Affix Pt Label Here
University of Washington
Department of Orthopaedics & Sports Medicine
Surgical Worksheet
Surgery Date__________________________
Surgeon: Frederick A Matsen
Pav OK
Winston J Warme
R2 OK
Urgent
Next Available
Dx:
Surgical Procedure:
Length of Stay:
Admission:
AM Admit
Attending Preop: No
First Post-op: 2 Week
Anesthesia: Choice
weeks from today
Interpreter
2-3 Days) Length of Surgery:
LS
OP
 IP
Yes
1 Week
No
 Other:
General
Epidural
Spinal
Local:
MAC
RN Monitor
Routine: CBC/CMP/COAGS/UAcC&S
Sed/CRP
Labs:
X-rays:
Transfusion: None
Consult:
None
PAT Position: Beach Chair
O/R Table:
Regular
O/R X-ray:
None
Special Equip: CPM Bed
Pre-op Meds: Cefazolin
Name:
U Number:
DOB:
DOS:
(1-2 Days
T + C Units (2 if Arthroplasty)
Medicine
Social Work  Orthotics
Supine
Prone
Lateral
Fx Table
RA Table
C-Arm
C-Arm
Regular
Healthmate
Cell Saver Autotrans Drains
Clindamycin Hold
Other:
(1 Hour 1.5 Hours 2 Hours)
Day Before Surgery
Axillary/Scalene Block
No Sedation
Other:
Autologous Units
Other:
Other:
Other:
Other:
Other:
IMPLANTS:
Acumed
 Locking Clavicle Plate
Synthes
 Periarticular Plates
 Lg Frag Screw Set Implant
 Mini Frag Set: 1.5, 2.0, 2.7 mm Screws
Biomet
 Neer II Shoulder
 Sm Frag Set: 3.5, 4.0 mm Tit Screws
 Discovery Elbow
 Modular Hand Impl/Instr Set
 Bio-Modular Shoulder System
 LC-DCP Plates: 3.5, 4.5 Narw & 4.5 Broad
 Bi-Angular/Bi-Polar Shoulder System
 DCP Plates: 3.5, 4.5 Narrow & 4.5 Broad
 Pelvic Recon Screws & Plates 3.5, 4.5, 6.5
 Recon Plate Set 2.7, & 3.5
Depuy
 Global Advantage TSA (& Ream and Run)  Kirschner “K” Wires
 Global Advantage CTA
 Delta Shoulder
Mitek
 Sulzer Custom Elbow
 Delta XTend Shoulder
 HRP & Global Shld Impl.
 Rockwood Clavicle Screw
Wright Medical
 Evolve Radial Heads
 Olympia Shoulder System
Exactech
 Equinoxe Shoulder Fracture System
 InterSpace Shoulder Cement Spacer
Zimmer
 Coonrad-Moorey Elbow Impl
 Olecranon Elbow
Smith&Nephew
 Cofield 2 TSA
 Humeral Plates
 Bigliani/Flatow Shoulder
 Anatomical Shoulder System
Stryker
 Solar TSA
 Trabecular Metal Humeral Stem
Tornier
 Aequalis Shoulder System
PLEASE COMPLETE BOTH SIDES
Filled out by/Date:
Arthroscopy Gear
Arthrex
 5.5mm FT Bio-Corkscrew Anchor (RCR)
 3.0mm Bio-SutureTak (Bankart/SLAP)
 STaR Sleeve
ConMed Linvatec
 Tendon Stripper
Smith & Nephew
 Acufex Graftmaster II
NW Tissue Center
 Allografts:
 Hamstring Allograft
 Cancellous Chips 15 cc & 30 cc
CPT
23472
23472
23472 + 23332
23470
23470 + 23331
23150
Please circle all Procedures that apply
Common Procedures
CPT Common Procedures
Total Shoulder Arthroplasty
23020 Capsular Release
Delta Arthroplasty
Revision Total Shoulder Arthroplasty 23700 MUA of Shoulder
Hemiarthroplasty Shoulder
24300 MUA of Elbow
Revision Shoulder Hemiarthroplasty
23420 Biceps Tenodesis (long head)
24342 Reinsertion distal biceps tendon
Osteophyte Resection - Humerus
24363
Total Elbow Arthroplasty
24363 + 24160 Revision Total Elbow Arthroplasty
23120 Clavicle Resection
23455
Open Bankart Repair
23800 Shoulder Fusion
23412
23410
23130
Open RCR - Chronic
Open RCR - Acute
Smooth and Move (Acromioplasty)
20900 ICBG (iliac crest bone graft)
20680 Hardware Removal
Please also circle all Diagnoses that apply
ICD-9 Common Diagnosis
ICD-9 Common Diagnosis
Arthritis
Stiffness
715.31 DJD/OA Shoulder
726.0 Adhesive capsulitis of shoulder "frozen shoulder"
716.11 Traumatic OA Shoulder
718.41 Contracture of shoulder
715.32 DJD/OA Elbow
718.42 Contracture of elbow
714.0 Rheumatoid Arthritis - Any Joint
719.51 Stiffness of shoulder, not elsewhere classified
719.52 Stiffness of elbow, not elsewhere classified
716.91 Cuff Tear Arthropathy
Infections
996.47 Failed Total Joint (See long list below)
711.9 Unspecified infective arthritis
733.41 AVN Shoulder
996.66 Infected Total Joint
998.59 Post Op Infection
Sprains and strains
840.4 Rotator cuff
Other
840.6 Supraspinatus
726.10 Rotator cuff syndrome NOS
840.3 Infraspinatus
726.11 Calcifying tendinitis of shoulder
840.5 Subscapularis
726.12 Bicipital tenosynovitis
718.11 Loose body in shoulder
729.5 Pain in limb
Nontraumatic rupture of tendon
727.61 Complete rupture of rotator cuff, nontraumatic
727.62 Tendons of biceps (long head)
718.31
831.00
831.01
831.02
831.03
831.04
839.61
718.81
Closed Dislocation of shoulder
Recurrent dislocation of shoulder
shoulder, unspecified
anterior dislocation of humerus
posterior dislocation of humerus
inferior dislocation of humerus
acromioclavicular joint
sternoclavicular joint
Shoulder instability
996.41
996.42
996.43
996.44
996.45
996.46
996.47
996.49
Failed Arthroplasty
Mechanical loosening of prosthetic joint
Dislocation of prosthetic joint
Prosthetic joint implant failure
Peri-prosthetic fracture around prosthetic joint
Peri-prosthetic osteolysis
Articular bearing surface wear of prosthetic joint
Other mechanical complication of prosthetic joint implant
Other mechanical