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OP - Head and Neck Cancer - Adult - Clinic [4833]

OP - Head and Neck Cancer - Adult - Clinic [4833] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, HOD, Radiation Oncology


SmartSet: OP - HEAD AND NECK CANCER - ADULT - CLINIC (ID:4833)
General Information
Display name: OP - Head and Neck Cancer - Adult - Clinic
Type: General
Merge priority:
Version comment:
Content source:
Synonyms: 1. .ONC
2. .RADONC
SmartSet notes:
Description:
Web information: Title URL
1.
Questionnaire:
Configuration
Patient Care Orders
TUBE PLACEMENT
Page 1 of 4
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:10:10 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

TUBE PLACEMENT, GASTROSTOMY ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
Allergies to IV contrast or iodine?
Is patient on anticoagulation therapy? If yes, specify
coagulation disorder and current medications in
comments box at bottom.
Last creatinine value? (will auto pull in date and value
in comment):
Last patient weight? (will auto pull in value and date
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Transport Method: Floor Determined/Entered
Diagnostic Tests and Imaging
DIAGNOSTIC TESTS AND IMAGING
PET CT SKULL BASE TO THIGH ONCE-RAD NEXT AVAILABLE, Routine
Relevant recent/past history?
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Evaluate for Distant Metastasis
Is patient pregnant or breastfeeding?
If evaluating pulmonary nodules, estimated size of
nodules?
Date of last chemotherapy?
Date of last radiation therapy?
Date of most recent surgery?
Is patient diabetic?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
For Scheduling purposes, is the patient
claustrophobic or require any form of sedation? Note:
ordering provider is responsible for prescribing oral
anxiolytic or ordering sedation services.
Does the patient have prior PET scans? If yes,
specify where & when in the comment box at bottom.
Last patient height? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date
in comment):
Transport Method: Floor Determined/Entered
Page 2 of 4
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:10:10 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 with
Contrast (Non-IV)
ONCE, 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:
Treatment Same Day as CT/Sim:
Page MD for Setup:
Physics Present at CT/SIM:
Patient Position - Body:
Patient Position - Other:
CT Slice Thickness:
Target Site:
Contrast:
Other Directions to CT Therapists:
Instructions for Patient:
Radiation Oncology Treatment CT/Sim without
Contrast
ONCE, 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:
Treatment Same Day as CT/Sim:
Page MD for Setup:
Physics Present at CT/SIM:
Patient Position - Body:
Patient Position - Other:
CT Slice Thickness:
Target Site:
Contrast:
Other Directions to CT Therapists:
Instructions for Patient:
Consults
CONSULTS
CONSULT TO SOCIAL SERVICES ONCE For 1 Occurrences, Routine
CONSULT TO OTOLARYNGOLOGY ONCE For 1 Occurrences, Routine, Consult for
Swallowing Evaluation
CONSULT TO NUTRITION ONCE For 1 Occurrences, Routine
CONSULT TO ONCOLOGY ONCE For 1 Occurrences, Routine
CONSULT TO DENTAL SERVICES ONCE For 1 Occurrences, STAT
Communication Order
Page 3 of 4
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:10:10 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org

COMMUNICATION ORDER
Patient Discharge Communication For Quit Smoking information please call the
Wisconsin Tobacco Quit Line 1-800-784-8669.
Criteria
Suggestions: UWHOD ORDERSET SUGGESTION RAD ONC[4500004]
Filter: UWIP ORDER SET RESTRICTOR - IP AND ADULT - NOT IP DC[3000403]
Restrict SmartSet:
Settings
Discontinue action:
Deselect sections for
Pended/Held orders:
Pended/Held orders
display:
Release date: Use System Definitions Setting
Disallow user override:
Page 4 of 4
Printed by STRAKA, KEVIN F [KFS1] at 9/26/2016 1:10:10 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2016CCKM@uwhealth.org