/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/cardiologyct-surgery/,

/clinical/cckm-tools/content/order-sets/inpatient/cardiologyct-surgery/name-98413-en.cckm

201707209

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Cardiology/CT Surgery

IP – Pacemaker/Defibrillator Implant – Adult – Preprocedure [899]

IP – Pacemaker/Defibrillator Implant – Adult – Preprocedure [899] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Cardiology/CT Surgery


IP - Pacemaker/Defibrillator Implant - Adult - Preoperative [899]
Admission Status
Level of Care (Single Response) [187516]
*An admit patient order has already been written, but the level of care at which the patient
should be placed still needs to be identified.
Place Patient on General Care [ADT0018] 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 (IMC)
[ADT0018]
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 [ADT0018] Intensive Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Admit to Inpatient (Single Response) [188296]
Admit To Inpatient [ADT0001] 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:
Post-Op/Phase II
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admission Status [88521]
Page 1 of 8
Printed by LIND, JANNA S [JSL237] at 7/24/2017 8:52:03 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: CARDIOVASCULAR
ELECTROPHYSIOLOGY
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:
Anticipated Discharge Date:
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service: CARDIOVASCULAR
ELECTROPHYSIOLOGY
Post-Op/Phase II
Admission Status (Single Response) [146780]
Admit To Inpatient Status [ADT0001] 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:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Patient Care Orders
Heart And Vascular Care Procedure - EP [115144]
Heart And Vascular Care Procedure - EP
[CARD0007]
ONCE For 1 Occurrences, Routine, Cardioversion
may need to be delayed or done with TEE guidance if
atrial arrrhymia duration greater than 48 hours and not
on documented anticoagulation for the last 3 weeks.
Please call cath/charge phone to coordinate
procedure 513-8562.
Special Procedures:
Reason for EP Procedure:
Assess patient for Cardiovascular Lab Ankle Brachial
Index? Yes
Vital Signs [9639]
Page 2 of 8
Printed by LIND, JANNA S [JSL237] at 7/24/2017 8:52:03 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Nutrition [9640]
NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
NPO for Procedure - Hold Diet for 18 Hours
[DIE0007]
EFFECTIVE MIDNIGHT, Starting tomorrow at 12:01
AM, Routine
NPO For Which Procedure?
Modifiers: NPO EXCEPT MEDICATIONS
Surgical Site Care [144906]
Pre-incisional Site Care [NURCOM0022] ONCE, Starting today For 1 Occurrences, On day of
procedure, clip hair from shoulder to shoulder, above
the clavicle line and down to nipple area.
Apply chlorhexidine gluconate to the patient's upper
back, neck, under arms, right and left side of chest.
As soon as prepping has begun, do not apply lotions,
moisturizers, deodorant or cosmetics. Put a clean
gown on the patient. Do not place electrode pad for
telemetry on left chest.
Intake and Output [9641]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine
Non-Categorized Patient Care Orders [99562]
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?
Contingency Parameters [144907]
Page 3 of 8
Printed by LIND, JANNA S [JSL237] at 7/24/2017 8:52:03 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
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): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Intravenous Therapy
IV Fluids [12829]
sodium chloride 0.9 % infusion - LEFT arm
[64367]
at 20 mL/hr, Intravenous, ON CALL For 1 Doses
Begin infusion in LEFT arm when Electrophysiology
Lab calls for the patient.
Cardiac Cath/EP
sodium chloride 0.9 % infusion - RIGHT arm
[64367]
at 20 mL/hr, Intravenous, ON CALL For 1 Doses
Begin infusion in RIGHT arm when Electrophysiology
Lab calls for the patient.
Cardiac Cath/EP
sodium chloride 0.9 % infusion - LEFT arm
[64367]
at 50 mL/hr, Intravenous, CONTINUOUS For 10
Hours
Begin infusion in LEFT arm at midnight on day of
procedure while patient is NPO.
Cardiac Cath/EP
sodium chloride 0.9% infusion - RIGHT arm
[64367]
at 50 mL/hr, Intravenous, CONTINUOUS For 10
Hours
Begin infusion in RIGHT arm at midnight on day of
procedure while patient is NPO.
Cardiac Cath/EP
Surgical Prophylaxis
First Line (Single Response) [186545]
cefuroxime (ZINACEF) intraVENOUS - Patient
who is 40-160 kg [800030]
1.5 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
cefuroxime (ZINACEF) intraVENOUS - Patient
who is 160 kg and greater [800030]
3 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
MRSA/Documented History of MRSA (Single Response) [186546]
Patients who are 40-160 kg [228053]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses,
Cardiac Cath/EP
Patients who are 160 kg and greater [228056]
cefuroxime (ZINACEF) intraVENOUS [800030] 3 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses,
Cardiac Cath/EP
Immediate/Severe Reactions to Pencillin or Known Cephalosporin Allergies [186553]
Page 4 of 8
Printed by LIND, JANNA S [JSL237] at 7/24/2017 8:52:03 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses,
Cardiac Cath/EP
Medications - Preoperative
Anti-infectives - Irrigations [12830]
tobramycin 300 mg in sodium chloride 0.9 %
1,000 mL POUR bottle [700535]
Irrigation, ON CALL Starting today For 1 Doses,
Cardiac Cath/EP
Non-categorized [144851]
chlorhexidine gluconate (HIBICLENS) 4 % topical
soln [64730]
Topical, PRN, pre-surgical prep, Cardiac Cath/EP
Laboratory
Labs [9642]
HCG, QUALITATIVE, URINE [UPREG] ONCE, 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?
Draw if patient is female of child bearing age (age 12
or with onset of menses to 55 inclusive).
CBC WITH DIFFERENTIAL [CBC] NEXT DRAW, 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?
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT DRAW, 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?
ELECTROLYTES [LYTE] NEXT DRAW, 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?
MAGNESIUM [MAG] NEXT DRAW, 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?
BUN [BUN] NEXT DRAW, 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?
CREATININE [CRET] NEXT DRAW, 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?
GLUCOSE [GLU] NEXT DRAW, 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?
Page 5 of 8
Printed by LIND, JANNA S [JSL237] at 7/24/2017 8:52:03 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

PROTHROMBIN TIME/INR [PT] NEXT DRAW, 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?
B-TYPE NATRIURETIC PEPTIDE [XBNP] NEXT DRAW, 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?
Conditional Labs [144908]
GLUCOSE [GLU] CONDITIONAL - RN COLLECT, Starting today For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if blood glucose
is less than 40 mg/dL or greater than 400 mg/dL.
Draw if blood glucose is less than 40 mg/dL or greater
than 400 mg/dL.
Blood Bank
Tests [100542]
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.
Blood Products [12026]
Red Blood Cells (Adult) [BLB0006] 1 UNIT, Starting today For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call 263-
8367):
Consent Status:
Page 6 of 8
Printed by LIND, JANNA S [JSL237] at 7/24/2017 8:52:03 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Plasma (Adult) [BLB0003] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Platelets (Adult) [BLB0004] 1 SINGLE, Starting today For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call 263-
8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Cryoprecipitate (Adult) [BLB0005] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Fibrin Glue, mLs Needed:
Blood Product [12027]
Red Blood Cells (Pediatric) [BLB0013] 1 UNIT, Starting today For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call 263-
8367):
Consent Status:
Page 7 of 8
Printed by LIND, JANNA S [JSL237] at 7/24/2017 8:52:03 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Plasma (Pediatric) [BLB0010] Starting today, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Platelets (Pediatric) [BLB0011] Starting today, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call 263-
8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Cryoprecipitate (Pediatric) [BLB0012] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [9643]
X-RAY CHEST PA & LAT VIEWS [R71020] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Preoperative Device
Implant
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
ECG - 12 Lead [EKG0008] ONCE For 1 Occurrences, Routine
Reason for exam: PRE-OPERATIVE
BestPractice
No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
Page 8 of 8
Printed by LIND, JANNA S [JSL237] at 7/24/2017 8:52:03 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org