/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/bmtoncologyhematology/,

/clinical/cckm-tools/content/order-sets/inpatient/bmtoncologyhematology/name-122306-en.cckm

201711332

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,BMT/Oncology/Hematology

IP/OP - Pre-Bone Marrow Testing - Pediatric - Supplemental [4641]

IP/OP - Pre-Bone Marrow Testing - Pediatric - Supplemental [4641] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


IP/OP - Pre-Bone Marrow Testing - Pediatric - Supplemental [4641]
Inpatient Laboratory
HLA Typing [126846]
STR ENGRAFTMENT SAMPLE, PRE-TX
[HCSTRPRE]
NEXT DRAW For 1 Occurrences, Routine, For Stem
Cell Transplant Only.
Indicate if donor or recipient:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA DR LOCUS [HCDRB1B] NEXT DRAW For 1 Occurrences, Routine
For Bone Marrow Transplants only: Type regardless of
A, B matching.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA A LOCUS [HCALOCB] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA B LOCUS [HCBLOCB] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA CLASS I AB BY LUMINEX [HCLUC1B] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA CLASS II AB BY LUMINEX [HCLUC2B] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Chemistries [126847]
ELECTROLYTES [LYTE] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GLUCOSE [GLU] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM [CA] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 1 of 17
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 2:01:22 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

PHOSPHATE [PHOS] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTEIN, TOTAL [TP] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
URIC ACID [URIC] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
URINALYSIS WITH MICROSCOPY [UA] ONCE For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HCG, QUALITATIVE [SPREG] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
For females of childbearing potential
Cardiac/Lipids [126848]
LIPID PANEL [LIPID] NEXT DRAW For 1 Occurrences, Routine, Test
includes Cholesterol, Total; HDL Cholesterol;
Triglyceride; LDL cholesterol, calculated; and non-
HDL cholesterol.
Patient must fast for a minimum of 10 hours and be
heparin free for 48 hours prior to specimen collection.
The patient can only have water during the fasting
period.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GI/Liver [126849]
ALBUMIN [ALB] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
AST/SGOT [AST] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALKALINE PHOSPHATASE [ALKP] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 2 of 17
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 2:01:22 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

LD, TOTAL [LDH] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GGT [GGT] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Hematology/Coagulation [126862]
CBC WITH DIFFERENTIAL [CBC] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR [PT] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FERRITIN [FER] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
RETICULOCYTE COUNT [RET] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Hepatitis [126863]
HEPATITIS A AB, IGG [HAVIGG] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS A AB, IGM [XHAVM] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS B CORE AB, TOTAL [HBCAB] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS B SURFACE AB (IMMUNE STATUS)
[HBSABI]
NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS B SURFACE AG [HBSAG] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS C AB [HCV] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HIV/HSV [126864]
Page 3 of 17
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 2:01:22 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

HIV AB/AG COMBO [HIVABAG] NEXT DRAW For 1 Occurrences, Routine, I, the
ordering provider, have verified that the
patient/patient's authorized representative was:
1. Notified that the patient will be subjected to an HIV
test unless the patient/rep declines the test;
2. Given educational materials on HIV and HIV testing;
3. Notified that they may decline the test and health
care providers may not use the fact that the
patient/rep declined an HIV test as a basis for denying
other services; and
4. Provided an opportunity to ask questions and to
decline the HIV test.
The ordering provider verifies:
5. The patient/patient's authorized representative
understands that an HIV test will be performed; and
6. The decision of the patient/rep regarding whether to
have an HIV test performed was not coerced or
involuntary.
Pt/Pt's Rep did not opt out. Steps listed in instructions
taken. If test is declined, type ".HIVTESTDECLINE" in
progress note.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HTLV I/II AB [XHTLV] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Infectious Disease [126865]
EBV AB TO VIRAL CAPSID AG, IGG
[HCEBVIGG]
NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
EBV AB TO VIRAL CAPSID AG, IGM [XEBVP2] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CMV ABS, IGG/IGM [XCMVC] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CMV QUANTITATIVE BY PCR [HCCMVDNA] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
RPR, CONFIRM IF POSITIVE [RPRFTA] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
TOXOPLASMA AB, IGG/IGM [HCTOXO] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Immunology [126868]
Page 4 of 17
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 2:01:22 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

IMMUNOGLOBULINS A,G,M [XGAM] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ABO/Rh [126871]
ANTIBODY SCREEN [ABSCR] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ABO AND RH TYPING [ABO] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Outpatient (Clinic) Laboratory
HLA Typing [120549]
STR ENGRAFTMENT SAMPLE, PRE-TX
[HCSTRPRE]
Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
HLA DR LOCUS [HCDRB1B] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
HLA A LOCUS [HCALOCB] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
HLA B LOCUS [HCBLOCB] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
HLA CLASS I AB BY LUMINEX [HCLUC1B] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
HLA CLASS II AB BY LUMINEX [HCLUC2B] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Chemistries [120551]
Electrolytes [LYTE] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Glucose [GLU] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Bun [BUN] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Creatinine [CRET] Status: Standing, Expires:9/5/18 MANUAL,Count:1,
Normal, Routine
Calcium [CA] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Magnesium [MAG] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Phosphate [PHOS] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Protein, Total [TP] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Uric Acid [URIC] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
URINALYSIS WITH MICROSCOPY [UA] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
HCG, QUALITATIVE [SPREG] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine, For females of childbearing potential
Cardiac/Lipids [120552]
Lipid Panel [LIPID] Status: Standing, Expires:9/5/18 MANUAL,Count:1,
Normal, Routine
GI/Liver [120553]
Albumin [ALB] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Page 5 of 17
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 2:01:22 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

AST/SGOT [AST] Status: Standing, Expires:9/5/18 MANUAL,Count:1,
Normal, Routine
ALT/SGPT [ALT] Status: Standing, Expires:9/5/18 MANUAL,Count:1,
Normal, Routine
Alkaline Phosphatase [ALKP] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Bilirubin, Total [TBIL] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
LD, Total [LDH] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
GGT [GGT] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Hematology/Coagulation [120554]
CBC with Differential [CBC] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Prothrombin Time/INR [PT] Status: Standing, Expires:9/5/18 MANUAL,Count:1,
Normal, Routine
Ferritin [FER] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Reticulocyte Count [RET] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Hepatitis [120555]
Hepatitis A Ab, IgG [HAVIGG] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Hepatitis A Ab, IgM [XHAVM] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Hepatitis B Core AB, Total [HBCAB] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Hepatisis B Surface AB (Immune Status)
[HBSABI]
Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Hepatitis B Surface AG [HBSAG] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Hepatitis C AB [HCV] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
HIV/HSV [120556]
HIV AB/AG COMBO [HIVABAG] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
HTLV I/II AB [XHTLV] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Infectious Disease [120557]
EBV AB TO VIRAL CAPSID AG, IGG
[HCEBVIGG]
Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
EBV AB TO VIRAL CAPSID AG, IGM [XEBVP2] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
CMV ABS, IGG/IGM [XCMVC] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
CMV QUANTITATIVE BY PCR [HCCMVDNA] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
RPR, Confirm if Positive [RPRFTA] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Toxoplasma IGG/IGM [HCTOXO] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Immunology [122465]
Immunoglobulins A,G,M [XGAM] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
ABO/Rh [120558]
Page 6 of 17
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 2:01:22 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

ABO and RH Typing [ABO] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
ANTIBODY SCREEN [ABSCR] Status: Standing, Expires:12/4/17 MANUAL,Count:1,
Normal, Routine
Peds Day Treatment Laboratory
HLA Typing [225461]
STR ENGRAFTMENT SAMPLE, PRE-TX
[HCSTRPRE]
NEXT DRAW For 1 Occurrences, Routine, For Stem
Cell Transplant Only.
Indicate if donor or recipient:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HLA DR LOCUS [HCDRB1B] NEXT DRAW For 1 Occurrences, Routine
For Bone Marrow Transplants only: Type regardless of
A, B matching.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HLA A LOCUS [HCALOCB] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HLA B LOCUS [HCBLOCB] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HLA CLASS I AB BY LUMINEX [HCLUC1B] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HLA CLASS II AB BY LUMINEX [HCLUC2B] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
Chemistries [225462]
ELECTROLYTES [LYTE] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
GLUCOSE [GLU] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
BUN [BUN] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
Page 7 of 17
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 2:01:22 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

CREATININE [CRET] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
CALCIUM [CA] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
MAGNESIUM [MAG] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
PHOSPHATE [PHOS] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
PROTEIN, TOTAL [TP] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
URIC ACID [URIC] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
URINALYSIS WITH MICROSCOPY [UA] ONCE For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HCG, QUALITATIVE [SPREG] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
For females of childbearing potential, Peds Diagnostic
Cardiac/Lipids [225463]
LIPID PANEL [LIPID] NEXT DRAW For 1 Occurrences, Routine, Test
includes Cholesterol, Total; HDL Cholesterol;
Triglyceride; LDL cholesterol, calculated; and non-
HDL cholesterol.
Patient must fast for a minimum of 10 hours and be
heparin free for 48 hours prior to specimen collection.
The patient can only have water during the fasting
period.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
GI/Liver [225464]
Page 8 of 17
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 2:01:22 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

ALBUMIN [ALB] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
AST/SGOT [AST] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ALT/SGPT [ALT] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ALKALINE PHOSPHATASE [ALKP] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
BILIRUBIN, TOTAL [TBIL] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
LD, TOTAL [LDH] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
GGT [GGT] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
Hematology/Coagulation [225465]
CBC WITH DIFFERENTIAL [CBC] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
PROTHROMBIN TIME/INR [PT] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
FERRITIN [FER] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
RETICULOCYTE COUNT [RET] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
Hepatitis [225466]
Page 9 of 17
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 2:01:22 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

HEPATITIS A AB, IGG [HAVIGG] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HEPATITIS A AB, IGM [XHAVM] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HEPATITIS B CORE AB, TOTAL [HBCAB] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HEPATITIS B SURFACE AB (IMMUNE STATUS)
[HBSABI]
NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HEPATITIS B SURFACE AG [HBSAG] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HEPATITIS C AB [HCV] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HIV/HSV [225467]
Page 10 of 17
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08/2017CCKM@uwhealth.org

HIV AB/AG COMBO [HIVABAG] NEXT DRAW For 1 Occurrences, Routine, I, the
ordering provider, have verified that the
patient/patient's authorized representative was:
1. Notified that the patient will be subjected to an HIV
test unless the patient/rep declines the test;
2. Given educational materials on HIV and HIV testing;
3. Notified that they may decline the test and health
care providers may not use the fact that the
patient/rep declined an HIV test as a basis for denying
other services; and
4. Provided an opportunity to ask questions and to
decline the HIV test.
The ordering provider verifies:
5. The patient/patient's authorized representative
understands that an HIV test will be performed; and
6. The decision of the patient/rep regarding whether to
have an HIV test performed was not coerced or
involuntary.
Pt/Pt's Rep did not opt out. Steps listed in instructions
taken. If test is declined, type ".HIVTESTDECLINE" in
progress note.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
HTLV I/II AB [XHTLV] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
Infectious Disease [225468]
EBV AB TO VIRAL CAPSID AG, IGG
[HCEBVIGG]
NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
EBV AB TO VIRAL CAPSID AG, IGM [XEBVP2] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
CMV ABS, IGG/IGM [XCMVC] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
CMV QUANTITATIVE BY PCR [HCCMVDNA] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
Page 11 of 17
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 2:01:22 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

RPR, CONFIRM IF POSITIVE [RPRFTA] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
TOXOPLASMA AB, IGG/IGM [HCTOXO] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ABO/Rh [225469]
ANTIBODY SCREEN [ABSCR] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
ABO AND RH TYPING [ABO] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Peds Diagnostic
Diagnostic Tests and Imaging
Inpatient Diagnostic Tests and Imaging [126874]
Audiology Testing [AUD0001] ONCE For 1 Occurrences, Routine
Transthoracic Resting Echocardiogram (PEDS)
[ECH0012]
Current signs and symptoms?
Relevant recent/past history?
What condition is suspected?
Is this the comprehensive post operation dishcharge
evaluation?
Will sedation be required?
Do you want Agitated Bubble Study? No
|
-- STAT priority is for *CLINICAL EMERGENCY* use
only --
A page will automatically send to the Pediatric
Cardiologist upon signing if a STAT Priority is
selected.
Page 12 of 17
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 2:01:22 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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08/2017CCKM@uwhealth.org

NM KIDNEY FUNCTION NON-IMAGING
[R78725]
ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Last patient height? (will auto pull in value and date in
comment):
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant or breastfeeding?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
CT CHEST ABDOMEN PELVIS W & W/ O IV
CONTRAST [R07130]
ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Can pt be given oral contrast?
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history:
Can Patient be given oral contrast?
Pt needs creatinine level w/in 30 days of exam? ( >
60 yrs old, Diabetes managed w/ meds, using
metformin combinations, chemo or amnioglycoside,
hist of renal disease [incl tumor, surg, kidney
transplant, dialysis], has hypertension w/ medical
therapy):
Last creatinine value? (will auto pull in date and value
in comment):
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
Page 13 of 17
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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08/2017CCKM@uwhealth.org

CT SINUS W & W/ O IV CONTRAST [R70488A] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history:
Can Patient be given oral contrast?
Pt needs creatinine level w/in 30 days of exam? ( >
60 yrs old, Diabetes managed w/ meds, using
metformin combinations, chemo or amnioglycoside,
hist of renal disease [incl tumor, surg, kidney
transplant, dialysis], has hypertension w/ medical
therapy):
Last creatinine value? (will auto pull in date and value
in comment):
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
X-RAY PANOREX (ORTHOPANTOGRAM)
[R70355]
ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Outpatient (Clinic) Diagnostic Tests and Imaging [120560]
Audiology Testing [AUD0001] Status: Future, Expected: 8/4/2017, Expires: 9/18/17,
Normal, Routine, Qty-1
Transthoracic Resting Echocardiogram (PEDS)
[ECH0012]
Status: Future, Expected: 8/4/2017, Expires: 9/18/17,
Normal
NM Kidney Function Non-Imaging [R78725] Status: Future, Expected: 8/4/2017, Expires: 9/18/17,
Normal, Routine
CT Chest Abdomen Pelvis w & w/o IV Contrast
[R07130]
Status: Future, Expected: 8/4/2017, Expires: 9/18/17,
Normal, Routine
CT Sinus w & w/o IV Contrast [R70488A] Status: Future, Expected: 8/4/2017, Expires: 9/18/17,
Normal, Routine
X-Ray Panorex (Orthopantogram) [R70355] Status: Future, Expected: 8/4/2017, Expires: 9/18/17,
Normal, Routine
Peds Day Treatment Diagnostic Tests and Imaging [225471]
Audiology Testing [AUD0001] ONCE For 1 Occurrences, Routine, Peds Diagnostic
Page 14 of 17
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 2:01:22 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Transthoracic Resting Echocardiogram (PEDS)
[ECH0012]
Current signs and symptoms?
Relevant recent/past history?
What condition is suspected?
Is this the comprehensive post operation dishcharge
evaluation?
Will sedation be required?
Do you want Agitated Bubble Study? No
|
-- STAT priority is for *CLINICAL EMERGENCY* use
only --
A page will automatically send to the Pediatric
Cardiologist upon signing if a STAT Priority is
selected.
Peds Diagnostic
NM KIDNEY FUNCTION NON-IMAGING
[R78725]
ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Last patient height? (will auto pull in value and date in
comment):
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant or breastfeeding?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Peds Diagnostic
Page 15 of 17
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 2:01:22 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

CT CHEST ABDOMEN PELVIS W & W/ O IV
CONTRAST [R07130]
ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Can pt be given oral contrast?
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history:
Can Patient be given oral contrast?
Pt needs creatinine level w/in 30 days of exam? ( >
60 yrs old, Diabetes managed w/ meds, using
metformin combinations, chemo or amnioglycoside,
hist of renal disease [incl tumor, surg, kidney
transplant, dialysis], has hypertension w/ medical
therapy):
Last creatinine value? (will auto pull in date and value
in comment):
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
Peds Diagnostic
CT SINUS W & W/ O IV CONTRAST [R70488A] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history:
Can Patient be given oral contrast?
Pt needs creatinine level w/in 30 days of exam? ( >
60 yrs old, Diabetes managed w/ meds, using
metformin combinations, chemo or amnioglycoside,
hist of renal disease [incl tumor, surg, kidney
transplant, dialysis], has hypertension w/ medical
therapy):
Last creatinine value? (will auto pull in date and value
in comment):
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
Peds Diagnostic
X-RAY PANOREX (ORTHOPANTOGRAM)
[R70355]
ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Peds Diagnostic
Page 16 of 17
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08/2017CCKM@uwhealth.org

For Patients 5 years of Age or Older
Inpatient Pulmonary Lab Testing [126877]
Pulmonary Lab Testing - Onc Allogeneic Profile
[999992]
ONCE For 1 Occurrences, Routine
Specify Test: Onc Allogeneic Profile (Spirometry, Lung
Volumes, Diffusing Capacity and SpO2)
Pulmonary Lab Testing - Onc Autoogous Profile
[999992]
ONCE, Routine
Reason for Exam:
Specify Test: Onc Autologous Profile (Spirometry,
Diffusing Capacity, and SpO2)
Outpatient (Clinic) Pulmonary Lab Testing [120564]
Pulmonary Lab Testing - Onc Allogeneic Profile
[999992]
Routine
Reason for Exam:
Specify Test: Onc Allogeneic Profile (Spirometry, Lung
Volumes, Diffusing Capacity and SpO2)
Pulmonary Lab Testing - Onc Autologous Profile
[999992]
Routine
Reason for Exam:
Specify Test: Onc Autologous Profile (Spirometry,
Diffusing Capacity, and SpO2)
Specify location (if desired):
Peds Day Treatment Pulmonary Lab Testing [225472]
Pulmonary Lab Testing - Onc Allogeneic Profile
[999992]
ONCE For 1 Occurrences, Routine
Specify Test: Onc Allogeneic Profile (Spirometry, Lung
Volumes, Diffusing Capacity and SpO2)
Peds Diagnostic
Pulmonary Lab Testing - Onc Autologous Profile
[999992]
ONCE, Routine
Reason for Exam:
Specify Test: Onc Autologous Profile (Spirometry,
Diffusing Capacity, and SpO2)
Peds Diagnostic
Consults
Consults [126875]
CONSULT TO RAD ONCOLOGY [1009121] RAD ONC NEXT AVAIL.
CONSULT TO PEDS AUDIOLOGY [1009227] ONCE For 1 Occurrences, What question regarding
the patient's medical care would you like the specialist
to answer?: Hearing Screen
CONSULT TO DENTAL SERVICES [1009271] ONCE For 1 Occurrences, What question regarding
the patient's medical care would you like the specialist
to answer? Dental Screen
CONSULT TO PEDS PSYCHOLOGY - INSIDE
UW Health [1009330]
Details
Page 17 of 17
Printed by STRAKA, KEVIN F [KFS1] at 8/4/2017 2:01:22 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org