/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-97824-en.cckm

201712349

page

100

UWHC,UWMF,

Tools,

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

IP - BMT - Allogeneic Stem Cell Transplant - Adult - Admission [1788]

IP - BMT - Allogeneic Stem Cell Transplant - Adult - Admission [1788] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


IP - BMT - Allogeneic Stem Cell Transplant - Adult - Admission [1788]
Admission Status
Level of Care (Single Response) [187515]
*An admit patient order has already been written, but the level of care at which the patient
should be placed still needs to be identified.
Place Patient on General Care [ADT0018] General Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Place Patient on Intermediate Care (IMC)
[ADT0018]
Intermediate Care, has already been signed. This
order will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intensive Care (ICU) [ADT0018] Intensive Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Admit to Inpatient (Single Response) [188296]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-
only surgery, or a previously-authorized inpatient
stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [106407]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: BONE MARROW TRANSPLANT
Rationale for LOS greater than 2 midnights:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [122711]
Page 1 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: BONE MARROW TRANSPLANT
Rationale for LOS greater than 2 midnights:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [130119]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis (Single Response) [150156]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Page 2 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:08:07 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs [22000]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Activity [22004]
Ad Lib [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition [22006]
Patient Approved for Additional Menu Items
[DIE0010]
Patient may order food items from UWHC café or
Mendota Market? Yes
Patient may order regular soda or other sugar-
sweetened beverages? Yes
Routine, CONTINUOUS For Until specified
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Intake and Output [22007]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today, Routine
BMT Transfusion Protocol [113191]
Page 3 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Initiate BMT Service Transfusion Protocol
[TRAN0001]
CONTINUOUS, Starting today, Routine
Analgesics to be Ordered:
Antihistamines to be Ordered:
Steroids to be Ordered:
Labs to be Ordered:
Total Volume (units) RBC (Pediatric):
Total Volume (mL) RBC (Pediatric):
Total Units Platelets (Pediatric) (1 random donor unit =
45-65 mL; Suggested dose = 1 RDU/12kg; 4 RDU=1
SDU):
Does patient require single donor platelets (If yes,
Blood Bank MD approval required): No
Platelet Threshold: 10,000/microliter
Hemoglobin Threshold: 8 grams/deciliter
Order blood products, premeds and/or post labs as
indicated using order set #4179 IP - BMT - Blood
Transfusion - Supplemental
Non-Categorized Patient Care Orders [33455]
Procedurecare per Bone Marrow Transplant Standard Operating Mouth
Measure Weight Upon Admission
[NURMON0015]
ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
Measure once upon admission
Measure Height Upon Admission [NURMON0052] ONCE For 1 Occurrences, Routine, Measure once
upon admission
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Nursing Communication [NURCOM0022] CONTINUOUS, Starting today, Neutropenic
Precautions should start on Day -3.
Contingency Parameters [22018]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 100
If diastolic blood pressure < (mmHg): 50
If temperature > (C): 38.2 or greater than 38.0 degrees
Celsius sustained for greater than 1 hour
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Pain not controlled with ordered analgesics or
ordered interventions
Medications - General
Date of Transplant [24750]
Note: Anticipated Date of Transplant [950018] CONTINUOUS Starting today
Anticipated Date of Transplant ***
Analgesics [22287]
Page 4 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain, pain or
symptomatic fever greater than 38.2 degrees Celsius
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
oxycodone tab RANGE [750032] 5-10 mg, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
Anti-emetics [152725]
ondansetron (ZOFRAN) tab [45939] 8 mg, Oral, EVERY 8 HOURS PRN, nausea/vomiting
Maximum 24 mg every 24 hours. For first line therapy.
Administer if patient not already on scheduled
ondansetron (ZOFRAN) as part of chemotherapy plan.
ondansetron (ZOFRAN) injection [800202] 8 mg, Intravenous, EVERY 8 HOURS PRN,
nausea/vomiting
Maximum 24 mg every 24 hours. For first line therapy.
Administer if patient not already on scheduled
ondanestron (ZOFRAN) as part of chemotherapy play.
Administer if patient is unable to tolerate orally.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting
For first line therapy if patient is receiving scheduled
ondansetron as part of chemotherapy plan. For
second line therapy if patient received ondansetron as
first line "as needed" therapy but there is no response
within 30 minutes
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
If ordered IV: push slowly, max rate 5 mg/minute.
For first line therapy if patient is receiving scheduled
ondansetron as part of chemotherapy plan. For
second line therapy if patient received ondansetron as
first line "as needed" therapy but there is no response
within 30 minutes
Antivirals - Start on Day of Admission [22304]
acyclovir (ZOVIRAX) cap [44025] 400 mg, Oral, 2 X DAILY
Start on day of Admission
Note: Initiate acyclovir 200 mg IV every 12 hours
if patient unable to tolerate oral medications
[950018]
PRN - NOTIFY PHARMACY WHEN NEEDED, patient
unable to tolerate oral medication
Note: Initiate acyclovir 200 mg IV every 12 hours if
patient unable to tolerate oral medications. Start on
Day of Admission. Maximum Dose = 200 mg
Antifungals - Start on Day 0 [22309]
fluconazole (DIFLUCAN) tab [45168] 400 mg, Oral, 1 X DAILY
Start on Day 0
Note: Initiate fluconazole 400 mg IV once a day if
patient unable to tolerate oral medications
[950018]
PRN - NOTIFY PHARMACY WHEN NEEDED, see
Admin Instructions
Note: Initiate fluconazole 400 mg IV once a day if
patient unable to tolerate oral medications
Anti-infectives - Start on Day 0 [99252]
Page 5 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

levofloxacin (LEVAQUIN) tab [54885] 500 mg, Oral, 1 X DAILY For 365 Days
Start on Day 0 Discontinue when ANC has been
greater than 500/microliter for 3 consecutive days.
Discontinue if patient develops neutropenic fever and
is started on additional antibiotic therapy. Administer
at least 4 hours before or 8 hours after antacids
containing magnesium or aluminum, sucralfate, iron,
multivitamin preparations with zinc, or didanosine.
Anti-infectives - Start When Absolute Neutrophil Count Is Greater Than 1,000/microliter [22310]
Note: Initiation of sulfamethoxazole-trimethoprim
[950018]
PRN - NOTIFY PHARMACY WHEN NEEDED, See
Admin Instructions
NOTE: Start sulfamethoxazole-trimethoprim
(BACTRIM) 400-80 mg 2 tab by mouth every Monday,
Wednesday and Friday when absolute neutrophil
count is greater than 1,000/microliter
Antacids [22313]
mag-al-simeth (MYLANTA ES) susp MULTIDOSE
[44073]
15 mL, Oral, EVERY 4 HOURS PRN, dyspepsia
Bowel Management [22312]
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY PRN, constipation
Dissolve in 240 mL of liquid For first line therapy.
senna-docusate (SENOKOT S) 8.6-50 MG per
tab [60530]
2 tab, Oral, 2 X DAILY PRN, constipation
For second line therapy if there is no response to first
line therapy within 12 hours
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Oral, 1 X DAILY PRN, constipation
For third line therapy if there is no response to second
line therapy within 12 hours
Hypnotics (Single Response) [228331]
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
melatonin tab [119466] 3 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Trazodone - Melatonin [227992] "And" Linked Panel
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use first line.
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
melatonin tab [119466] 3 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use second line if failure to respond to trazodone
within 60 minutes
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Hypnotics (Single Response) [228334]
traZODONE (DESYREL) tab [720150] 25 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
If needed, give prior to midnight if possible. May
contribute to sedation the following day.
Page 6 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:08:07 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

melatonin tab [119466] 1 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Magnesium Supplementation [22325]
magnesium sulfate intraVENOUS [800111] 2 g, Intravenous, 1 X DAILY PRN, serum magnesium
less than or equal to 1.4 mg/dL
Potassium Supplements [22324]
potassium chloride 20 mEq/ 50 mL bag
CENTRAL LINE ONLY [46256]
20 mEq, Intravenous, 1 X DAILY PRN, serum
potassium less than or equal to 3.2 mmol/L, for 60
Minutes
Stress Ulcer Prophylaxis (Single Response) [22316]
famotidine (PEPCID) tab [45134] 20 mg, Oral, 1 X DAILY (HS)
Non-categorized [22326]
cepastat lozenge [114373] 1-2 lozenge, Oral, EVERY 2 HOURS PRN, sore throat
diphenhydramine (BENADRYL) cap [36791] 25 mg, Oral, EVERY 4 HOURS PRN, itching
polyvinyl alcohol (ARTIFICIAL TEARS) 1.4%
ophthalmic soln [64529]
1-2 drop, Eyes (Each), 4 X DAILY PRN, dry eyes
diphenhydramine-lidocaine-al&mag-simethicone
(MAGIC MOUTHWASH) susp [104892]
15-30 mL, Swish & Swallow, EVERY 4 HOURS PRN,
mucositis
folic acid (FOLVITE) tab - NOTE : Start on Day +
14 [37644]
1 mg, Oral, 1 X DAILY
NOTE : Start on Day + 14
multivitamin with mineral tab [800240] 1 tab, Oral, 1 X DAILY
labetalol injection [800192] 20 mg, Intravenous, EVERY 1 HOUR PRN,
hypertension
For Systolic Blood Pressure greater than or equal to
160 mmHg and OR Diastolic Blood Pressure greater
than or equal to 100 mmHg
naloxone (NARCAN) injection [800199] 0.1 mg, Intravenous, PRN, opioid overdose
Administer every 3 minutes times 4 doses for
respiratory rate less than 8 breaths/minute or sedation
score of 5 or greater. Notify MD if naloxone
administered.
sodium chloride (SALINE) 0.65 % nasal spray
[41865]
2 spray, Nostril (Each), EVERY 4 HOURS PRN, nasal
dryness
May leave at bedside.
biotene calcium mouthwash RANGE [750070] 10-15 mL, Swish & Spit, EVERY 4 HOURS PRN, dry
mouth
Leave at bedside.
Premedications for Needle Insertion [106310]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is immediate.
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, peripheral line
insertion - see Admin Instructions
Do NOT apply to area greater than 200 square
centimeters (maximum 2.5 g/site; maximum 4 sites
per hour, 6 times per day). Do NOT leave on longer
than 2 hours. Use for stable patient, no allergies to
lidocaine, with at least 30 minutes time prior to IV use
Page 7 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

sodium chloride (bacteriostatic) 0.9 % injection
[50585]
0.05-0.1 mL, Intradermal, PRN, peripheral line
insertion - see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
Medications - Anti-infectives For Fever
Order one Gram-positive and one Gram-negative agent
Neutropenic Fever Standard Operating Procedure URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/oncology/name-97716-en.cckm
Gram-positive Coverage [105048]
vancomycin (VANCOCIN) intraVENOUS -
Choose when there is concern for cellulitis or line
infection [800084]
1 g, Intravenous, PRN - NOTIFY PHARMACY WHEN
NEEDED, See Admin Instructions
Give every 12 hours for first temperature spike greater
than 38.2 Celsius or temperature greater than 38.0
Celsius sustained for one hour or longer
Gram-negative Coverage (Single Response) [106256]
Pharmacokinetic/Pharmacodynamic Dose
Optimization of Antibiotics for the Treatment of
Gram Negative Infection
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/?path=/content/cpg/infection-and-
isolation/name-97543-en.cckm
Treatment of Patients with Reported Allergies to
Beta-Lactam Antibiotics – Adult – Inpatient clinical
practice guideline
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/?path=/content/cpg/infection-and-
isolation/name-97535-en.cckm
cefepime (MAXIPIME) intraVENOUS [240031]
cefepime (MAXIPIME) 1 g vial + minibag [52161] 1 g, Intravenous, PRN - NOTIFY PHARMACY
WHEN NEEDED
Give for first temperature spike greater than 38.2
Celsius or temperature greater than 38.0 Celsius
sustained for one hour or longer
for 30 Minutes
cefepime (MAXIPIME) 1 g vial + minibag [52161] 1 g, Intravenous, PRN - NOTIFY PHARMACY
WHEN NEEDED
Start 6 hours after initial one-time order. Give every
6 hours for first temperature spike greater than 38.2
Celsius or temperature greater than 38.0 Celsius
sustained for one hour or longer
for 4 Hours
NOTE: Run cefepime over 4 hours every 6 hours.
For additional information please refer to
“Pharmacokinetic/ Pharmacodynamic Dose
Optimization of Antibiotics for the Treatment of
Gram Negative Infection” as above [950056]
PRN - NOTIFY PHARMACY WHEN NEEDED
meropenem (MERREM) intraVENOUS - Choose
meropenem when patient has received both
cefepime and piperacillin/ tazobactam in the past
90 days. [800055]
500 mg, Intravenous, PRN - NOTIFY PHARMACY
WHEN NEEDED For 365 Days, See Admin
Instructions
Administer every 6 hours per UWHC Guidelines for
the Pharmacokinetic/Pharmacodynamic Dose
Optimization of Antibiotics for the Treatment of Gram
Negative Infection for first fever spike.
Page 8 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

aztreonam (AZACTAM) intraVENOUS - Choose
when patient has severe or immediate IgE
mediated allergy to beta-lactam antibiotics. Must
order concurrent IV vancomycin. [800013]
2 g, Intravenous, PRN - NOTIFY PHARMACY WHEN
NEEDED For 365 Days
Do Not Administer IV Push Give every 8 hours for first
temperature spike greater than 38.2 Celsius or
temperature greater than 38.0 Celsius sustained for
one hour or longer. See Treatment of Patients with
Reported Allergies to Beta-Lactam Antibiotics - Adult -
Inpatient clinical practice guideline.
ciprofloxacin (CIPRO) intraVENOUS - Choose
when patient has severe or immediate IgE
mediated allergy to beta-lactam antibiotics. Must
order concurrent IV vancomycin [800031]
400 mg, Intravenous, PRN - NOTIFY PHARMACY
WHEN NEEDED
Give every 8 hours for first temperature spike greater
than 38.2 Celsius or temperature greater than 38.0
Celsius sustained for one hour or longer
See Treatment of Patients with Reported Allergies to
Beta-Lactam Antibiotics - Adult - Inpatient clinical
practice guideline.
Medications - Flushes/Catheter Maintenance
Flushes - Peripheral [22318]
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care
Flush per Vascular Access Device guidelines
Flushes - CVC or Tunneled Hickman [22320]
heparin lock flush 10 units/mL 5 mL injection
[75031]
1-150 units, Flush, PRN, flush/line care
Flush per Vascular Access Device guidelines
Flushes - PICC Line Flush [22321]
heparin lock flush 10 units/mL 5 mL injection
[75031]
1-150 units, Flush, PRN, flush/line care
Flush per Vascular Access Device guidelines
Laboratory
On Admission [22093]
CBC WITH DIFFERENTIAL [CBC] NEXT DRAW, Starting today 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, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] NEXT DRAW, Starting today 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, Starting today 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, Starting today 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 9 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

GLUCOSE [GLU] NEXT DRAW, Starting today 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, Starting today 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, Starting today 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, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALBUMIN [ALB] NEXT DRAW, Starting today 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, Starting today 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, Starting today 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, Starting today 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, Starting today 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, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] NEXT DRAW, Starting today 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 10 of 18
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12/2017CCKM@uwhealth.org

GGT [GGT] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LD, TOTAL [LDH] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
IMMUNOGLOBULIN G, SERUM [XIGG] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
IMMUNOGLOBULIN A [XIGA] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
IMMUNOGLOBULIN M [XGAM3] NEXT DRAW, Starting today 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 CLEARANCE [HCCCLR] Panel
CREATININE [CRET] NEXT AM For 1 Occurrences, Routine
CREATININE, URINE (FOR CLEARANCE)
[HCUCCR]
NEXT AM For 1 Occurrences, Routine
VOLUME AND PERIOD, URINE [HCVP] NEXT AM For 1 Occurrences, Routine
PROTEIN, TOTAL, URINE, 24 HOUR [UPRO] ONCE, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
C. DIFF TOXIN B PCR, B6/6 SCREENING ONLY
[CDIFFS]
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?
On Admission, if Patient has Central Venous Catheter [25970]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL For 1 Days, Routine, For optimum
diagnosis of sepsis, sample 3-4 sites only on the first
day of a septic episode. Cultures on subsequent days
are of minimal diagnostic value. Culture detects
bacteria, Candida and Cryptococcus. If filamentous
fungi are suspected see Culture, Blood, Filamentous
Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? If patient has an
existing central venous catheter. One sample from
each existing port.
Draw Once, for First Temperature Greater than or Equal to 38.2 Celsius or Sustained Fever of 38.0
Celsius for Greater than 1 Hour - Days -6 through 0 [25971]
Page 11 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:08:07 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

For First Fever Spike: [NURCOM0055] ONCE, Starting today For 1 Occurrences, Routine,
For first fever spike, draw from all ports of line and
peripheral. To be placed with Culture, Blood, Bacteria
and Yeast order.
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL For 7 Days, Routine, For optimum
diagnosis of sepsis, sample 3-4 sites only on the first
day of a septic episode. Cultures on subsequent days
are of minimal diagnostic value. Culture detects
bacteria, Candida and Cryptococcus. If filamentous
fungi are suspected see Culture, Blood, Filamentous
Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
One sample from each port and Peripheral / Other:
peripherally, if patient has existing central venous
catheter. Days -6 through 0.
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days -6 - 0
CULTURE, URINE [URC] CONDITIONAL For 7 Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days -6 through 0.
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
CONDITIONAL For 7 Days, Routine, For patients with
an ET tube or tracheostomy, quantitative mini-BAL by
RT or bronchoscopic BAL are the preferred methods
of specimen collection.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days -6 through 0.
Draw Once, for First Temperature Greater than or Equal to 38.2 Celsius or Sustained Fever of 38.0
Celsius for Greater than 1 Hour - Days 1 through 7 [25972]
Page 12 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:08:07 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL, Starting 12/23/17 For 7 Days,
Routine, For optimum diagnosis of sepsis, sample 3-4
sites only on the first day of a septic episode. Cultures
on subsequent days are of minimal diagnostic value.
Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
One sample from each port and Peripheral / Other:
peripherally, if patient has existing central venous
catheter. Days 1 through 7.
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL, Starting 12/23/17 For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days 1 - 7.
CULTURE, URINE [URC] CONDITIONAL, Starting 12/23/17 For 7 Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days 1 through 7.
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
CONDITIONAL, Starting 12/23/17 For 7 Days,
Routine, For patients with an ET tube or
tracheostomy, quantitative mini-BAL by RT or
bronchoscopic BAL are the preferred methods of
specimen collection.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days 1 through 7.
Draw Once, for First Temperature Greater than or Equal to 38.2 Celsius or Sustained Fever of 38.0
Celsius for Greater than 1 Hour - Days 8 through 14 [25973]
Page 13 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:08:07 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL, Starting 12/30/17 For 7 Days,
Routine, For optimum diagnosis of sepsis, sample 3-4
sites only on the first day of a septic episode. Cultures
on subsequent days are of minimal diagnostic value.
Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
One sample from each port and Peripheral / Other:
peripherally, if patient has existing central venous
catheter. Days 8 through 14.
CULTURE, URINE [URC] CONDITIONAL, Starting 12/30/17 For 7 Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days 8 through 14.
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL, Starting 12/30/17 For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
DAys 8 - 14.
Days 8 through 14
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
CONDITIONAL, Starting 12/30/17 For 7 Days,
Routine, For patients with an ET tube or
tracheostomy, quantitative mini-BAL by RT or
bronchoscopic BAL are the preferred methods of
specimen collection.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days 8 through 14.
Draw Once, for First Temperature Greater than or Equal to 38.2 Celsius or Sustained Fever of 38.0
Celsius for Greater than 1 Hour - Days 15 through 21 [25974]
Page 14 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:08:07 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL, Starting 1/6/18 For 7 Days, Routine,
For optimum diagnosis of sepsis, sample 3-4 sites
only on the first day of a septic episode. Cultures on
subsequent days are of minimal diagnostic value.
Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
One sample from each port and Peripheral / Other:
peripherally, if patient has existing central venous
catheter. Days 15 through 21.
CULTURE, URINE [URC] CONDITIONAL, Starting 1/6/18 For 7 Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days 15 through 21.
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL, Starting 1/6/18 For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days 15 - 21.
Days 15 through 21
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
CONDITIONAL, Starting 1/6/18 For 7 Days, Routine,
For patients with an ET tube or tracheostomy,
quantitative mini-BAL by RT or bronchoscopic BAL are
the preferred methods of specimen collection.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days 15 through 21.
Draw Once, for First Temperature Greater than or Equal to 38.2 Celsius or Sustained Fever of 38.0
Celsius for Greater than 1 Hour - Days 22 through 28 [25975]
Page 15 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:08:07 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL, Starting 1/13/18 For 7 Days, Routine,
For optimum diagnosis of sepsis, sample 3-4 sites
only on the first day of a septic episode. Cultures on
subsequent days are of minimal diagnostic value.
Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
One sample from each port and Peripheral / Other:
peripherally, if patient has existing central venous
catheter. Days 22 through 28.
CULTURE, URINE [URC] CONDITIONAL, Starting 1/13/18 For 7 Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days 22 through 28.
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL, Starting 1/13/18 For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days 22 - 28.
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
CONDITIONAL, Starting 1/13/18 For 7 Days, Routine,
For patients with an ET tube or tracheostomy,
quantitative mini-BAL by RT or bronchoscopic BAL are
the preferred methods of specimen collection.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days 22 through 28.
Draw Once, for First Temperature Greater than or Equal to 38.2 Celsius or Sustained Fever of 38.0
Celsius for Greater than 1 Hour - Days 29 through 35 [25976]
Page 16 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:08:07 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL, Starting 1/20/18 For 7 Days, Routine,
For optimum diagnosis of sepsis, sample 3-4 sites
only on the first day of a septic episode. Cultures on
subsequent days are of minimal diagnostic value.
Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
One sample from each port and Peripheral / Other:
peripherally, if patient has existing central venous
catheter. Days 29 through 35.
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL, Starting 1/20/18 For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days 29 - 35
CULTURE, URINE [URC] CONDITIONAL, Starting 1/20/18 For 7 Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days 29 through 35.
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
CONDITIONAL, Starting 1/20/18 For 7 Days, Routine,
For patients with an ET tube or tracheostomy,
quantitative mini-BAL by RT or bronchoscopic BAL are
the preferred methods of specimen collection.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Once, for first
temperature greater than or equal to 38.2 Celsius or
sustained fever of 38.0 Celsius for greater than 1 hour.
Days 29 through 35.
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging - Once if temperature greater than 38.2 Celsius or sustained fever of 38.0
Celsius for greater than 1 hour [22060]
Page 17 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:08:07 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

X-RAY CHEST PA & LAT VIEWS [R71020] CONDITIONAL For 1 Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? new onset fever
What specific question(s) would you like answered by
this exam? neutropenic fever
Relevant recent/past history? patient is post allogeneic
stem cell transplant.
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
If Conditional, What Condition? Draw Once if
temperature greater than 38.2 Celsius or sustained
fever of 38.0 Celsius for greater than 1 hour
Consults
Consult [22127]
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
Bone Marrow Transplant Patient
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: OTHER
Evaluate and follow during stem cell transplant
Consult Radiation Oncology (Inpatient)
[CON0066]
ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Evaluate and plan for
total body radiation therapy
Consult Audiology (Inpatient) [CON0125] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: baseline assessment, pre-
transplant
Consult ENT (Inpatient) [CON0024] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): evaluate for potential
infection
Consult Ophthalmology-General (Inpatient)
[CON0048]
ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): baseline exam to
include; Slit Lamp and Schirmir's test
BestPractice
No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
Page 18 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:08:07 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org