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Procedures Criteria Tonsillectomy (Pediatric) PATIENT: Name CPT/ICD: Code PROVIDER: Name Signature D.O.B Facilitv 10# Service Date ID# GROUP # Phone# Date ICD-9-CM: CPT: 28.2, 28.3 42820,42821,42825,42826 INDICATIONS (choose one and see below) 0 100 Peritonsillar abscess 0 200 Chronic tonsillitis 0 300 Recurrent acute tonsillitis 0 400 Obstructive tonsillar hypertrophy 0 500 Suspected tonsillar malignancy 0 600 Tonsillar hemorrhage 0 700 Tonsillar cryptitis 0 Indication Not Listed (Provide clinical justification below) 100 Peritonsillar abscess (ONE) 0 110 Acute airway obstruction 0 120 Needle aspiration contraindicated because of age 0 130 Peritonsillar abscess =.2x by Hx 200 Chronic tonsillitis (BOTH) 0 210 SxJfindings(BOTH) 0 211 Throat pain =.6 wks by Hx 0 212 Findings (ONE) 0 -1 Tender cervical lymph nodes 0 -2 Tonsillar ery1hemalexudates 0 -3 Temperature> 100.4 F 0 -4 Documented increase in tonsil size 0 220 Abx Rx =. 10 days x2 300 Recurrent acute tonsillitis (BOTH) 0 310 SxJfindingsduring acute episode (BOTH) 0 311 Throat pain 0 312 Other findings (ONE) 0 -1 Tonsillar erythema/exudates by PE 0 -2 Temperature> 101 F 0 -3 Cervical lymph nodes (ONE) 0 A) Tender/enlarged 0 B»1.5cm 0 0 -4 Documented increase in tonsil size -5 Group A Beta-hemoly1ic strep by culture 0 320 Frequency of documented acute episodes (ONE) 0 321 =.3/yr for 3 yrs 0 322 =.4/yr for 2 yrs 0 323 =.5/yr for 1 yr 400 Obstructive tonsillar hypertrophy (ALL) 0 410 SxJfindings(ONE) 0 411 Hyponasal/hypernasal speech 0 412 Snoring/mouth breathing =.6 months 0 413 Suspected sleep apnea 0 414 Persistent drooling 0 415 Swallowing impairment =.6 mos with (ONE) 0 -1 Weight loss 0 -2 Failure to thrive 0 -3 Dysphagia with solids 0 0 420 3+/4+ tonsillar enlargement by PE 430 Normal palate by PE ADD ADDITIONAL CASE COMMENTS BELOW

Outpatient Surgery Order 10 yo w/r wi ij/o Re(,Li~ stf<ep HISTORY+hRCQt. bepSccleS of s;tRep In the. past \2rY\C); Ldst epStdQ.C I mcrrtl'i Q'Jc Re{l-il~-d 2c.OLiR-S;e-£: cf. Al3x: Sxs -t€veR- Sh:\'YIC\ch C{che, .sC'-Re -thRC...qt~ f"'dhB j~ rfll$E.Pj [-"2. dd ~ 'S. of .sChool c e.Clch e.PI5:tDle S()CR\'J:; ctl (f.'cul .s:vtallDw 1r'iC) PMH' v AllergiesNKDA- Adult Illness -e Medications--€T Prior Operations bRct«2-r) @ qRrn ( t:0th Plad Ili.£~l' ~11na) Childhood Illness ShC!<-i(\C\) c\lff-{CLiI-h, ~ 1\ ' J ., J >\t\iq (,'Wir)J Tobacco q> '~ ; I , V J_' Patient'sName.l£:L \ \ evrr \ - --" Doctor's Name . - Date of Outpatient Surgery_i ~ INSTRUCTIONS TO THE PATIENT 1. Please come to the main AdmittingOfficetwo to seven days before scheduled surgery, for preoperative testing and registration. 2, Be sure to bring Medicaid, Medicare or other insurance cards withyou when you come. 3. Please bring this form withyou. 4. The night before surgery, DO NOT eat or drink anything (including water) after midnight. 5. Other instructions: LABORATORY REQUESTS 0 AutoCount 0 Protime 0 CBC 0 PTT 0 Urinalysis 0 Type&Screen 0 K+ 0 EKG 0 Pregnancy 0 Other: MEDICATIONORDERS 0 Cefazolin 1 gm IV1 hour pre-op (give intraoperative dose 3 hours later for prolonged procedures) 0 Cefotetan gm IV1 hour pre-op (for abdominal procedures only) 0 No pre-op antibiotic 0 Other: X-RAY REQUESTS 0 Chest 0 Other: PROPOSEDPOST-op PAINMANAGEMENT: 0 PCA 0 Epidural 0 Other OTHER ORDERS Habits: Etoh rp Family History PHYSICAL EXAM VITAL SIGNS: BIP Pulse -. 3 , I< ~<:, \ S r, Dk'omlnCltri Heent L- + pn 1'-1 '~' . r'- Heart r¥1~el <D~SlI LungselectR. Mental Status f Other DIAGNOSIS chRcnic.'tDhS",lIr1IS J Recu~ S:TRep ANESTHETIC 0 Local 0 IVRegional 0 Spinal 0 Other: 0 Monitored Anesthesia ~ (MAC) B'General OPERATIVE PROCEDURE: 1t:>hS\ \\€c-ta-ny-t C\cI-enold ec. ~ ..... - ~ Physician Signature fo -iq-O'l Date ,," "! Outpatient Surgery Order ", . Revised: 9-6-00

u -- ----- 4. The night before surgery, DO NOT eat or drink anything (including water) aftifJrlf"ilWr 5. Other instructions: "l1lft' - -:: - - -~ v ,~ J -- ,.,,(1 c~ Outpatient Surgery Order . 3qcLtYold feinali wilit )1.IS HISTORY 1W\S) II i h ~ -+fI--cl.RrtDflJYzsi Hay 'UJ ~v~l' h j . c: X i ~Y\.R t:nJ ,~1JNLit{ Sfit~ . J~)t ~hl-S~c{ .IDctCUfS ()~ .I-}Jl1tJl T Il!dc'fjS Dr- Om,hllRf - cpStx-l ft1XOilf- hi£( bt:l.cl S-1WY1n~ . eKhcwskd all ~ tfiVtf( tfuS!,!t PMH1-ltt'n.q qCJod It it:lhf~ r-tsJ-. Allergies 10' IUW4 / Adult Illness ~ Medications (Z5 Prior Operations JQ Childhood Illness (2f Habits: Etoh tt5 Tobacco t)5 . Family History f!5 bLR.i.dJ _~ - . «~5fi(£fi1A U~S~14d {.;. ca/lt"fl,a j---:Y::)I\,;AL EXAM GNS: BIP Pulse een! @f.t>Y\.S\ I <+ j- tc\l(hi\'~ u V eJA eart (0 t1Jt1.Sd~i pI n \6 LABORATORY REQUESTS :MOj8q pelOUse Snlel' JU8!11d ~ 96ue4:> [j.ungs 0 Auto Count 0 Protime UOISS.PI uodn Mental Status 0 CBC 0 PIT SfII81S UI9IuetpiuD tU6ts ON 0 Urinalysis 0 Type&Screen' i.1YCWn dIM .. . 0 K+ 0 EKG I ..Pf:AGNOSIS '. 0 Pregnancy 0 Other: --to bshutjiy..z IrdcYtok/hS'i Jlar 11.Jj p-e vhtJp iv1 MEDICATION ORDERS J 0 Cefazolin 1 gm IV 1 hour pre-op (give intraoperative ANESTHETIC dose 3 hours later for prolonged procedures) 0 Local 0 Cefotetan gm IV 1 hour pre-op (for 0 IV Regional abdominal procedures only) 0 Spinal 0 No pre-op antibiotic 0 Other: 0 Other: t:;J Patient's Name? t11f\tV\t 2- ,- -- - . - "- Doctor's Name ~ - - -- - ---' Dateof OutpatientSurgery to .- J l-=-.Q. 5 INSTRUCTIONS TO THE PATIENT 1. Please come to the main Admitting Office two to seven days before scheduled surgery, for preoperative testing and registration. 2. Be sure to bring Medicaid, Medicare or other insurance cards with you when you come. 3. Please bring this form with you. 0 Monitored Anesthesia . Care (MAC) fl General X-RAY REQUESTS 0 Chest 0 Other: OPERATIVE PROCEDURE: ~S\\\Y-C~ ~Ad.Q116Idec~ PROPOSED POST-op PAIN MANAGEMENT: 0 PCA 0 Epidural 0 Other OTHER ORDERS . ,---- Y '-" Physician Signature - 11)- II -OS" Date J- Outpatient Surgery Order Revised: 9.6.00

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*C. Outpatient Surgery Order . \ < ~ . . 3~Did rYlQl1iWI~'cf . HISTORY Idw1 s nodIrl ~ bad bn~Ct - )( I ~ tt~o ptW$lYlCj T @ClSf'i ~~9 ",naSClI {(}Yl{J~fi l i lit II 'ff0¥ rPiind. \HaY Irtfoi'" fmSill'n I I ndnc nC _c_-- - - --- ~ Patient's Name '. Part \ £V'U Doctor's Name Date of outpat~~;Su~ry- -05 INSTRUCTIONS TO THE PATIENT 1. Please come to the main AdmittingOfficetwoto seven days before scheduled surgery, for preoperative testing and registration. 2. Be sure to brinyMedicaid,Medicareorother insurance cards withyouwhenyoucome. /- 3. Please bring this form ~ou. HIP UPDATE 4. The nightbefor~~~"" anything (including ~_./ghr 5. Otherinstructior(il Change inpatienl8l81us asnoted --::-:--~':-? --"> LABORATOR~. - 0 AutoCount otime 0 CBC 0 PTT 0 Urinalysis 0 Type&Screen 0 K+ 0 EKG 0 Pregnancy 0 Other: MEDICATIONORDERS 0 Cefazolin 1 gm IV 1 hour pre-op (give intraoperative dose 3 hours later for prolonged procedures) 0 Cefotetan gm IV1 hour pre-op (for abdominal procedures only) 0 No pre-op antibiotic 0 Other: X-RAY REQUESTS 0 Chest 0 Other: PROPOSED POST-op PAIN MANAGEMENT: 0 PCA 0 Epidural 0 Other OTHER ORDERS PMH Allergies tJiiOA- AdultIllness f;6 Medications ~ Prior Operations f/ ChildhoodIllness ~ Habits: Etoh LP Tobacco'. Family History fO b LuCLIYI.J1 tJr/trtk-s-flws IC\ ,) [v~) cal7C'YlO . PHYSICAL EXAM r--- . VITAL SIGNS: SIP Pulse Heent 3 - 4 t- P en k. br1,Sl Ls @ t;eart ~PfD\ .1.j~LUngS ~ ~ Mental Status Other"\.) 10 L- DIAGNOSIS tltJJuwWrtsnlW /1Aj pe~fwp~ ANESTHETIC J 0 Local 0 MonitoredAnesthesia 0 IV Regional 1.:::\ -A Care (MAC) 0 Spinal lEI-Seneral 0 Other: OPERATIVE PROCEDURE: TOYtS1Lttc~ ~~)~ , Physician Signature (0, 1/ --(;C; Date 5475S.500E.,Ogden, UT 8440~978 Phone:(801)479-2111 Fax: (801) 479-2007 OutpatientSurgery Order Revised: 9-6-00

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