/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-97837-en.cckm

201711307

page

100

UWHC,UWMF,

Tools,

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

IP - Chemotherapy - Pediatric - Admission [1494]

IP - Chemotherapy - Pediatric - Admission [1494] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


IP - Chemotherapy - Pediatric - Admission [1494]
Admission Status
Level of Care (Single Response) [186484]
*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 (Single Response) [82665]
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:
Page 1 of 10
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [7248]
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 [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Isolation Status
Isolation [121598]
Isolation - Protective Precautions - Panel
[116356]
Protective Precautions [ISO0001] CONTINUOUS
Reason for Protective Precautions:
Protective - Positive Pressure Room
[NURCOM0109]
CONTINUOUS
Patient Care Orders
Vital Signs [94325]
Vital Signs [NURMON0013] EVERY 8 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Pediatric Early Warning Signs [NURMON0060] SEE COMMENTS, Starting today with First
Occurrence As Scheduled, Every 4 hours.
Patient Monitoring [94326]
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today, Routine
Activity [94327]
Page 2 of 10
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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 [94328]
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Patient Approved for Additional Menu Items
[DIE0010]
Patient may order food items from UWHC café or
Mendota Market?
Patient may order regular soda or other sugar-
sweetened beverages?
Routine, CONTINUOUS
Respiratory [94331]
Note: If ordering patient on oxygen, also order Respiratory Therapy consult.
Pulse Oximetry [NURMON0009] SEE COMMENTS, Starting today with First
Occurrence As Scheduled, Routine, Every *** hours.
Non-Categorized Patient Care Orders [20359]
Measure Height [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine,
Obtain upon admission.
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Oral Care [129501]
Oral Care [NURCOM0022] CONTINUOUS, Starting today, Brush teeth with
Biotene toothpaste on a soft toothbrush for 90
seconds twice a day. Replace toothbrush weekly.
Rinse mouth with 15-30 mL of normal saline after
brushing. Swish and spit vigorously four times a day.
Give new bottle of saline every day. If patient unable
to tolerate normal saline, may use sterile water.
Perform lip care twice per day.
Skin Care [225309]
Chlorhexidine Gluconate (CHG) treatment
[NURCOM0022]
1X DAILY
Central Line Care [24574]
Maintain PICC [NURVAD0050] CONTINUOUS, Routine
Device Status: Ready For Use
Site:
PICC Secured With:
Flush With(Must also enter separate medication order
to obtain drug): Heparinized Saline
Site Assessment Frequency: EVERY 8 HOURS
Page 3 of 10
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Maintain Tunneled Central Venous Catheter
[NURVAD0003]
CONTINUOUS, Routine
Device Status: Ready For Use
Type: Hickman
Site:
Location:
Flush With(Must also enter separate medication order
to obtain drug): Heparinized Saline (Every 24 hours or
after each use)
Site Assessment Frequency: EVERY 8 HOURS
Maintain Central Implanted Port [NURVAD0005] CONTINUOUS, Routine
Device Status: Ready For Use
Type:
Site:
Maintain catheter, site, and dressing per Nursing and
Patient Care Policy, 1.56 AP - Central Vascular
Access Device Use, Maintenance and Removal (Adult
& Pediatric).
Contingency Parameters [121602]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
If diastolic blood pressure > (mmHg): 65
If diastolic blood pressure < (mmHg): 45
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 180
If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
Pulse Oximetry < (%): 95
Other: Hemoglobin is less than or equal to 8.0
g/dL,Platelet count is less than or equal to
10K/uL,Absolute neutrophil count (ANC) is less than
500/uL,Patient has more than 3 diarrheal stools per
day,Patient has more than 3 emesis per day
Contingency Parameters [121603]
Page 4 of 10
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 85
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If temperature < (C):
If heart rate > (bpm): 160
If heart rate < (bpm): 80
If respiratory rate >: 40
If respiratory rate <: 20
If blood glucose > (mg/dL): 200
If blood glucose < (mg/dL): 80
If pain score >:
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: Hemoglobin is less than or equal to 8.0
g/dL,Platelet count is less than or equal to
10K/uL,Absolute neutrophil count (ANC) is less than
500/uL,Patient has more than 3 diarrheal stools per
day,Patient has more than 3 emesis per day
Contingency Parameters [121605]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 87
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 140
If heart rate < (bpm): 75
If respiratory rate >: 30
If respiratory rate <: 18
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: Hemoglobin is less than or equal to 8.0
g/dL,Platelet count is less than or equal to
10K/uL,Absolute neutrophil count (ANC) is less than
500/uL,Patient has more than 3 diarrheal stools per
day,Patient has more than 3 emesis per day
Contingency Parameters [121606]
Page 5 of 10
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 3:40:35 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 125
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 120
If heart rate < (bpm): 70
If respiratory rate >: 24
If respiratory rate <: 14
Pulse Oximetry < (%): 93
Other: Hemoglobin is less than or equal to 8.0
g/dL,Platelet count is less than or equal to
10K/uL,Absolute neutrophil count (ANC) is less than
500/uL,Patient has more than 3 diarrheal stools per
day,Patient has more than 3 emesis per day
Contingency Parameters [121607]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 140
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 110
If heart rate < (bpm): 60
If respiratory rate >: 22
If respiratory rate <: 12
Pulse Oximetry < (%): 93
Other: Hemoglobin is less than or equal to 8.0
g/dL,Platelet count is less than or equal to
10K/uL,Absolute neutrophil count (ANC) is less than
500/uL,Patient has more than 3 diarrheal stools per
day,Patient has more than 3 emesis per day
Intravenous Therapy
Premedication for Needle Insertion [30232]
Lidocaine [152737]
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, prior to needle sticks
to reduce pain. See "LMX Use Instructions" order in
Active Orders report or the Admin Instructions for
application details
FOR PATIENTS 5 Kg OR LESS: Do NOT apply to
area greater than 100 square centimeters.
(maximum 1 g/site; maximum 1 site per hour, 6
times per day).
FOR PATIENTS 5.1-10 Kg: Do NOT apply to area
greater than 100 square centimeters. (maximum 1
g/site; maximum 2 sites per hour, 6 times per day).
FOR PATIENTS GREATER THAN 10 Kg: Do NOT
apply to area greater than 200 square centimeters.
(maximum 2.5 g/site; maximum 4 sites per hour, 6
times per day).
For patients less than 1 year old do NOT leave on
longer than 1 hour. For patients 1 year or older do
NOT leave on longer than 2 hours
Page 6 of 10
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Details
Medications - General
Bowel Management - Scheduled [121571]
polyethylene glycol (MIRALAX) oral packet -
NOTE: Suggested dose 8.5 or 17 g/dose one or
two times a day [61829]
Oral
Hold for loose stools
NOTE: Suggested dose 8.5 or 17 g/dose one or two
times a day
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
- NOTE: Suggested dose 1 or 2 tablets one or two
times a day [60530]
Oral
Hold for loose stools
NOTE: Suggested dose 1 or 2 tablets one or two
times a day
lactulose (CEPHULAC) soln - NOTE: Suggested
dose 2.5-10 mL/dose one to three times a day
[75426]
Oral
Hold for loose stools
lacNOTE: Suggested dose 2.5-10 mL/dose one to
three times a day
Bowel Management - As Needed [19348]
polyethylene glycol (MIRALAX) oral packet -
NOTE: Suggested dose 8.5 or 17 g/dose one or
two times a day as needed [61829]
Oral
Hold for loose stools
NOTE: Suggested dose 8.5 or 17 g/dose one or two
times a day as needed
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
- NOTE: Suggested dose 1 or 2 tablets one to two
times a day as needed [60530]
Oral
Hold for loose stools
NOTE: Suggested dose 1 or 2 tablets one to two times
a day as needed
lactulose (CEPHULAC) soln - NOTE: Suggested
dose 2.5-10 mL/dose one to three times a day as
needed [75426]
Oral
Hold for loose stools
NOTE: Suggested dose 2.5-10 mL/dose one to three
times a day as needed
Antifungals (Single Response) [121572]
fluconazole (DIFLUCAN) susp - NOTE:
Suggested dose 4-6 mg/kg/dose (Maximum 400
mg/dose) [800222]
Oral, 1 X DAILY (HS) Starting today
NOTE: Suggested dose 4-6 mg/kg/dose (Maximum
400 mg/dose)
fluconazole (DIFLUCAN) tab - NOTE: Suggested
dose 4-6 mg/kg/dose (Maximum 400 mg/dose)
[45168]
Oral, 1 X DAILY (HS) Starting today
NOTE: Suggested dose 4-6 mg/kg/dose (Maximum
400 mg/dose)
Antibiotics (Single Response) [121573]
sulfamethoxazole-trimethoprim (BACTRIM) 200-
40 MG/5ML susp - NOTE: Suggested dose 2.5
mg trimethoprim/kg/dose (Maximum 160 mg of
trimethoprim/dose) [58784]
2.5 mg/kg, Oral, 2 X DAILY SAT, SUN
NOTE: Suggested dose 2.5 mg trimethoprim/kg/dose
(Maximum 160 mg of trimethoprim/dose)
sulfamethoxazole-trimethoprim (BACTRIM) 200-
40 mg per half-tab - NOTE: Suggested dose 2.5
mg trimethoprim/kg/dose (Maximum 160 mg of
trimethoprim/dose) [720141]
Oral, 2 X DAILY SAT, SUN
NOTE: Suggested dose 2.5 mg trimethoprim/kg/dose
(Maximum 160 mg of trimethoprim/dose)
sulfamethoxazole-trimethoprim (BACTRIM) 400-
80 MG per tab - NOTE: Suggested dose 2.5 mg
trimethoprim/kg/dose (Maximum 160 mg of
trimethoprim/dose) [42457]
Oral, 2 X DAILY SAT, SUN
NOTE: Suggested dose 2.5 mg trimethoprim/kg/dose
(Maximum 160 mg of trimethoprim/dose)
atovaquone (MEPRON) 750 MG/5ML susp -
NOTE: Order for patients < 4 months and greater
than 2 years allergic to sulfamethoxazole
Maximum Dose = 1500 mg/dose [50620]
30 mg/kg, Oral, 1 X DAILY
NOTE: Order for patients < 4 months and greater
than 2 years allergic to sulfamethoxazole
Page 7 of 10
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

atovaquone (MEPRON) 750 MG/5ML susp -
NOTE: Order for patients 4 to 24 months of age
allergic to sulfamethoxazole Maximum Dose =
1500 mg/dose [50620]
45 mg/kg, Oral, 1 X DAILY
NOTE: Order for patients 4 to 24 months of age
allergic to sulfamethoxazole
Sucrose for Oral Analgesia [110384]
sucrose (SWEET-EASE) 24% buccal soln
[794009]
Oral, PRN, pain, mild pain or potentially painful
procedures. See Admin Instructions
Non-categorized [121574]
heparin lock flush 10 UNIT/ML injection [75031] 1-150 units, Flush, PRN, flush/line care
Flush per VAD guideline
heparin lock flush 100 units/mL 5 mL injection
[64978]
500 units, Flush, PRN, flush/line care
Implanted port use ONLY to be used when de-
accessing port. Flush per VAD guidelines
Laboratory
Admission Labs (Labs Not Completed in Past 7 Days) [20363]
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?
SMEAR TO ORDERING MD [HCSMER] 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?
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?
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?
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?
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?
Page 8 of 10
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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?
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?
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?
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?
URINALYSIS WITH MICROSCOPY [UA] 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?
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?
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?
Consults
Consults [20365]
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: OTHER (Routine Chemo
Admission)
Evaluate and treat.
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult:
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Activity
Tolerance
Consult Pediatric Health Psychology (Inpatient)
[CON0202]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-Friday)
or if special assessment needs.
Reason for Consult: Routine Chemotherapy
Admission
Page 9 of 10
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Consult Child Life Specialist (Inpatient)
[CON0014]
ONCE, Starting today For 1 Occurrences, Routine
Activity Level:
Reason for Consult: OTHER (Routine Chemotherapy
Admission)
Evaluate and treat.
Consult School [CON0153] ONCE, Starting today For 1 Occurrences, Routine,
The consulting provider needs to be verbally notified
of this order. A link to Web Paging is available below.
Reason for Consult:
Consult Spiritual Care (Inpatient) [CON0056] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Routine Chemotherapy
Admission
Consult Vocational Services (Inpatient)
[CON0085]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Other (Comment) (Routine
Chemotherapy Admission)
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 10 of 10
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 3:40:35 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org