*PHYORD* pre-operative physiCian orders - OhioHealth

ADMISSION DATE SURGERY DATE PATIENT NAME LAST FIRST MI
DATE OF BIRTH AGE GENDER HOME PHONE WORK PHONE CELL PHONE/PAGER
M F
DIAGNOSIS iCd-9 Codes INSURANCE PLAN
PROCEDURE/SURGERY
INSURANCE PRE-CERT DEPT. PHONE PRE-CERTIFICATION #/AUTHORIZATION # # PRE-CERTIFIED DAYS SECOND INSURANCE
pt type one: admission day surgery op surgery op in a bed oFF-site: LoCation _______________
instructions: place an “x” in the appropriate boxes and fill in necessary information.
history & physical - marking in this box will result in the completion of the h/p and all required testing per anesthesia protocol & pat physician including cardiac testing if
indicated, but excluding type and screen / Crossmatch if additional testing is required, please mark appropriate box(es) below.
pat physician: name ____________________________________________ sign _____________________________________________ date _____________________
note: If patient has been pregnant or transfused within 3 months of surgery date, the specimen must be redrawn within 3 days of surgery. Otherwise the
specimen is valid for 14 days after the draw.
transFusion / bLood banK orders
type & screen _______________________________
type & Crossmatch pack auto ______/dd _____units
type & Crossmatch packed Cells ________units
order must Come From the surgeon -
not to be ordered by pat.
site
hospitaL
see above
¸
testing must FoLLow
anesthesia protoCoL
history & physiCaL
(within 30 days of surgery)
CardiaC testing
EKG (within 6 months)
Stress Test
Echo Cardiogram
Other:
Lab (within 30 days)
Hgb
Hct
PLT
CBC
PT, INR
PTT
Bleeding Time
K+
Na +
Creatinine
BUN
Glucose
SGOT/ALK PHOS
Other
Other
Pregnancy Test According
to PreOp Protocol
puLm sCreen / FunCtion
date: time:
x-ray proCedures
Chest - AP & LAT (within 6 months)
Other X-Ray
oFF
site
pat
Date of testing _____________________/Time _____________________
oFF site CardiaC testing
Date of testing _______________________________________
Cardiologist ______________________________________Phone_______________
oFF site testing physiCian
Date of testing _______________________________________
Testing Physician __________________________________Phone ______________
Comments and/or orders
(please write clearly)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
supportive diagnosis:
List related diagnoses or ICD-9 codes to support medical necessity of the
tests requested.
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
preoperative orders
NO
YES : please go to page 2 & 3 preoperative orders
pre-op iv:
Lactated ringers at Kvo
if CrF patient, normal saline at Kvo
if diabetic patient, contact anesthesia
surgery Consent Form signed by surgeon and enCLosed
patient to sign the surgery Consent Form on day oF surgery
note: p.a.t. does not schedule the following tests: pFt (pulmonary function
test), mri, pulmonary screen, Ct-sCan, intravenous pyelogram, or barium
enema. to schedule, please call Central scheduling at 566-1111. pulmonary
screen 566-5278.
PHYSICIAN NAME PHYSICIAN SIGNATURE DATE
pre-operative
physiCian orders
PATIENT IDENTIFICATION LABEL
3006779 (5/19/2011) PAGE 1 OF 3
*PHYORD*

pre-operative physiCian orders
Name: _________________________________________ Time: _______________________ Date: _________________
Instructions: Circle / Check box all orders that apply.
required FieLd For aCCurate antibiotiC administration CaLCuLation
CURRENT WEIGHT: _________________ lbs. _______________ kg. HEIGHT: ____________ ft. _______________ in.
NKDA ALLERGY(S) & REACTIONS: ____________________________________________________________________________
Latex Allergy No Yes – Reaction : ________________________ IVP Dye No Yes – Reaction : _____________________
antibiotiC aLLergy: a positive response to one or more of the following 4 signs / symptoms:
Respiratory difficulty (trouble breathing or chest tightness) Hypotension (low blood pressure or fainting)
Immediate reaction of swelling or hives
Emergency Room visit / Emergency visit to physician
surgiCaL proCedure drug oF ChoiCe (iv) aLLergies to drug oF ChoiCe (iv)
(antibiotiCs to be administered by anesthesia)
(vanComyCin to be administered in preop)
GI (Gastrointestinal)
General Surgery
Cefoxitin 2 grams
Cefazolin (dosing below) & metronidazole (Flagyl) 500mg
1 gram if patient weight < 80 kg.
2 grams if patient weight ≥ 80 kg.
Clindamycin (dosing scale below) & gentamicin 80 mg
600 mg if weight < 80 kg.
900 mg if weight ≥ 80 kg.
Vascular/ Thoracic
Open Heart Procedures
Neurological
Ortho/Podiatry
Implantable devices
GU (Genitourinary)
GYN and Urology
Synthetic pubovaginal sling
Head and Neck
Major Soft Tissues
Cefazolin
1 gram if patient weight < 80 kg.
2 grams if patient weight ≥ 80 kg.
iF mrsa screening is negative or results unavailable and not
allergic to Cefazolin
Cefazolin
1 gram if patient weight < 60 kg.
2 grams if patient weight ≥ 60 kg.
Bactroban : ½ tube each nostril
Cefuroxime (Zinacef) 1.5gm
Cefazolin
1 gram if patient weight < 80 kg.
2 grams if patient weight ≥ 80 kg
Cefazolin
1 gram if patient weight < 80 kg.
2 grams if patient weight ≥ 80 kg
if patient has a hx of staphlococcus aureus infection within
the past 2 years
Vancomycin (dosing scale below)
1 gram if patient weighs < 80 kg
1.5 gram if patients weighs ≥ 80 kg
Cefazolin
1 gram if patient weight < 80 kg.
2 grams if patient weight ≥ 80 kg.
Cefoxitin 2 grams
Cefazolin
1 gram if patient weight < 80 kg.
2 grams if patient weight ≥ 80 kg.
Vancomycin 1 gram
Clindamycin
600 mg if weight < 80 kg.
900 mg if weight ≥ 80 kg.
if mrsa screening is positive or allergic to Cefazolin
Vancomycin (dosing scale below) & gentamicin 80 mg
1 gram if patient weighs ≤ 65 kg
1.5 gram if patients weighs 66 – 90 kg
2 gram if patient weighs > 90 kg
Bactroban : ½ tube each nostril
Vancomycin 1 gram
Clindamycin
600 mg if weight < 80 kg.
900 mg if weight ≥ 80 kg.
Clindamycin 900 mg
if patient has a hx of staphlococcus aureus infection within
the past 2 years
Vancomycin (dosing scale below)
1 gram if patient weighs < 80 kg
1.5 gram if patients weighs ≥ 80 kg
Clindamycin (dosing scale below) & gentamicin 80 mg
600 mg if weight < 80 kg.
900 mg if weight ≥ 80 kg.
Ciprofloxacin 400 mg (urology only)
Doxycycline 200 mg (urology only)
Clindamycin (dosing scale below)
600 mg if weight < 80 kg.
900 mg if weight ≥ 80 kg.
SBE Prophylaxis per AHA
guidelines
Ampicillin 1 gram
Cefazolin 1 gram
Vancomycin 1 gram
Clindamycin (dosing scale below)
600 mg if weight < 80 kg.
900 mg if weight ≥ 80 kg.
entereg pre op orders
Patient Criteria for Entereg (alvimopan) Use:
By Checking the items 1 – 4 I confirm I have verified the following:
❑ 1. Entereg (alvimopan) is indicated for partial or small bowel resection with primary anastomosis.
❑ 2. Patient has not taken theraputic doses of opiods for more than seven (7) consecutive days immedatly prior to Entereg.
❑ 3. Patient does not have hepatic disorders.
❑ 4. Patient does not have severe renal failure.
Pre-Op: ❑ Entereg 12mg capsule orally NOW (must be given 30 minutes to 5 hours prior to surgery – give in pre-op)
Post–Op: Follow “Entereg Fast Track” protocol on Post-Op Inpatient General Surgery Physician Orders.
PHYSICIAN NAME PHYSICIAN SIGNATURE DATE TIME
pre-operative
physiCian orders
PATIENT IDENTIFICATION LABEL
3006779 (5/19/2011) PAGE 2 OF 3
*PHYORD*

pre-operative physiCian orders
Name: _________________________________________ Time: _______________________ Date: _________________
dvt prophyLaxis
Heparin 5000 units (SQ) x 1 dose prior to surgery
T.E.D. Hose _____ Bilateral _____ Right ______ Left
SCDs ________________________________________
Enoxaparin (Lovenox) 40 mg sq x1 ________________
Other DVT Orders : _____________________________
breast speCiaL needs
sub-areola injection of nuclear isotope Tc 99m
Sulfur Colloid per
Nuclear Medicine Protocol
______ Right ______Left _____Bilateral
Needle placement with ultrasound/mammography
_____ Right ______ Left _____ Bilateral
Appointment time ________________
ortho teCh – CerviCaL CoLLar / post-op shoe
Miami J Collar (preop to size)
Post-Op Surgical Shoe: Size : ____________________
protoCoL For parathyroideCtomy
First PTH level drawn in Pre-Op
Nuclear Medicine IV injection of Isotope,
25 mCi Tc99m Sestamibi
mri and Ct
Placement of Fiducials in preop per protocol ____________
Right Frontal Temporal Parietal
Left Frontal Temporal Parietal
Posterior Fossa
MRI with Stealth Protocol
nuCLear mediCine “other” protoCoL
Melanoma injection of nuclear isotope Tc99m
Sulfur Colloid per Nuclear Medicine Protocol
Melanoma site : _______________________________
sLeep apnea protoCoL
MRI of _______________________________________
CT with Stealth Protocol
CT Scan of ___________________________________
additional orders
PHYSICIAN NAME PHYSICIAN SIGNATURE DATE
pre-operative
physiCian orders
PATIENT IDENTIFICATION LABEL
3006779 (5/19/2011) PAGE 3 OF 3
*PHYORD*

anesthesia protoCoL
*h&p on aLL patients within 30 days oF surgery*
LoCaL & ConsCious sedation
HEALTHY ASYMPTOMATIC PATIENTS
No additional testing nescessary
maC (monitored anesthesia care)
< 50 years old No additional testing nescessary
HEALTHY ASYMPTOMATIC PATIENTS
> 50 years old Hgb EKG
generaL & spinaL anesthetiC
1) Low risK surgery with minimum bLood Loss (75 years old
2) high risK surgery: iF patient matChes Criteria,
assign FoLLowing Lab
CBC
No additional testing
Hgb
Hgb EKG
Hgb EKG Creat
Type & Screen / Cross Match x2 units
■ Intra-abdominal, Intrathoracic, Vascular ■ Amputation, Major Bladder, Femur
■ Lumbar, Thoracic or Cervical SPine ■ Knee or Hip other than replacement
■ Knee, Ankle, or Hip Replacement
■ Elbow, Shoulder
■ Urologic other than major Bladder, Hernia
■ C-section, Mastectomy, Breast Mass
mediCaL history seCtion
note: if patient
has a medical
history, consider
lab from medical
history section.
Stable Coronary Artery Disease Hgb EKG
Unstable Coronary Artery Disease Hgb EKG CXR
Cardiac clearance within 3 months of surgery date
Antiarrhythmic medication K+ EKG
Digoxin K+ Creat EKG
Diuretics K+
Hypertension (HTN) Creat EKG
Pulmonary Disease
Smoker 1pk/day X 20 years
EKG CXR
PFT
Only obtain if signs & symptoms suggest
newer or pulmonary disease
Diabetes glucose Creat EKG
Renal Disease Hct/Hgb K+ Creat BUN
Hepatic Disease pt/inr, ptt SGOT/ALK Phos
Hepatitis Exposure pt/inr, ptt SGOT/ALK Phos
Cerebral Vascular Accident (CVA) CBC EKG
CNS Disease Creat EKG
Anticoagulants CBC pt/inr, ptt
Bleeding Disorder CBC pt/inr, ptt T&S or T&C
Malignancy (chemotherapy) CBC pt/inr, ptt EKG CXR
Radiation Therapy WBC EKG CXR
Leukemia CBC pt/inr, ptt
Steroids glucose Na+ K+
Female of childbearing age
pregnancy test: urine or serum
3006779 (5/19/2011)
this page is not a permanent part oF the patient's Chart