PLACE LABEL HERE
SURGERY PRE-OP
ORDERS
The following orders will be implemented. Orders with a “” 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 ________
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?

 Yes, admit as inpatient, proceed to # 3 No, proceed to # 2
2.
Is this an inpatient only procedure?  Yes, admit as inpatient, proceed to # 3
3.
Diagnosis: ________________________________________________________________________________
4.
Level of Care:  Critical
5.
 Telemetry: If patient Medical/Surgical, must complete form # 36084
6.
 Isolation:  Contact
7.
Consult(s):  IMPACT Evaluation: _________  WOCN Reason: ____________
 Intermediate
 Droplet
 Acute Care
 Airborne
 No, outpatient
Location/Specialty Unit Preference __________
For: _________________
 Breast Health Services
 Other: ______________________________________ For: _________________  Notified
8.









Diagnostics: Per Anesthesia form # 33644
 IMPACT to order diagnostics
 Urine hCG for any menstruating female ≥ 12 years of age
 CBC
 Chem 7
 CMP
 LFT
 Amylase
 PSA
 H&H
 PT PTT  Platelet Function Study (if PT, PTT abnormal)  Platelet count
 U/A
 iPTH
 Type and Crossmatch  0 units or  ____ #units (transfusion armband) or  Type & Rh (cannot transfuse)
 CXR, Reason__________________
 EKG, Reason__________________, Read by:_______________
 Other: ____________________________________________________________
9.


MRSA nasal swab (provider select one):
 End Stage Renal Disease on Peritoneal or Hemodialysis
 Long Term Care (patient from nursing home)
 Total Hip Surgery
 Total Knee Surgery
 Total Shoulder Surgery
 Unicompartmental Knee Replacement Surgery 
 Spinal Fusion Surgery
 Laminectomy
 Microdiscectomy
 Open Heart Procedure
 History of MRSA infection
10.
For all MRSA positive results, nurse to initiate form # 2645, Positive MRSA Screen Prior to Surgical Procedure Protocol
11.
Pre-op instructions:
12.
Diet:

 Chlorhexidine 4% shower at home
NPO past midnight (patients > 12 y/o) unless otherwise ordered by anesthesia
NPO ____________ (patient ≤ 12 y/o) unless otherwise ordered by anesthesia

13.
 Other Diet Instructions: ________________________________________________
 Incentive spirometry
*3-18195*
FORM 3-18195 REV. 02/2016
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 “” 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
15.
Apply antiembolic device:  Sequential compression device  Antiembolic stockings
 Other: _____________________________
16.
Clip surgical site for procedure in pre-op area
17.
Regional Anesthesia:  Femoral Block
18.
 Robotic Surgery: Indocyanine Green (ICG)  2.5 mg
19.
Antibiotics:
 Scalene Block
 Other: _____________________
 3.75 mg  Other: ________ IV x 1 dose in Pre-Op
Anesthesia administers: Mefoxin, Invanz, Ancef, Gentamicin, Cleocin, Flagyl
Procedure
Cardiac,
Vascular,
or OTHER
Colon
Hysterectomy
Vaginal Sling
Prostate
PEG Surgery
Head/Neck/
Neurological
Penile
Prosthesis
Pediatric (≤12
y/o)
Antibiotic x 1 dose
 Ancef (cefazolin) 2 gm IV or
3 gm if > 120 kg
RN administers: Vancomycin, Cipro
*Beta Lactam (Penicillin and Cephalosporin) Allergy
 Cleocin (clindamycin) 600 mg IV
OR
OR
 Vancomycin < 90 kg: 1 gm over 1 hr or ≥ 90 kg: 1.5 gm over 1.5 hrs
REQUIRED RATIONALE  Hx MRSA/positive
 Cipro (ciprofloxacin) 400 mg IV administered over 1 hr
OR
AND
Flagyl (metronidazole) 500 mg IV
 Cipro (ciprofloxacin) 400 mg IV administered over 1 hr
OR
AND
Flagyl (metronidazole) 500 mg IV
 Mefoxin (cefoxitin) 2 gm IV
OR
 Invanz (ertapenem) 1 gm IV
 Ancef (cefazolin) 2 gm IV or
3 gm if > 120 kg
OR
 Mefoxin (cefoxitin) 2 gm IV
 Gentamicin 5 mg/kg IV pharmacy to dose x 1 dose
 Ancef (cefazolin) 2 gm IV or
3 gm if > 120 kg
AND
OR
OR
Cleocin (clindamycin) 600 mg IV
 Mefoxin (cefoxitin) 2 gm IV
 Ancef (cefazolin) 2 gm IV or
 Vancomycin < 90 kg: 1 gm over 1 hr or ≥ 90 kg: 1.5 gm over 1.5 hrs
REQUIRED RATIONALE  Hx MRSA/positive
3 gm if > 120 kg
OR

 Gentamicin 5 mg/kg IV
 Gentamicin 5 mg/kg IV pharmacy to dose x 1 dose
AND 1 OF THE FOLLOWING
pharmacy to dose x 1 dose
OR
 Cleocin (clindamycin) 600 mg IV
AND 1 OF THE FOLLOWING: 
OR
 Ancef (cefazolin) 2 gm IV or
 Vancomycin <90 kg: 1 gm over 1 hr or ≥ 90 kg: 1.5 gm over 1.5 hrs
3 gm if > 120 kg
REQUIRED RATIONALE  Hx MRSA/positive
OR
 Mefoxin (cefoxitin) 2 gm IV 

 Ancef (cefazolin) 25 mg/kg
OR  Other: _________________________________________________
_____ mg IV (max 2 gm)
(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
FORM 3-18195 REV. 02/2016
_________________________________
Physician Signature
WHITE: Medical Record
CANARY: Pharmacy
___________
PID Number
Page 2 of 2