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/clinical/cckm-tools/content/order-sets/inpatient/bmtoncologyhematology/name-97826-en.cckm

20170106

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 - Autologous Stem Cell Transplant - Adult - Admission [1821]

IP - BMT - Autologous Stem Cell Transplant - Adult - Admission [1821] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


SmartSet: IP - BMT - AUTOLOGOUS STEM CELL TRANSPLANT - ADULT -
ADMISSION (ID:1821)
General Information
Display name: IP - BMT - Autologous Stem Cell Transplant - Adult - Admission
Type: General
Merge priority: 0
Version comment:
Content source:
Synonyms: 1. BMT
2. AUTOLOGOUS STEM CELL TRANSPLANT
3. BMT AUTO
4. .BMT
SmartSet notes:
Description:
Web information: Title URL
1.
Questionnaire:
Configuration
Admission Status
Level of Care
Place Patient on General Care 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) 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) 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)
Page 1 of 17
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Admit To Inpatient 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)
Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response)
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status
Admit To Inpatient Attending:
Admitting Resident:
Requested Floor:
Service: BONE MARROW TRANSPLANT
Rationale for LOS greater than 2 midnights:
Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status
Admit To Inpatient Attending:
Admitting Resident:
Requested Floor:
Service: BONE MARROW TRANSPLANT
Rationale for LOS greater than 2 midnights:
Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Venous Thromboembolism (VTE) Prophylaxis
Page 2 of 17
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01/2017CCKM@uwhealth.org

VTE Prophylaxis
Low VTE Risk
VTE Prophylaxis - Reason Not Ordered ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response)
enoxaparin (LOVENOX) subcutaneous injection 40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk
Sequential Compression Device (SCD)
(TREATMENT)
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY)
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis
VTE Prophylaxis - Reason Not Ordered ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis
Low VTE Risk
VTE Prophylaxis - Reason Not Ordered ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response)
enoxaparin (LOVENOX) subcutaneous injection 40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk
Sequential Compression Device (SCD)
(TREATMENT)
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY)
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis
VTE Prophylaxis - Reason Not Ordered ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs
Page 3 of 17
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Vital Signs EVERY 4 HOURS, Starting S For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Activity
Ad Lib CONTINUOUS, Starting S, 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
Patient Approved for Additional Menu Items 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 EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Respiratory
Intake and Output
Measure Intake And Output EVERY 8 HOURS, Starting S, Routine
Measure Intake And Output EVERY 4 HOURS, Starting S, Routine
BMT Transfusion Protocol
Initiate BMT Service Transfusion Protocol CONTINUOUS, Starting S, 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
Page 4 of 17
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Non-Categorized Patient Care Orders
Measure Weight Upon Admission ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
Measure once upon admission
Measure Height Upon Admission ONCE For 1 Occurrences, Routine, Measure once
upon admission
Measure Weight 1X DAILY, Starting S, Routine
Weigh With?
Weigh when?
Nursing Communication CONTINUOUS, Starting S, Neutropenic Precautions
should start on Day -3.
Contingency Parameters
Notify Provider 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
Note: Anticipated Date of Transplant CONTINUOUS Starting S
Anticipated Date of Transplant ***
Analgesics - Acetaminophen PRN
acetaMINOPHEN (TYLENOL) tab 650 mg, Oral, EVERY 4 HOURS PRN, pain/fever
Mild pain, multimodal therapy or temperature greater
than 38.2 C
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension
650 mg, Oral, EVERY 4 HOURS PRN, pain
Mild pain, multimodal therapy or temperature greater
than 38.2 C
Analgesics - Opioids - PRN
oxycodone tab RANGE 5-10 mg, Oral, EVERY 4 HOURS PRN, pain
Severe pain
Anti-emetics
Page 5 of 17
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ondansetron (ZOFRAN ODT) disintegrating tab 8 mg, Oral, EVERY 4 HOURS PRN, nausea/vomiting
First line therapy. Administer if patient not already on
scheduled ondansetron (ZOFRAN) as part of
chemotherapy plan. Maximum 24 mg every 24
hours.
ondansetron (ZOFRAN) injection 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 plan. Administer if patient is unable to
tolerate orally.
prochlorperazine (COMPAZINE) tab 10 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Second line therapy. Administer when there is no
response to first line therapy with 30 minutes.
prochlorperazine (COMPAZINE) injection 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Second line therapy. Administer if there is no
response to first line therapy within 30 minutes.
Antivirals - Start on Day of Admission
acyclovir (ZOVIRAX) cap 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
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
fluconazole (DIFLUCAN) tab 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
PRN - NOTIFY PHARMACY WHEN NEEDED, see
Admin Instructions
Note: Initiate fluconazole 400 mg IV once a day if
patient unable to tolerate oral medications
Bacterial Prophylaxis
levofloxacin (LEVAQUIN) tab 500 mg, Oral, 1 X DAILY (HS) Starting S 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 - Starting When Absolute Neutrophil Count Is Greater Than 1,000/microliter
Note: Initiation of sulfamethoxazole-trimethoprim 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
Page 6 of 17
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mag-al-simeth (MYLANTA ES) susp
MULTIDOSE
15 mL, Oral, EVERY 4 HOURS PRN, dyspepsia
Bowel Management
polyethylene glycol (MIRALAX) oral powder 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
2 tab, Oral, 2 X DAILY PRN, constipation
For second line therapy
magnesium hydroxide (MILK OF MAGNESIA)
susp
30 mL, Oral, 1 X DAILY PRN, constipation
Third line therapy. Administer when there is no
response to first and second line therapies and
immediate laxation is needed.
Hypnotics
traZODONE (DESYREL) tab 25-50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions. May repeat X 1 if no response within
60 minutes. If there is no sufficient response to
second dose, contact physician for further direction.
Magnesium Supplementation
magnesium sulfate intraVENOUS 2 g, Intravenous, 1 X DAILY PRN, serum magnesium
less than or equal to 1.4 mg/dL
Potassium Supplements
potassium chloride 20 mEq/ 100 mL bag 20 mEq, Intravenous, 1 X DAILY PRN, serum
potassium less than or equal to 3.2 mmol/L, for 60
Minutes
Stress Ulcer Prophylaxis
ranitidine (ZANTAC) tab 150 mg, Oral, 1 X DAILY (HS)
Non-categorized
cepastat lozenge 1-2 lozenge, Oral, EVERY 2 HOURS PRN, sore
throat
diphenhydramine (BENADRYL) cap 25 mg, Oral, EVERY 4 HOURS PRN, itching
polyvinyl alcohol (ARTIFICIAL TEARS) 1.4%
ophthalmic soln
1-2 drop, Eyes (Each), 4 X DAILY PRN, dry eyes
diphenhydramine-lidocaine-al&mag-simethicone
(MAGIC MOUTHWASH) susp
15-30 mL, Swish & Swallow, EVERY 4 HOURS PRN,
mucositis
folic acid (FOLVITE) tab - NOTE : Start on Day +
14
1 mg, Oral, 1 X DAILY
NOTE : Start on Day + 14
multivitamin with mineral tab 1 tab, Oral, 1 X DAILY
naloxone (NARCAN) injection 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 2 spray, Nostril (Each), EVERY 4 HOURS PRN,
nasal dryness
May leave at bedside.
biotene calcium mouthwash RANGE 10-15 mL, Swish & Spit, EVERY 4 HOURS PRN, Dry
mouth
Leave at bedside
guaifenesin (ROBITUSSIN) 100 MG/5ML soln Oral, EVERY 4 HOURS PRN, cough
Premedications for Needle Insertion
Page 7 of 17
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lidocaine (LMX) 4% topical dressing kit 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
lidocaine (XYLOCAINE) 1% injection 0.1-0.4 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. Choice of medication should be based on
patient’s previous experience/preference, history of
lidocaine allergy and ease of access
sodium chloride (bacteriostatic) 0.9 % injection 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. Choice of medication should be based on
patient’s previous experience/preference, history of
lidocaine allergy and ease of access
Medications - Anti-infectives For Fever
Broad Spectrum Coverage
cefepime (MAXIPIME) intraVENOUS
cefepime (MAXIPIME) 2 g vial + minibag 2 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 1 g, Intravenous, PRN - NOTIFY PHARMACY
WHEN NEEDED, See admin instructions
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
PRN - NOTIFY PHARMACY WHEN NEEDED,
See admin instructions
meropenem (MERREM) intraVENOUS - Choose
meropenem when patient has received both
cefepime and piperacillin/ tazobactam in the
past 90 days.
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 17
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aztreonam (AZACTAM) intraVENOUS - Choose
when patient has severe or immediate IgE
mediated allergy to beta-lactam antibiotics.
Must order concurrent IV vancomycin.
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
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.
Gram-positive Coverage
vancomycin (VANCOCIN) intraVENOUS -
Choose when there is concern for cellulitis or
line infection
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
Anaerobic Coverage
metRONIDazole (FLAGYL) intraVENOUS -
Choose when there is concern for intra-
abdominal infection
500 mg, Intravenous, PRN - NOTIFY PHARMACY
WHEN NEEDED
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
metRONIDazole (FLAGYL) tab - Choose when
there is concern for intra-abdominal infection
500 mg, Oral, PRN - NOTIFY PHARMACY WHEN
NEEDED
Give every four times a day for first temperature spike
greater than 38.2 Celsius or temperature greater than
38.0 Celsius sustained for one hour or longer
Medications - Flushes/Catheter Care
Flushes - Peripheral
sodium chloride 0.9% flush 10 mL injection Flush, PRN, flush/line care
Flush per Vascular Access Device guidelines
Flushes - CVC or Tunneled Hickman
heparin lock flush 10 units/mL 5 mL injection 1-150 units, Flush, PRN, flush/line care
Flush per Vascular Access Device guidelines
Flushes - PICC Line Flush
heparin lock flush 10 units/mL 5 mL injection 1-150 units, Flush, PRN, flush/line care
Flush per Vascular Access Device guidelines
Laboratory
Page 9 of 17
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01/2017CCKM@uwhealth.org

On Admission
CBC WITH DIFFERENTIAL NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 17
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URIC ACID NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
KAPPA/LAMDBA QUANT FREE LIGHT NEXT DRAW, Starting S 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 ELECTROPHORESIS, REFLEX TO
IFIX
Lab Test Directory URL: https://uconnect.wisc.edu/clinical/tools-
resources/lab-test-directory/immunology/name-
68190-en.labtest
PROTEIN, TOTAL NEXT DRAW, Starting S 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 ELECTROPHORESIS, REFLEX TO
IFIX
NEXT DRAW, Starting S 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 ELECTROPHORESIS, URINE 24 HR ONCE, Starting S For 1 Occurrences, Routine, This
test is used to quantitate monoclonal bands
previously identified by urine immunofixation.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE CLEARANCE Panel
CREATININE NEXT AM For 1 Occurrences, Routine
CREATININE, URINE (FOR CLEARANCE) NEXT AM For 1 Occurrences, Routine
VOLUME AND PERIOD, URINE NEXT AM For 1 Occurrences, Routine
Page 11 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2017 11:45:36 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

PROTEIN, TOTAL, URINE, 24 HOUR ONCE, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
IMMUNOFIXATION WITH REFLEX TO
QUANTITATION, URINE, 24 HOURS
ONCE, Starting S 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 existing central venous catheter
CULTURE, BLOOD, BACTERIA AND YEAST CONDITIONAL - RN COLLECT For 4 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 though 0
For First Fever Spike: ONCE, Starting S 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 CONDITIONAL - RN COLLECT 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 CONDITIONAL - RN COLLECT 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
Page 12 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2017 11:45:36 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

CULTURE, URINE CONDITIONAL - RN COLLECT 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 through 0.
CULTURE, SPUTUM WITH GRAM STAIN CONDITIONAL - RN COLLECT 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
CULTURE, BLOOD, BACTERIA AND YEAST CONDITIONAL - RN COLLECT, Starting S+8 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 CONDITIONAL - RN COLLECT, Starting S+8 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 CONDITIONAL - RN COLLECT, Starting S+8 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 through 7.
Page 13 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2017 11:45:36 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

CULTURE, SPUTUM WITH GRAM STAIN CONDITIONAL - RN COLLECT, Starting S+8 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
CULTURE, BLOOD, BACTERIA AND YEAST CONDITIONAL - RN COLLECT, Starting S+15 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 CONDITIONAL - RN COLLECT, Starting S+15 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 through 14.
URINALYSIS WITH MICROSCOPY CONDITIONAL - RN COLLECT, Starting S+15 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
Page 14 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2017 11:45:36 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

CULTURE, SPUTUM WITH GRAM STAIN CONDITIONAL - RN COLLECT, Starting S+15 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
CULTURE, BLOOD, BACTERIA AND YEAST CONDITIONAL - RN COLLECT, Starting S+22 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 CONDITIONAL - RN COLLECT, Starting S+22 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 through 21.
URINALYSIS WITH MICROSCOPY CONDITIONAL - RN COLLECT, Starting S+22 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
Page 15 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2017 11:45:36 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

CULTURE, SPUTUM WITH GRAM STAIN CONDITIONAL - RN COLLECT, Starting S+22 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.
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
X-RAY CHEST PA & LAT VIEWS 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
Consults
Consult Physical Therapy (Inpatient) Eval and
Treat
ONCE, Starting S For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
Bone Marrow Transplant Patient
Consult Social Work (Inpatient) ONCE, Starting S For 1 Occurrences, Routine
Reason for Consult: OTHER
Evaluate and follow during stem cell transplant.
BestPractice
No Hospital Problems have yet been identified.
Specify Hospital Problem(s) You will be prompted to specify a hospital problem on
signing.
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Printed by STRAKA, KEVIN F [KFS1] at 1/4/2017 11:45:36 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

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Printed by STRAKA, KEVIN F [KFS1] at 1/4/2017 11:45:36 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org