pre-op holding area. Pharmacy
to deliver to pre-operative holding area
IntraOp
hydrocortisone sodium succinate injection
[800189]
100 mg, Intravenous, ON CALL For 1 Doses, IntraOp
mitomycin (MUTAMYCIN) in water (sterile) 2 mL
tissue injection [700596]
0.6 mg, Injection, ON CALL For 1 Doses
Please call pharmacy when patient has arrived for the
procedure so the medication can be prepared.
IntraOp
mitomycin (MUTAMYCIN) in sodium chloride 0.9
% bladder soln [700540]
40 mg, Intravesical, ON CALL For 1 Doses
Please call pharmacy when patient has arrived for the
procedure so the medication can be prepared.
IntraOp
Diagnostic Tests and Imaging [104980]
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
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
Page 13 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/16/2018 3:33:15 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

99205- w/ Resident (GC) - Level V LOS Code
Consults - New or Established [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
Preoperative Exam (Global) [1265]
Preoperative H&P, No Charge, Surgical Package LOS Code
Page 14 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/16/2018 3:33:15 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org