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/clinical/cckm-tools/content/order-sets/hod/radiation-oncology/name-97784-en.cckm

201712341

page

100

UWHC,UWMF,

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

RAD ONC - Simulation - Adult - Procedure [4592]

RAD ONC - Simulation - Adult - Procedure [4592] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, HOD, Radiation Oncology


RAD ONC - Simulation - Adult - Procedure [4592]
WithOUT IV Contrast
Acuity Simulation [123718]
Acuity Simulation with Pre-Labs [124057]
Radiation Oncology Acuity Simulation
[RADONC0005]
Routine
Diagnosis:
Target Site:
Patient Position:
Is There a Possibility of Pregnancy:
Scheduling Request:
Claustrophobia:
Treatment Fields:
Physics Present at CT/SIM:
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Treatment CT/ Sim without Contrast [123720]
Breast - Left - Treatment CT/Sim with Pre-Labs
[239142]
Radiation Oncology Treatment CT/Sim without
Contrast [RADONC0006]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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: Left Breast
Parameters to Include: Neck - Lungs
Scheduling Request: STANDARD - Within 7 Days
Page MD for Setup:
Physics Present at CT/SIM: No
Patient Position - Body: HFS - Head First Supine
Patient Position - Other: Arms Up
Approximate Number of Fractions:
Target Site: Breast
Contrast: No
Other Directions to CT Therapists:
Instructions for Patient:
Breast: Positioning,Wire Marking,Breathing
Technique
Positioning: Wingboard
Wire Marking: Surgical Incisions
Breathing Technique: Free Breathing,Breath Hold
Treatment Same Day as CT/Sim: No
CT Slice Thickness: 2.0 mm
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Breast - Prone - Treatment CT/Sim with Pre-Labs
[239157]
Page 1 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Radiation Oncology Treatment CT/Sim without
Contrast [RADONC0006]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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: Breast Cancer
Parameters to Include: Neck - Lungs
Scheduling Request: STANDARD - Within 7 Days
Page MD for Setup:
Physics Present at CT/SIM: No
Patient Position - Body: HFP - Head First Prone
Patient Position - Other: Arms Up
Approximate Number of Fractions:
Target Site:
Contrast: No
Other Directions to CT Therapists:
Instructions for Patient:
Target Site: Breast
Breast: Positioning,Wire Marking,Breathing
Technique
Positioning: Prone
Wire Marking: Surgical Incisions
Breathing Technique: Free Breathing
Treatment Same Day as CT/Sim: No
CT Slice Thickness: 2.0 mm
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Breast - Right - Treatment CT/Sim with Pre-Labs
[239689]
Page 2 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Radiation Oncology Treatment CT/Sim without
Contrast [RADONC0006]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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: Right Breast
Parameters to Include: Neck - Lungs
Scheduling Request: STANDARD - Within 7 Days
Page MD for Setup:
Physics Present at CT/SIM: No
Patient Position - Body: HFS - Head First Supine
Patient Position - Other: Arms Up
Approximate Number of Fractions:
Target Site:
Contrast: No
Other Directions to CT Therapists:
Instructions for Patient:
Target Site: Breast
Breast: Positioning,Wire Marking,Breathing
Technique
Positioning: Wingboard
Wire Marking: Surgical Incisions
Breathing Technique: Free Breathing
Treatment Same Day as CT/Sim: No
CT Slice Thickness: 2.0 mm
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
General CNS - Treatment CT/Sim with Pre-Labs
[240649]
Radiation Oncology Treatment CT/Sim without
Contrast [RADONC0006]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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: Null
Parameters to Include: Head
Scheduling Request:
Page MD for Setup:
Physics Present at CT/SIM: No
Patient Position - Body: HFS - Head First Supine
Patient Position - Other: Arms Down
Approximate Number of Fractions:
Target Site: Brain
Treatment Type:
Contrast: No
Other Directions to CT Therapists:
Instructions for Patient:
Treatment Same Day as CT/Sim: No
CT Slice Thickness: 2.0 mm
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Page 3 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

GYN - IMRT - Treatment CT/Sim with Pre-Labs
[239691]
Radiation Oncology Treatment CT/Sim without
Contrast [RADONC0006]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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: Null
Parameters to Include: Abdomen - Mid Femur
Scheduling Request: STANDARD - Within 7 Days
Page MD for Setup:
Physics Present at CT/SIM: No
Patient Position - Body: HFS - Head First Supine
Patient Position - Other: Arms on Chest and Legs
Straight OR Frog Legged
Approximate Number of Fractions:
Target Site:
Contrast: No
Other Directions to CT Therapists: Two scans,
bladder full and empty. Vaginal marker on bladder
empty scan.
Instructions for Patient: Full Bladder
Target Site: Pelvis
Pelvis: Markings,Immobilization
Immobilization: Body Fix without Compression
Markings: Vaginal
Treatment Same Day as CT/Sim: No
CT Slice Thickness: 2.0 mm
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Lung - Regular - Treatment CT/Sim with Pre-
Labs [237966]
Page 4 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Radiation Oncology Treatment CT/Sim without
Contrast [RADONC0006]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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: Lung Cancer
Parameters to Include: Lungs
Scheduling Request:
Page MD for Setup:
Physics Present at CT/SIM: Yes
Patient Position - Body: HFS - Head First Supine
Patient Position - Other: Arms up
Approximate Number of Fractions:
Target Site:
Contrast: No
Other Directions to CT Therapists:
Instructions for Patient:
Target Site: Chest
Chest: 4D,Immobilization
Immobilization: Vac-Lok
Treatment Same Day as CT/Sim: No
CT Slice Thickness: 2.0 mm
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Lung - SBRT - Treatment CT/Sim with Pre-Labs
[237967]
Radiation Oncology Treatment CT/Sim without
Contrast [RADONC0006]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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: Lung Cancer
Parameters to Include: Lungs
Scheduling Request: STANDARD - Within 7 Days
Page MD for Setup:
Physics Present at CT/SIM: Yes
Patient Position - Body: HFS - Head First Supine
Patient Position - Other: Arms up
Approximate Number of Fractions:
Target Site:
Contrast: No
Other Directions to CT Therapists:
Instructions for Patient:
Target Site: Chest
Chest: SBRT,4D,Immobilization,Breathing
Technique
Breathing Technique: 4DCT and if on ViewRay
please add MIBH without compression
Immobilization: Body Fix with Compression
Treatment Same Day as CT/Sim: No
CT Slice Thickness: 2.0 mm
Page 5 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Palliative - Spine - Treatment CT/Sim with Pre-
Labs [239692]
Radiation Oncology Treatment CT/Sim without
Contrast [RADONC0006]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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: Null
Parameters to Include: Spine
Scheduling Request:
Page MD for Setup:
Physics Present at CT/SIM:
Patient Position - Body:
Patient Position - Other:
Approximate Number of Fractions:
Target Site:
Contrast:
Other Directions to CT Therapists:
Instructions for Patient:
Target Site:
Treatment Same Day as CT/Sim:
CT Slice Thickness:
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Standard Treatment CT/Sim with Pre-Labs
[239156]
Radiation Oncology Treatment CT/Sim without
Contrast [RADONC0006]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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:
Parameters to Include:
Scheduling Request:
Page MD for Setup:
Physics Present at CT/SIM:
Patient Position - Body:
Patient Position - Other:
Approximate Number of Fractions:
Target Site:
Contrast:
Other Directions to CT Therapists:
Instructions for Patient:
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
WITH IV Contrast
Page 6 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

patients with diabetes For
2.0 mg/dL use Renal Insufficiency group-if creatinine 1.4 -
if creatinine greater than 2.0 mg/dL, contrast is not recommended -
diabetic patients-nonFor
3.0 mg/dLuse Renal Insufficiency group-if creatinine 1.8 -
if creatinine greater than 3.0 mg/dL, contrast is not recommended -
3.0 mg/dL-diabetic and creatinine is 1.8 -non-
Premedications - For Patients with Seafood Allergy [132699]
methylprednisolone sodium succ. (SOLU-
MEDROL) intraVENOUS [800058]
32 mg, Intravenous, ONCE For 1 Doses
Administer at 12 prior to contrast injection
methylprednisolone sodium succ. (SOLU-
MEDROL) intraVENOUS [800058]
32 mg, Intravenous, ONCE For 1 Doses
Administer 2 hours prior to contrast injection
diphenhydramine (BENADRYL) cap [36791] 50 mg, Oral, ONCE For 1 Doses
Administer 1 hour prior to contrast injection
diphenhydramine (BENADRYL) injection [800106] 50 mg, Intravenous, ONCE For 1 Doses
Administer 15-20 minutes prior to contrast injection
Radiation Oncology
IV Contrast - Standard - NOTE: If ordering from this group select BOTH [123721]
Treatment CT/ Sim with Pre-Labs [124055]
Radiation Oncology Treatment CT/Sim with
IV/Bladder Contrast [RADONC0004]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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:
Parameters to Include:
Scheduling Request:
Page MD for Setup:
Physics Present at CT/SIM:
Patient Position - Body:
Patient Position - Other:
Approximate Number of Fractions:
Target Site:
Contrast:
Other Directions to CT Therapists:
Instructions for Patient:
CREATININE [CRET] Status: Standing, Expires:1/8/19 MANUAL,Count:1,
Normal, Routine
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Contrast and Other Orders [241976]
with IV/ Bladder Contrast:Patients
Inpatients: Creatinine is required within 7 days
Outpatients: Creatinine is required within 30 days
NPO for Procedure - Hold Diet [DIE0007] CONTINUOUS NPO, Starting today For 1 Days,
Routine
NPO For Which Procedure? Radiation Oncology
Modifiers: NPO EXCEPT MEDICATIONS
Radiation Oncology
Page 7 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Vital Signs [NURMON0013] ONCE, Starting today For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Radiation Oncology
iohexol (OMNIPAQUE) 300 MG/ML injection
[156029]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
iohexol (OMNIPAQUE) 240 MG/ML injection
[156030]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
iodixanol (VISIPAQUE 320) 320 MG/ML injection
[53460]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
Note: Hold metformin-containing medications the
AM of procedure and for 48 hours post-procedure
[950018]
EVERY 8 HOURS For 48 Hours, Radiation
Oncology
lidocaine (LMX) 4% topical dressing kit [66882] Topical, 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
Radiation Oncology
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.
Radiation Oncology
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Radiation Oncology
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care, Flush per VAD
guidelines
Flush per VAD guidelines
Radiation Oncology
heparin lock flush 10 UNIT/ML injection [75031] 1-150 units, Flush, PRN, flush/line care
Flush per VAD Guidelines
Radiation Oncology
heparin lock flush 100 UNIT/ML injection [64978] 500 units, Flush, PRN, flush/line care
Implanted port use ONLY to be used when de-
accessing port. Flush per VAD guidelines
Radiation Oncology
IV Contrast - Standard - Renal Insufficiency - NOTE: If ordering from this group select BOTH [123763]
Treatment CT/ Sim with Pre-Labs [124055]
Page 8 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Radiation Oncology Treatment CT/Sim with
IV/Bladder Contrast [RADONC0004]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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:
Parameters to Include:
Scheduling Request:
Page MD for Setup:
Physics Present at CT/SIM:
Patient Position - Body:
Patient Position - Other:
Approximate Number of Fractions:
Target Site:
Contrast:
Other Directions to CT Therapists:
Instructions for Patient:
CREATININE [CRET] Status: Standing, Expires:1/8/19 MANUAL,Count:1,
Normal, Routine
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Contrast and Other Orders [241985]
with IV/ Bladder Contrast:Patients
Inpatients: Creatinine is required within 7 days
Outpatients: Creatinine is required within 30 days
NPO for Procedure - Hold Diet [DIE0007] CONTINUOUS NPO, Starting today For 1 Days,
Routine
NPO For Which Procedure? Radiation Oncology
Modifiers: NPO EXCEPT MEDICATIONS
Radiation Oncology
Vital Signs [NURMON0013] ONCE, Starting today For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Radiation Oncology
iohexol (OMNIPAQUE) 300 MG/ML injection
[156029]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
iohexol (OMNIPAQUE) 240 MG/ML injection
[156030]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
iodixanol (VISIPAQUE 320) 320 MG/ML injection
[53460]
100 mL, Intravenous, ONCE For 1 Doses
Give with 30 mL bacteriostatic water via power
injector
Radiation Oncology
Note: Hold metformin-containing medications the
AM of procedure and for 48 hours post-procedure
[950018]
EVERY 8 HOURS For 48 Hours, Radiation
Oncology
Page 9 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

lidocaine (LMX) 4% topical dressing kit [66882] Topical, 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
Radiation Oncology
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.
Radiation Oncology
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Radiation Oncology
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care, Flush per VAD
guidelines
Flush per VAD guidelines
Radiation Oncology
heparin lock flush 10 UNIT/ML injection [75031] 1-150 units, Flush, PRN, flush/line care
Flush per VAD Guidelines
Radiation Oncology
heparin lock flush 100 UNIT/ML injection [64978] 500 units, Flush, PRN, flush/line care
Implanted port use ONLY to be used when de-
accessing port. Flush per VAD guidelines
Radiation Oncology
IV Contrast - GYN - IMRT - NOTE; If ordering from this group select BOTH [225475]
Treatment CT/ Sim with Pre-Labs [226405]
Page 10 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Radiation Oncology Treatment CT/Sim with
IV/Bladder Contrast [RADONC0004]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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: Null
Parameters to Include: Abdomen - Mid Femur
Scheduling Request:
Page MD for Setup:
Physics Present at CT/SIM: No
Patient Position - Body: HFS - Head First Supine
Patient Position - Other: Arms down
Approximate Number of Fractions:
Target Site: Abdomen,Pelvis
Contrast: IV Contrast
Other Directions to CT Therapists: Two scans,
bladder full and empty. Vaginal marker on bladder
empty scan. IV contrast on bladder full scan.
Instructions for Patient: Full Bladder
Abdomen:
Pelvis: Bladder (Scans)
Bladder (Scans): Empty
Last creatinine value? (will auto pull in date and
value in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Known Allergies:
Diabetes:
Previous Scan with Contrast:
CREATININE [CRET] Status: Standing, Expires:1/8/19 MANUAL,Count:1,
Normal, Routine
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Contrast and Other Orders [241988]
with IV/ Bladder Contrast:Patients
Inpatients: Creatinine is required within 7 days
Outpatients: Creatinine is required within 30 days
NPO for Procedure - Hold Diet [DIE0007] CONTINUOUS NPO, Starting today For 1 Days,
Routine
NPO For Which Procedure? Radiation Oncology
Modifiers: NPO EXCEPT MEDICATIONS
Radiation Oncology
Vital Signs [NURMON0013] ONCE, Starting today For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Radiation Oncology
iohexol (OMNIPAQUE) 300 MG/ML injection
[156029]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
Page 11 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

iohexol (OMNIPAQUE) 240 MG/ML injection
[156030]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
iodixanol (VISIPAQUE 320) 320 MG/ML injection
[53460]
100 mL, Intravenous, ONCE For 1 Doses
Give as wide-open IV drip
Radiation Oncology
Note: Hold metformin-containing medications the
AM of procedure and for 48 hours post-procedure
[950018]
EVERY 8 HOURS For 48 Hours, Radiation
Oncology
lidocaine (LMX) 4% topical dressing kit [66882] Topical, 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
Radiation Oncology
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.
Radiation Oncology
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Radiation Oncology
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care, Flush per VAD
guidelines
Flush per VAD guidelines
Radiation Oncology
heparin lock flush 10 UNIT/ML injection [75031] 1-150 units, Flush, PRN, flush/line care
Flush per VAD Guidelines
Radiation Oncology
heparin lock flush 100 UNIT/ML injection [64978] 500 units, Flush, PRN, flush/line care
Implanted port use ONLY to be used when de-
accessing port. Flush per VAD guidelines
Radiation Oncology
IV Contrast - Head or Stereotactic CT - NOTE: If ordering from this group select BOTH [123755]
Treatment CT/ Sim with Pre-Labs [124055]
Page 12 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Radiation Oncology Treatment CT/Sim with
IV/Bladder Contrast [RADONC0004]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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:
Parameters to Include: Head
Scheduling Request:
Page MD for Setup:
Physics Present at CT/SIM: Yes
Patient Position - Body:
Patient Position - Other: Arms Down
Approximate Number of Fractions:
Target Site: Brain
Contrast: IV Contrast
Other Directions to CT Therapists:
Instructions for Patient:
Brain: Mask
Mask: Face
Last creatinine value? (will auto pull in date and
value in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Known Allergies:
Diabetes:
Previous Scan with Contrast:
CREATININE [CRET] Status: Standing, Expires:1/8/19 MANUAL,Count:1,
Normal, Routine
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Contrast and Other Orders [241979]
with IV/ Bladder Contrast:Patients
Inpatients: Creatinine is required within 7 days
Outpatients: Creatinine is required within 30 days
NPO for Procedure - Hold Diet [DIE0007] CONTINUOUS NPO, Starting today For 1 Days,
Routine
NPO For Which Procedure? Radiation Oncology
Modifiers: NPO EXCEPT MEDICATIONS
Radiation Oncology
Vital Signs [NURMON0013] ONCE, Starting today For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Radiation Oncology
iohexol (OMNIPAQUE) 300 MG/ML injection
[156029]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
iohexol (OMNIPAQUE) 240 MG/ML injection
[156030]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
iodixanol (VISIPAQUE 320) 320 MG/ML injection
[53460]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
Page 13 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Note: Hold metformin-containing medications the
AM of procedure and for 48 hours post-procedure
[950018]
EVERY 8 HOURS For 48 Hours, Radiation
Oncology
lidocaine (LMX) 4% topical dressing kit [66882] Topical, 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
Radiation Oncology
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.
Radiation Oncology
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Radiation Oncology
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care, Flush per VAD
guidelines
Flush per VAD guidelines
Radiation Oncology
heparin lock flush 10 UNIT/ML injection [75031] 1-150 units, Flush, PRN, flush/line care
Flush per VAD Guidelines
Radiation Oncology
heparin lock flush 100 UNIT/ML injection [64978] 500 units, Flush, PRN, flush/line care
Implanted port use ONLY to be used when de-
accessing port. Flush per VAD guidelines
Radiation Oncology
IV Contrast - Head or Stereotactic CT - Renal Insufficiency - NOTE: If ordering from this group select
BOTH [123759]
Treatment CT/ Sim with Pre-Labs [124055]
Page 14 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Radiation Oncology Treatment CT/Sim with
IV/Bladder Contrast [RADONC0004]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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:
Parameters to Include: Head
Scheduling Request:
Page MD for Setup:
Physics Present at CT/SIM: Yes
Patient Position - Body:
Patient Position - Other: Arms Down
Approximate Number of Fractions:
Target Site: Brain
Contrast: IV Contrast
Other Directions to CT Therapists:
Instructions for Patient:
Brain: Mask
Mask: Face
Last creatinine value? (will auto pull in date and
value in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Known Allergies:
Diabetes:
Previous Scan with Contrast:
CREATININE [CRET] Status: Standing, Expires:1/8/19 MANUAL,Count:1,
Normal, Routine
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Contrast and Other Orders [241982]
with IV/ Bladder Contrast:Patients
Inpatients: Creatinine is required within 7 days
Outpatients: Creatinine is required within 30 days
NPO for Procedure - Hold Diet [DIE0007] CONTINUOUS NPO, Starting today For 1 Days,
Routine
NPO For Which Procedure? Radiation Oncology
Modifiers: NPO EXCEPT MEDICATIONS
Radiation Oncology
Vital Signs [NURMON0013] ONCE, Starting today For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Radiation Oncology
iohexol (OMNIPAQUE) 300 MG/ML injection
[156029]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
iohexol (OMNIPAQUE) 240 MG/ML injection
[156030]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
Page 15 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

iodixanol (VISIPAQUE 320) 320 MG/ML injection
[53460]
100 mL, Intravenous, ONCE For 1 Doses
Give as wide-open IV drip
Radiation Oncology
Note: Hold metformin-containing medications the
AM of procedure and for 48 hours post-procedure
[950018]
EVERY 8 HOURS For 48 Hours, Radiation
Oncology
lidocaine (LMX) 4% topical dressing kit [66882] Topical, 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
Radiation Oncology
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.
Radiation Oncology
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Radiation Oncology
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care, Flush per VAD
guidelines
Flush per VAD guidelines
Radiation Oncology
heparin lock flush 10 UNIT/ML injection [75031] 1-150 units, Flush, PRN, flush/line care
Flush per VAD Guidelines
Radiation Oncology
heparin lock flush 100 UNIT/ML injection [64978] 500 units, Flush, PRN, flush/line care
Implanted port use ONLY to be used when de-
accessing port. Flush per VAD guidelines
Radiation Oncology
IV Contrast - Head and Neck - NOTE: If ordering from this group select BOTH [210201]
Treatment CT/ Sim with Pre-Labs [124055]
Page 16 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Radiation Oncology Treatment CT/Sim with
IV/Bladder Contrast [RADONC0004]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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: Null
Parameters to Include: Head and Neck
Scheduling Request:
Page MD for Setup:
Physics Present at CT/SIM: Yes
Patient Position - Body: HFS - Head First Supine
Patient Position - Other: Arms Down
Approximate Number of Fractions:
Target Site: Head and Neck
Contrast: IV Contrast
Other Directions to CT Therapists:
Instructions for Patient:
Head & Neck: Mask
Mask: Head and Shoulder
Last creatinine value? (will auto pull in date and
value in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Known Allergies:
Diabetes:
Previous Scan with Contrast:
Treatment Same Day as CT/Sim: No
CT Slice Thickness: 2.0 mm
CREATININE [CRET] Status: Standing, Expires:1/8/19 MANUAL,Count:1,
Normal, Routine
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Contrast and Other Orders [122925]
with IV/ Bladder Contrast:Patients
Inpatients: Creatinine is required within 7 days
Outpatients: Creatinine is required within 30 days
NPO for Procedure - Hold Diet [DIE0007] CONTINUOUS NPO, Starting today For 1 Days,
Routine
NPO For Which Procedure? Radiation Oncology
Modifiers: NPO EXCEPT MEDICATIONS
Radiation Oncology
Vital Signs [NURMON0013] ONCE, Starting today For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Radiation Oncology
iohexol (OMNIPAQUE) 300 MG/ML injection
[156029]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
iohexol (OMNIPAQUE) 240 MG/ML injection
[156030]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
Page 17 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

iodixanol (VISIPAQUE 320) 320 MG/ML injection
[53460]
Intravenous, ONCE For 1 Doses, Radiation
Oncology
Note: Hold metformin-containing medications the
AM of procedure and for 48 hours post-procedure
[950018]
EVERY 8 HOURS For 48 Hours, Radiation
Oncology
lidocaine (LMX) 4% topical dressing kit [66882] Topical, 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
Radiation Oncology
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.
Radiation Oncology
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Radiation Oncology
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care, Flush per VAD
guidelines
Flush per VAD guidelines
Radiation Oncology
heparin lock flush 10 UNIT/ML injection [75031] 1-150 units, Flush, PRN, flush/line care
Flush per VAD Guidelines
Radiation Oncology
heparin lock flush 100 UNIT/ML injection [64978] 500 units, Flush, PRN, flush/line care
Implanted port use ONLY to be used when de-
accessing port. Flush per VAD guidelines
Radiation Oncology
Other Contrast
GYN - 4 Field Bladder Contrast - NOTE: If ordering from this group select BOTH [123722]
Gyn - 4 Field - Treatment CT/ Sim with Pre-Labs
[124087]
Page 18 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Radiation Oncology Treatment CT/Sim with
IV/Bladder Contrast [RADONC0004]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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: Null
Parameters to Include: Abdomen and Pelvis
Treatment Same Day as CT/Sim: No
Page MD for Setup:
Physics Present at CT/SIM: No
Patient Position - Body: HFS - Head First Supine
Patient Position - Other: Arms on Chest and Legs
Straight OR Frog Legged
CT Slice Thickness: 2.0 mm
Target Site: Abdomen,Pelvis
Abdomen:
Pelvis: Bladder (Scans)
Bladder (Scans): Full
Contrast: Bladder Contrast
Last creatinine value? (will auto pull in date and
value in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Known Allergies:
Diabetes:
Previous Scan with Contrast:
Other Directions to CT Therapists:
Instructions for Patient: Full Bladder
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Contrast and Other Orders [122926]
with IV/ Bladder Contrast:Patients
Inpatients: Creatinine is required within 7 days
Outpatients: Creatinine is required within 30 days
iothalmate meglumide in sodium chloride 0.9%
(CONRAY) intravesical soln [791520]
Intravesical, ONCE For 1 Doses
Mix 3 mL iothalamate 60% with 100 mL sodium
chloride 0.9% and give intrasvesically
Radiation Oncology
lidocaine (STERILE UROJECT) 2 % gel [785049] Urethral, ONCE For 1 Doses, Radiation Oncology
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today For Until specified,
Routine, To discontinue this order, enter a new order
for "Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes
in the new order.
Type: Indwelling Single Lumen
Indication for Placement: Other (Comment Required)
(Radiation Oncology)
Initiate Urinary Catheter Removal Protocol? (NP/PA
Must Select "No"): Yes
Details: To Dependent Drainage
Does this need to be inserted/placed?
Radiation Oncology
Page 19 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Prostate - Fossa Bladder Contrast - NOTE: If ordering from this group select BOTH [210200]
Prostate - Fossa - Treatment CT/ Sim with Pre-
Labs [124087]
Radiation Oncology Treatment CT/Sim with
IV/Bladder Contrast [RADONC0004]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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 Cancer
Parameters to Include: Abdomen and Pelvis
Treatment Same Day as CT/Sim: No
Page MD for Setup:
Physics Present at CT/SIM: No
Patient Position - Body: HFS - Head First Supine
Patient Position - Other: Arms on Chest
CT Slice Thickness: 2.0 mm
Target Site: Pelvis
Pelvis:
Contrast: Bladder Contrast
Last creatinine value? (will auto pull in date and
value in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Known Allergies:
Diabetes:
Previous Scan with Contrast:
Other Directions to CT Therapists:
Instructions for Patient: Full Bladder
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Contrast and Other Orders [122926]
with IV/ Bladder Contrast:Patients
Inpatients: Creatinine is required within 7 days
Outpatients: Creatinine is required within 30 days
iothalmate meglumide in sodium chloride 0.9%
(CONRAY) intravesical soln [791520]
Intravesical, ONCE For 1 Doses
Mix 3 mL iothalamate 60% with 100 mL sodium
chloride 0.9% and give intrasvesically
Radiation Oncology
lidocaine (STERILE UROJECT) 2 % gel [785049] Urethral, ONCE For 1 Doses, Radiation Oncology
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today For Until specified,
Routine, To discontinue this order, enter a new order
for "Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes
in the new order.
Type: Indwelling Single Lumen
Indication for Placement: Other (Comment Required)
(Radiation Oncology)
Initiate Urinary Catheter Removal Protocol? (NP/PA
Must Select "No"): Yes
Details: To Dependent Drainage
Does this need to be inserted/placed?
Radiation Oncology
Page 20 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Prostate - No Nodes Bladder Contrast - NOTE: If ordering from this group select BOTH [210198]
Prostate - No Nodes - Treatment CT/ Sim with
Pre-Labs [124087]
Radiation Oncology Treatment CT/Sim with
IV/Bladder Contrast [RADONC0004]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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 Cancer
Parameters to Include: Pelvis
Treatment Same Day as CT/Sim: No
Page MD for Setup:
Physics Present at CT/SIM: No
Patient Position - Body: HFS - Head First Supine
Patient Position - Other: Arms on Chest
CT Slice Thickness: 2.0 mm
Target Site: Pelvis
Pelvis: Rectal Balloon
Contrast: Bladder Contrast
Last creatinine value? (will auto pull in date and
value in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Known Allergies:
Diabetes:
Previous Scan with Contrast:
Other Directions to CT Therapists:
Instructions for Patient: Full Bladder
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Contrast and Other Orders [122926]
with IV/ Bladder Contrast:Patients
Inpatients: Creatinine is required within 7 days
Outpatients: Creatinine is required within 30 days
iothalmate meglumide in sodium chloride 0.9%
(CONRAY) intravesical soln [791520]
Intravesical, ONCE For 1 Doses
Mix 3 mL iothalamate 60% with 100 mL sodium
chloride 0.9% and give intrasvesically
Radiation Oncology
lidocaine (STERILE UROJECT) 2 % gel [785049] Urethral, ONCE For 1 Doses, Radiation Oncology
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today For Until specified,
Routine, To discontinue this order, enter a new order
for "Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes
in the new order.
Type: Indwelling Single Lumen
Indication for Placement: Other (Comment Required)
(Radiation Oncology)
Initiate Urinary Catheter Removal Protocol? (NP/PA
Must Select "No"): Yes
Details: To Dependent Drainage
Does this need to be inserted/placed?
Radiation Oncology
Page 21 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Prostate - Nodes Bladder Contrast - NOTE: If ordering from this group select BOTH [210199]
Prostate - Nodes Bladder Contrast - NOTE: If
ordering from this group select BOTH [124087]
Radiation Oncology Treatment CT/Sim with
IV/Bladder Contrast [RADONC0004]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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 Cancer
Parameters to Include: Abdomen and Pelvis
Treatment Same Day as CT/Sim: No
Page MD for Setup:
Physics Present at CT/SIM: No
Patient Position - Body: HFS - Head First Supine
Patient Position - Other: Arms on Chest
CT Slice Thickness: 2.0 mm
Target Site: Pelvis,Abdomen
Abdomen:
Pelvis: Rectal Balloon
Contrast: Bladder Contrast
Last creatinine value? (will auto pull in date and
value in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Known Allergies:
Diabetes:
Previous Scan with Contrast:
Other Directions to CT Therapists:
Instructions for Patient: Full Bladder
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Contrast and Other Orders [122926]
with IV/ Bladder Contrast:Patients
Inpatients: Creatinine is required within 7 days
Outpatients: Creatinine is required within 30 days
iothalmate meglumide in sodium chloride 0.9%
(CONRAY) intravesical soln [791520]
Intravesical, ONCE For 1 Doses
Mix 3 mL iothalamate 60% with 100 mL sodium
chloride 0.9% and give intrasvesically
Radiation Oncology
lidocaine (STERILE UROJECT) 2 % gel [785049] Urethral, ONCE For 1 Doses, Radiation Oncology
Page 22 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today For Until specified,
Routine, To discontinue this order, enter a new order
for "Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes
in the new order.
Type: Indwelling Single Lumen
Indication for Placement: Other (Comment Required)
(Radiation Oncology)
Initiate Urinary Catheter Removal Protocol? (NP/PA
Must Select "No"): Yes
Details: To Dependent Drainage
Does this need to be inserted/placed?
Radiation Oncology
Swallow Contrast - NOTE: If ordering from this group select BOTH [123726]
Treatment CT/ Sim with Pre-Labs [124056]
Radiation Oncology Treatment CT/Sim with
Contrast (Non-IV) [RADONC0011]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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:
Parameters to Include:
Scheduling Request:
Page MD for Setup:
Physics Present at CT/SIM:
Patient Position - Body:
Patient Position - Other:
Approximate Number of Fractions:
Target Site:
Contrast:
Other Directions to CT Therapists:
Instructions for Patient:
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
barium sulfate (E-Z-PASTE) 60% esophageal
cream RADIOLOGY ONLY [791511]
30 mL, Oral, ONCE For 1 Doses, Radiation Oncology
Bowel Contrast - NOTE: If ordering from this group select BOTH [123727]
Treatment CT/ Sim with Pre-Labs [124056]
Page 23 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Radiation Oncology Treatment CT/Sim with
Contrast (Non-IV) [RADONC0011]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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:
Parameters to Include:
Scheduling Request:
Page MD for Setup:
Physics Present at CT/SIM:
Patient Position - Body:
Patient Position - Other:
Approximate Number of Fractions:
Target Site:
Contrast:
Other Directions to CT Therapists:
Instructions for Patient:
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Stomach Contrast - NOTE: If ordering from this group select BOTH [123728]
Treatment CT/ Sim with Pre-Labs [124056]
Radiation Oncology Treatment CT/Sim with
Contrast (Non-IV) [RADONC0011]
Routine
Consent obtained from patient?
Claustrophobia:
Is There a Possibility of Pregnancy:
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:
Parameters to Include:
Scheduling Request:
Page MD for Setup:
Physics Present at CT/SIM:
Patient Position - Body:
Patient Position - Other:
Approximate Number of Fractions:
Target Site:
Contrast:
Other Directions to CT Therapists:
Instructions for Patient:
HCG, QUALITATIVE, URINE [UPREG] Status: Standing, Expires:4/8/18 MANUAL,Count:1,
Normal, Routine
Page 24 of 24
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:33:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org