PLACE LABEL HERE
SURGERY PRE-OP
ORDERS
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
Allergies: ______
Surgical Procedure(s): ______
______Date of Procedure(s): ______
1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?
q Yes, admit as inpatient, proceed to # 3 q No, proceed to # 2
2. Is this an inpatient only procedure? q Yes, admit as inpatient, proceed to # 3 q No, outpatient
3. Diagnosis: ______
4. Level of Care: q Critical q Intermediate q Acute Care Location/Specialty Unit Preference ______
5. q Telemetry: If patient Medical / Surgical, must complete form # 36084
6. q Isolation: q Contact q Droplet q Airborne For: ______
7. Consult(s): q IMPACT Evaluation: ______q WOCN Reason: ______q Breast Health Services
q Other: ______For: ______q Notified
8. Diagnostics: Per Anesthesia form # 33644
q IMPACT to order diagnostics
q Urine hCG for any menstruating female ≥ 12 years of age
q CBC q Chem 7 q CMP q LFT q Amylase q PSA
q H&H q PT qPTT q Platelet Function Study (if PT, PTT abnormal) q Platelet count
q U/A q iPTH
q Type, Screen and Hold ____ # units Packed Red Cells or
q Type & Rh (cannot transfuse)
q CXR, Reason ______
q EKG, Reason ______, Read by: ______
q Other: ______
9. MRSA & MSSA nasal swab:
All Total Joint Replacement Surgeries
Unicompartmental Knee Replacement Surgery
Spinal Fusion Surgery
Laminectomy
Microdiscectomy
Open Heart Procedure
10. For all MRSA/MSSA positive results, nurse to initiate form # 2645, Positive MRSA/MSSA Screen Prior to
Surgical Procedures Protocol
11. Pre-op instructions: Chlorhexidine 4% shower at home q Surgical Procedure does not require 4% Chlorhexidine
preop
12. Diet: NPO past midnight (patients > 12 y/o) unless otherwise ordered by anesthesia
NPO ______(patient ≤ 12 y/o) unless otherwise ordered by anesthesia
q Other Diet Instructions: ______
13. q Incentive spirometry
Order writer’s initials ______
*3-18195* FORM 3-18195 REV. 10/2017 WHITE: Medical Record CANARY: Pharmacy Page 1 of 2
PLACE LABEL HERE
SURGERY PRE-OP
ORDERS
The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
DAY OF SURGERY
14. Chlorhexidine 2% wipes to be done in Pre-op q Surgical Procedure does not require 2% wipes preop
15. Apply antiembolic device: q Sequential compression device q Antiembolic stockings
q Other: ______
16. Clip surgical site for procedure in pre-op area
17. Regional Anesthesia: q Femoral Block q Scalene Block q Other: ______
18. q Robotic Surgery: Indocyanine Green (ICG) q 2.5 mg q 3.75 mg q Other: ______IV x 1 dose in Pre-Op
19. Antibiotics:
Anesthesia administers: Mefoxin, Invanz, Ancef, Gentamicin, Cleocin, Flagyl RN administers: Vancomycin, Cipro
Procedure / Antibiotic x 1 dose / *Beta Lactam (Penicillin and Cephalosporin) AllergyCardiac, Vascular,
or OTHER / q Ancef (cefazolin) 2 gm IV or
3 gm if > 120 kg / q Cleocin (clindamycin) 600 mg IV
OR
q Vancomycin < 90 kg: 1 gm over 1 hr or ≥ 90 kg: 1.5 gm over 1.5 hrs
REQUIRED RATIONALE q Hx MRSA/positive
Colon / q Mefoxin (cefoxitin) 2 gm IV
OR
q Invanz (ertapenem) 1 gm IV / q Cipro (ciprofloxacin) 400 mg IV administered over 1 hr
AND
Flagyl (metronidazole) 500 mg IV
Hysterectomy / q Ancef (cefazolin) 2 gm IV or
3 gm if > 120 kg
OR
q Mefoxin (cefoxitin) 2 gm IV / q Cipro (ciprofloxacin) 400 mg IV administered over 1 hr
AND
Flagyl (metronidazole) 500 mg IV
Vaginal Sling
Prostate
PEG Surgery / q Ancef (cefazolin) 2 gm IV or
3 gm if > 120 kg
OR
q Mefoxin (cefoxitin) 2 gm IV / q Gentamicin 5 mg/kg IV pharmacy to dose x 1 dose
AND
Cleocin (clindamycin) 600 mg IV
Head/Neck/
Neurological / q Ancef (cefazolin) 2 gm IV or
3 gm if > 120 kg
/ q Vancomycin < 90 kg: 1 gm over 1 hr or ≥ 90 kg: 1.5 gm over 1.5 hrs
REQUIRED RATIONALE q Hx MRSA/positive
Penile
Prosthesis / q Gentamicin 5 mg/kg IV pharmacy to dose x 1 dose
AND 1 OF THE FOLLOWING:
q Ancef (cefazolin) 2 gm IV or
3 gm if > 120 kg
OR
q Mefoxin (cefoxitin) 2 gm IV / q Gentamicin 5 mg/kg IV pharmacy to dose x 1 dose
AND 1 OF THE FOLLOWING
q Cleocin (clindamycin) 600 mg IV
OR
q Vancomycin <90 kg: 1 gm over 1 hr or ≥ 90 kg: 1.5 gm over 1.5 hrs
REQUIRED RATIONALE q Hx MRSA/positive
Pediatric
(≤12 y/o) / q Ancef (cefazolin) 25 mg/kg
_____ mg IV (max 2 gm) / q Other: ______
(All should be re-dosed for ≥ 1,500 ml blood loss and Ancef and Mefoxin redosed if surgery last > 3 hrs)
ADDITIONAL ORDERS:
______
______
______
Date Time Physician Signature PID Number
FORM 3-18195 REV. 10/2017 WHITE: Medical Record CANARY: Pharmacy Page 2 of 2