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/clinical/cckm-tools/content/order-sets/hod/radiation-oncology/name-97782-en.cckm

201609270

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100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,HOD,Radiation Oncology

RAD ONC - Prostate Seed Implant - Adult - Pre/Postoperative [4580]

RAD ONC - Prostate Seed Implant - Adult - Pre/Postoperative [4580] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, HOD, Radiation Oncology


SmartSet: RAD ONC - PROSTATE SEED IMPLANT - ADULT -
PRE/POSTOPERATIVE (ID:4580)
General Information
Display name: RAD ONC - Prostate Seed Implant - Adult - Pre/Postoperative
Type: General
Merge priority:
Version comment:
Content source:
Synonyms: 1. .RADONC
SmartSet notes:
Description:
Web information: Title URL
1.
Questionnaire:
Configuration
Admission Status
Level of Care
Place Patient on General Care General Care, has already been signed. This order
will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intermediate Care Intermediate Care, has already been signed. This
order will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intensive Care (ICU) has already been signed. This order will ensure that
the patient is placed at the appropriate level of care.
Admit to Inpatient (Single Response)
Page 1 of 10
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:07:45 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

Admit To Inpatient Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically
necessary because of either an anticipated LOS
>2 midnights, complexity and/or severity of illness,
an inpatient-only surgery, or a previously-
authorized inpatient stay. Rationale listed below.
Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Pre-Op Day Of Procedure
Admit to Observation (Single Response)
Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admit to Outpatient Short Stay (Single
Response)
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admission
Admit To Inpatient Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Pre-Op Day Of Procedure
Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admission
Page 2 of 10
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:07:45 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

Admit To Inpatient Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Pre-Op Day Of Procedure
Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Pre-Day of Procedure
Diagnostic Tests and Imaging
ECG - 12 Lead With Rhythm Status: Future, Expires: M+13, Normal, Routine
X-RAY CHEST PA & LAT VIEWS Status: Future, Expires: M+14, Normal, Routine
Ultrasound Guided Prostate Volume Study ONCE For 1 Occurrences, Routine
Reason for Exam: Prostate Seed Implantation
Plannning
Radiation Oncology
lidocaine (STERILE UROJECT) 2 % gel Other, ONCE For 1 Doses
Premedication for prostate ultrasound
Radiation Oncology
Laboratory
CBC WITH DIFFERENTIAL Status: Standing, Expires:S+45 MANUAL,Count:1,
Normal, Routine
PLATELET COUNT Status: Standing, Expires:S+45 MANUAL,Count:1,
Normal, Routine
PTT Status: Standing, Expires:S+45 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR Status: Standing, Expires:S+45 MANUAL,Count:1,
Normal, Routine
BUN Status: Standing, Expires:S+45 MANUAL,Count:1,
Normal, Routine
CREATININE Status: Standing, Expires:S+45 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES Status: Standing, Expires:S+45 MANUAL,Count:1,
Normal, Routine
CALCIUM Status: Standing, Expires:S+45 MANUAL,Count:1,
Normal, Routine
Page 3 of 10
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:07:45 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

GLUCOSE Status: Standing, Expires:S+45 MANUAL,Count:1,
Normal, Routine
Medications - Prescriptions
phenazopyridine (PYRIDIUM) 200 MG tab 200 mg, 20 tab, 0, starting t, Normal, Pre-Day of
Procedure
tamsulosin (FLOMAX) 0.4 MG cap 0.8 mg, 180 cap, 3, starting t, Normal, Pre-Day of
Procedure
ciprofloxacin (CIPRO) 500 MG tab 500 mg, 14 tab, 0, starting t, Normal, Pre-Day of
Procedure
Follow Up Appointment
Schedule Appointment with Radiation Oncology Routine
Reason for Appointment: Post Prostate Seed Implant
When do you want appointment: 1 month
postoperative
Which Clinic or Specialty: Radiation Oncology
Which Provider (Optional):
Pre-Op Day of Procedure
Isolation Status
Isolation - Enhanced Contact - Clostridium
Difficile
CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Contact - MRSA CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Contact - VRE CONTINUOUS, Separate order must be placed for
isolation cart., Pre-Op Day Of Procedure
Isolation - Protective Precautions - Panel
Protective Precautions CONTINUOUS
Reason for Protective Precautions:
Pre-Op Day Of Procedure
Protective - Positive Pressure Room CONTINUOUS, Pre-Op Day Of Procedure
Isolation - Contact - Multidrug Resistant
Organism - Panel
Isolation - Contact - Multidrug Resistant
Organism (MDR)
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart CONTINUOUS, Routine, Pre-Op Day Of
Procedure
Isolation - Contact - Extensively Resistant
Organism (XDR) - Panel
Isolation - Contact - Extensively Drug Resistant
Organism (XDR)
CONTINUOUS, Pre-Op Day Of Procedure
Isolation Cart CONTINUOUS, Routine, Pre-Op Day Of
Procedure
Non-Categorized Patient Care Orders
Page 4 of 10
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:07:45 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

Vital Signs ONCE For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Pre-Op Day Of Procedure
Diet - NPO Except Medications EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Pre-Op Day Of Procedure
Have Patient Change Into Hospital Gown (No
Underwear)
ONCE For 1 Occurrences, Pre-Op Day Of Procedure
Complete Pre-Procedure Checklist in Health
Link
ONCE For 1 Occurrences, Pre-Op Day Of Procedure
Instruct Patient that Radiation Oncology
Physicians Will Meet With Patient in Treatment
Area Before Procedure to Address Any Last
Minute Questions/Concerns
ONCE, Pre-Op Day Of Procedure
Instruct Family to Wait in CIU Patient Room ONCE, Pre-Op Day Of Procedure
Contingency Parameters
Notify Provider Provider to Notify: Other (Comment)
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:
If Radiation Oncology resident *** unavailable, page
attending physician *** first, or Radiation Oncology
triage nurse *** at 8795 (note not available before
7AM), Pre-Op Day Of Procedure
Radiation Oncology
Medications - Anti-infectives
cefoxitin (MEFOXIN) intraVENOUS - NOTE:
Order for patients less than 80 Kg
1 g, Intravenous, ON CALL For 1 Doses, Radiation
Oncology
cefoxitin (MEFOXIN) intraVENOUS - NOTE:
Order for patients 80 Kg or greater
2 g, Intravenous, ON CALL For 1 Doses, Radiation
Oncology
Page 5 of 10
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:07:45 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

ciprofloxacin injection - NOTE: Order for patients
allergic to cephalosporins/penicillin
400 mg, Intravenous, ON CALL For 1 Doses,
Radiation Oncology
clindamycin (CLEOCIN) intraVENOUS - NOTE:
Order for patients allergic to
cephalosporins/penicillin and ciprofloxacin
900 mg, Intravenous, ON CALL For 1 Doses,
Radiation Oncology
Medications
dexamethasone (DECADRON) intraVENOUS 10 mg, Intravenous, ONCE For 1 Doses, Radiation
Oncology
PACU
Non-Categorized
Notify Care Initiation Unit (CIU) When Patient is
Ready for Phase II Recovery and Provider
Report
ONCE For 1 Occurrences, PACU
Prostate Seeds Are Radioactive; However,
Patient's Pelvis Shields Healthcare Workers
From Radioactivty
CONTINUOUS, PACU
Apply Ice Pack to Perineum and Assess
Perineum for Bleeding/Hematoma
CONTINUOUS, PACU
Save Urine, But Flush Stool CONTINUOUS, PACU
PostOp/Phase II
Vital Signs
Vital Signs SEE COMMENTS, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
PRN
Post-Op/Phase II
Activity
Activity CONTINUOUS, Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Post-Op/Phase II
Nutrition
Page 6 of 10
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:07:45 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

General Diet EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Post-Op/Phase II
Anti-Emetics
ondansetron (ZOFRAN) tab 4 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting, Post-Op/Phase II
ondansetron (ZOFRAN) injection 4 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
When unable to tolerate orally
Post-Op/Phase II
Analgesics
acetaMINOPHEN (TYLENOL) tab RANGE 325-650 mg, Oral, EVERY 4 HOURS PRN,
pain/fever, mild/moderate pain, multi-modal analgesic
therapy, or fever, Post-Op/Phase II
hydrocodone-acetaMINOPHEN (NORCO) 5-325
MG per tab RANGE
1-2 tab, Oral, EVERY 6 HOURS PRN, pain, severe
pain, Post-Op/Phase II
Contingency Parameters
Notify Provider Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 80
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 35.5
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 60
If respiratory rate >: 30
If respiratory rate <: 8
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL): 30 mL/hour for 2 hours
Other: If pain not controlled with ordered analgesics
or interventions,If patient is nauseous,If patient
passes large blood clots,If patient not able to urinate
Post-Op/Phase II
Non-Categorized
Discharge Patient Disposition:
Discharge Date: 9/26/2016
Call Radiation Physicist (Pager 3084 or 2073)
When Patient is Ready to be Discharged from
Inpatient Unit
ONCE For 1 Occurrences, Post-Op/Phase II
Radiation Oncology Follow Up
Diagnostic Tests and Imaging
Page 7 of 10
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:07:45 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

Radiation Oncology Treatment CT/Sim without
Contrast
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy: No
Last patient height? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date
in comment):
Diagnosis: Prostate Seed Implantation
Parameters to Include: Pelvis
CT Slice Thickness:
Treatment Same Day as CT/Sim: No
Page MD for Setup: Both
Physics Present at CT/SIM:
Patient Position - Body:
Patient Position - Arms:
Patient Position - Head:
Patient Position - Other:
Positioning Devices - Mask:
Positioning Devices - Mouth Piece:
Positioning Devices - Chest:
Positioning Devices - Body:
Marking / Immobilization:
Breathing Technique:
Target Site Brain:
Target Site Head and Neck:
Target Site Chest:
Target Site Breast:
Target Site Pelvis:
Target Site Abdomen:
Target Site Other:
Instructions for Patient:
Discharge Orders
Reason for Hospitalization
Why You Were Hospitalized Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, You were hospitalized for ***
Activity
Activity - Resume Normal Activity Upon
Discharge
Routine
Discharge Activity: Other (Comment)
Resume normal activity upon discharge, Phase II
Discharge
Nutrition
Resume Normal Diet as Tolerated Routine
General:
Diet Modifications:
Other Diet Modifications:
Resume normal diet as tolerated
Wound Care
Page 8 of 10
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:07:45 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

Wound Care Routine, May apply cold pack to area under scrotum
2 - 3 times daily for 20 - 30 minutes each time. May
take acetaminophen (TYLENOL) for pain
Medication Instructions
Medication Instructions Routine, Continue to take oral antibioitcs and
tamsulosin (FLOMAX).
Fill phenazopyridine (PYRIDIUM) prescription if
having symptoms.
Contingency Parameters
Contact Radiation Oncology Routine, Call Radiation Oncologist on call at (608)
263-8500 for passing large amounts of pure blood or
large blood clots (more than 1 cup over a 24 hour
period), bowel problems that last more than 1-2 days,
fever, signs of infection or pain not controlled by
prescribed medications.
Diagnosis
Diagnosis - Prostate Neoplasm
Malignant neoplasm of prostate Malignant neoplasm of prostate
Prostate cancer Malignant neoplasm of prostate
Carcinoma in situ of prostate Carcinoma in situ of prostate
Personal history of malignant neoplasm of
prostate
Personal history of malignant neoplasm of
prostate
Family history of malignant neoplasm of
prostate
Family history of malignant neoplasm of
prostate
Benign neoplasm of prostate Benign neoplasm of prostate
Neoplasm of uncertain behavior of prostate Neoplasm of uncertain behavior of prostate
Criteria
Suggestions: UWHOD ORDERSET SUGGESTION RAD ONC[4500004]
Filter: UWIP ORDER SET RESTRICTOR - NOT TSC/MSC[3000407]
Restrict SmartSet:
Settings
Discontinue action:
Deselect sections for
Pended/Held orders:
Pended/Held orders
display:
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Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:07:45 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

Release date: Use System Definitions Setting
Disallow user override:
Page 10 of 10
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:07:45 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org