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/clinical/cckm-tools/content/order-sets/ambulatory/urology/name-98517-en.cckm

20180104

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UWHC,UWMF,

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

OP - Urologic Surgery - Adult - Preoperative [2955]

OP - Urologic Surgery - Adult - Preoperative [2955] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Urology


OP - Urologic Surgery - Adult - Preoperative [2955]
for Adult Patients OnlyIntended
Pre-Day of Procedure
Medications - Prescriptions - Bowel Prep [92223]
magnesium citrate soln [39309] 296 mL, 300 mL, 0, starting 1/4/18 until 2/3/18,
Normal, Pre-Day of Procedure
phosphate (FLEET) enema [37517] 1 enema, 1 enema, 0, starting 1/4/18 until 1/4/18,
Normal, Pre-Day of Procedure
Laboratory [91634]
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:2/18/18 MANUAL,Count:1,
Normal, Routine
CBC WITHOUT DIFFERENTIAL [HEMO] Status: Standing, Expires:2/18/18 MANUAL,Count:1,
Normal, Routine
HEMATOCRIT [HCT] Status: Standing, Expires:2/18/18 MANUAL,Count:1,
Normal, Routine
PLATELET COUNT [PLT] Status: Standing, Expires:2/18/18 MANUAL,Count:1,
Normal, Routine
PTT [PTT] Status: Standing, Expires:2/18/18 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:2/18/18 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:2/18/18 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:2/18/18 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:2/18/18 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:2/18/18 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:2/18/18 MANUAL,Count:1,
Normal, Routine
PSA TOTAL, SCREEN [PSAM] Status: Standing, Expires:2/18/18 MANUAL,Count:1,
Normal, Routine
PSA TOTAL, DIAGNOSTIC [PSA] Status: Standing, Expires:2/18/18 MANUAL,Count:1,
Normal, Routine
PSA TOTAL, DIAGNOSTIC WITH REFLEX TO
FREE PSA [HCPSADRF]
Status: Standing, Expires:2/18/18 MANUAL,Count:1,
Normal, Routine
URINALYSIS WITH MICROSCOPY AND
CULTURE IF >5 WBC/HPF [HCUACULT]
Status: Standing, Expires:2/18/18 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:2/18/18 MANUAL,Count:1,
Normal, Routine
Diagnostic Tests and Imaging [91636]
ECG - 12 Lead [EKG0008] Status: Future, Expires: 2/4/2019, Normal, Routine
X-RAY ABDOMEN SINGLE VIEW [R74018] Status: Future, Expires: 3/4/2019, Normal, Routine
CT FLANK PAIN [R99992] Status: Future, Expires: 3/4/2019, Normal, Routine
Consults [198900]
Page 1 of 8
Printed by WILLIAMS, HEATHER R [HRS0] at 1/4/2018 12:44:19 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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]
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
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
Page 2 of 8
Printed by WILLIAMS, HEATHER R [HRS0] at 1/4/2018 12:44:19 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
Premedications for Needle Insertion [153960]
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
Medications - Non-categorized [113809]
diphenhydramine (BENADRYL) injection [800106] 50 mg, Intravenous, ON CALL For 1 Doses, Pre-Op
Day Of Procedure
Laboratory [91637]
HEMATOCRIT [HCT] 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
ELECTROLYTES [LYTE] 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 3 of 8
Printed by WILLIAMS, HEATHER R [HRS0] at 1/4/2018 12:44:19 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

GLUCOSE [GLU] 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
BUN [BUN] 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
CREATININE [CRET] 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
CALCIUM [CA] 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
ALBUMIN [ALB] 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
AST/SGOT [AST] 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
ALT/SGPT [ALT] 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
ALKALINE PHOSPHATASE [ALKP] 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
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
Page 4 of 8
Printed by WILLIAMS, HEATHER R [HRS0] at 1/4/2018 12:44:19 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
Diagnostic Tests and Imaging [91656]
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
Non-Categorized Patient Care Orders [92357]
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
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
Page 5 of 8
Printed by WILLIAMS, HEATHER R [HRS0] at 1/4/2018 12:44:19 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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]
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
IntraOp
Medications [89864]
Page 6 of 8
Printed by WILLIAMS, HEATHER R [HRS0] at 1/4/2018 12:44:19 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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
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
Page 7 of 8
Printed by WILLIAMS, HEATHER R [HRS0] at 1/4/2018 12:44:19 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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]
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 WILLIAMS, HEATHER R [HRS0] at 1/4/2018 12:44:19 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org