/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/ambulatory/,/clinical/cckm-tools/content/order-sets/ambulatory/vascular-surgery/,

/clinical/cckm-tools/content/order-sets/ambulatory/vascular-surgery/name-98511-en.cckm

20170248

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Vascular Surgery

FDS - Carotid Endarterectomy - Adult - Preprocedure [5292]

FDS - Carotid Endarterectomy - Adult - Preprocedure [5292] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Vascular Surgery


FDS - Carotid Endarterectomy - Adult - Preprocedure [5292]
for Adult Patients OnlyIntended
Pre-Day of Procedure
Non-Categorized Patient Care Orders [111679]
chlorhexidine gluconate (HIBICLENS) 4 % topical
liquid [64730]
237 mL, , starting 2/9/17, Normal
Medications-MRSA/MSSA Positive [138973]
Note: Please select the orders below if patient is MRSA or MSSA positive
mupirocin (BACTROBAN) 2 % ointment [45826] 1 Tube, 0, starting 2/9/17, E-Prescribe
chlorhexidine gluconate (HIBICLENS) 4 % topical
liquid [64730]
237 mL, , starting 2/9/17, E-Prescribe
Labs - MRSA and MSSA Screening [219363]
MRSA/MSSA BY PCR [HCMSSA] Status: Standing, Expires:6/11/17 Manual,Count:1,
Office collect, Routine, A Pre-Surgical screen consists
of one culturette swab from both left and right nares.
This assay cannot detect MSSA when MRSA is
present.
Laboratory [86963]
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
MAGNESIUM [MAG] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
PHOSPHATE [PHOS] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
PTT [PTT] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
URINALYSIS WITH MICROSCOPY AND
CULTURE IF >5 WBC/HPF [HCUACULT]
Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
Labs - Blood Bank [154611]
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.
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.
Type and Screen
Order if specimen collection will be less than 72 hours prior to surgery.
ANTIBODY SCREEN [ABSCR] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
Page 1 of 7
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Diagnostic Tests and Imaging [181641]
ECG - 12 Lead [EKG0008] Status: Future, Expires: 3/9/18, Normal, Routine
Routine EEG [EEG0004] Status: Future, Expires: 8/13/18, Normal, Routine
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
VTE Prophylaxis [109260]
• 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
Page 2 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 2/9/2017 4:11:51 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, ON CALL For 1 Doses
If patient scheduled for block, give after block placed
IntraOp
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE For 1 Occurrences, Routine
Reason Not Ordered:
Pre-Op Day Of Procedure
Non Categorized Patient Care Orders [181642]
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
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?
Pre-Op Day Of Procedure
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
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
IV Fluids [181761]
dextrose 5%-NaCl 0.45% infusion [51613] at 20 mL/hr, Intravenous, CONTINUOUS, Pre-Op
Day Of Procedure
sodium chloride 0.9 % infusion [64367] at 20 mL/hr, Intravenous, CONTINUOUS, Pre-Op
Day Of Procedure
Page 3 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 2/9/2017 4:11:51 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

Anti-platelets [181763]
Omit preoperative aspirin dose if patient took AM
dose [NURCOM0022]
ONCE For 1 Occurrences, Omit preoperative aspirin
dose if patient took AM dose, Pre-Op Day Of
Procedure
aspirin rectal suppository [34799] 300 mg, Rectal, ONCE For 1 Doses
Omit Preoperative Aspirin Dose if Patient Took AM
Dose
Pre-Op Day Of Procedure
aspirin chew tab [720164] 81 mg, Oral, ONCE For 1 Doses
Omit pre-op dose if patient took AM dose
Pre-Op Day Of Procedure
clopidogrel (PLAVIX) tab [720168] 75 mg, Oral, ONCE For 1 Doses
Omit pre-op dose if patient took AM dose
Pre-Op Day Of Procedure
Laboratory [181643]
CBC WITHOUT DIFFERENTIAL [HEMO] 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, WHOLE BLOOD
[HCWBLYTS]
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
BUN [BUN] 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, WHOLE BLOOD [HCWBCRET] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
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] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
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, IONIZED, WHOLE BLOOD
[HCWBICA]
STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
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 - RN COLLECT 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 4 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 2/9/2017 4:11:51 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

PTT [PTT] STAT - RN COLLECT 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
MAGNESIUM [MAG] STAT - RN COLLECT 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
PHOSPHATE [PHOS] STAT - RN COLLECT 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
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
Tests [91574]
TYPE AND SCREEN [HCTS] STAT - RN COLLECT, 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
Surgical Prophylaxis
First Line (Single Response) [219736]
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
MRSA/Documented History of MRSA (Single Response) [181937]
Patients who are 40 - 120 kg [219450]
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 = 2000mg
Pre-Op Day Of Procedure
Patients who are 121 kg and greater [219453]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Maximum dose = 2000mg
Pre-Op Day Of Procedure
Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies [219454]
Page 5 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 2/9/2017 4:11:51 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
IntraOp
Diagnostic Tests and Imaging [181645]
Routine EEG [EEG0004] ONCE, Routine
Reason for Monitoring: Surgical
IntraOp
Diagnosis
Diagnosis - Pre Op [711]
Pre-operative general physical examination
[255759]
Other specified pre-operative examination
Diagnosis - Smoking Cessation [134767]
Tobacco use disorder [305.1.ICD-9-CM] Tobacco use disorder
Personal history of tobacco use, presenting
hazards to health [V15.82.ICD-9-CM]
Personal history of tobacco use, presenting hazards
to health
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
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
Page 6 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 2/9/2017 4:11:51 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

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 7 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 2/9/2017 4:11:51 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org