/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-97839-en.cckm

201612362

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 Long Stay - Adult - Admission [1102]

IP - Chemotherapy Long Stay - Adult - Admission [1102] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


SmartSet: IP - CHEMOTHERAPY LONG STAY - ADULT - ADMISSION
(ID:1102)
General Information
Display name: IP - Chemotherapy Long Stay - Adult - Admission
Type: General
Merge priority: 0
Version comment:
Content source:
Synonyms: 1. CHEMOTHERAPY
2. CHEMO
3. INDUCTION CHEMOTHERAPY
4. CONSOLIDATION CHEMOTHERAPY
5. BMT
6. BONE MARROW TRANSPLANT
7. ONCOLOGY
8. .ONC
SmartSet notes:
Description: Intended for Adult Patients Only
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.
Page 1 of 14
Printed by STRAKA, KEVIN F [KFS1] at 12/21/2016 12:01:01 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Admit to Inpatient (Single Response)
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:
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 Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status
Admit To Inpatient Status Attending:
Admitting Resident:
Requested Floor:
Service: HEMATOLOGY
Rationale for LOS greater than 2 midnights:
Page 2 of 14
Printed by STRAKA, KEVIN F [KFS1] at 12/21/2016 12:01:01 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

Admit To Observation Status Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Venous Thromboembolism (VTE) Prophylaxis
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
Page 3 of 14
Printed by STRAKA, KEVIN F [KFS1] at 12/21/2016 12:01:01 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

VTE Prophylaxis - Reason Not Ordered ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs
Vital Signs SEE COMMENTS, Starting S with First Occurrence
As Scheduled, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 4 hours if Absolute Neutrophil Count (ANC)
less than 500, otherwise every 8 hours
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:
Ambulate 3 Times Daily CONTINUOUS, Starting S, Routine
AD LIB:
AMBULATE: 3x daily
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Chair 3 Times Daily CONTINUOUS, Starting S, Routine
AD LIB:
AMBULATE:
CHAIR: 3x daily
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition
Page 4 of 14
Printed by STRAKA, KEVIN F [KFS1] at 12/21/2016 12:01:01 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

Patient Approved for Additional Menu Items CONTINUOUS
Patient may order food items from UWHC café or
Mendota Market? Yes
Patient may order regular soda or other sugar-
sweetened beverages? Yes
General Diet EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Neutropenic Diet if Absolute Neutrophil Count
(ANC) less than 500
EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Neutropenic
Bedside Meal Instructions:
Room Service Class:
Respiratory
Pulse Oximetry ONCE, Starting S, Routine
Oxygen Therapy CONTINUOUS, Starting S, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 90
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Intake and Output
Patient Approved for Additional Menu Items CONTINUOUS
Patient may order food items from UWHC café or
Mendota Market?
Measure Intake And Output EVERY 8 HOURS, Starting S, Routine
Non-Categorized Patient Care Orders
Measure Weight 1X DAILY, Starting S, Routine
Weigh With?
Weigh when?
Neutropenic precautions, if Absolute Neutrophil
Count (ANC) less than 500
CONTINUOUS, Starting S, Neutropenic precautions,
if Absolute Neutrophil Count (ANC) less than 500
Contingency Parameters
Page 5 of 14
Printed by STRAKA, KEVIN F [KFS1] at 12/21/2016 12:01:01 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

Notify Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg): 90
If diastolic blood pressure < (mmHg):
If temperature > (C): greater than or equal to 38.2, or
greater than or equal to 38 for longer than 1 hour
If temperature < (C):
If heart rate > (bpm): 100
If heart rate < (bpm): 60
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: Hemoglobin is less than or equal to 8
grams/deciliter,Platelet count is less than or equal to
10,000/microliter,Absolute Neutrophil Count less than
500
Intravenous Therapy
Premedications for Needle Insertion
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
IV Fluids
Page 6 of 14
Printed by STRAKA, KEVIN F [KFS1] at 12/21/2016 12:01:01 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

Insert and Maintain Peripheral IV CONTINUOUS, Starting S For Until specified,
Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Note: Refer to Chemotherapy Treatment Plan
for Intravenous Fluids
ONCE For 1 Doses
Refer to Chemotherapy Treatment Plan for
Intravenous Fluids
sodium chloride 0.9 % infusion Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% infusion Intravenous, CONTINUOUS
Medications
Analgesics
acetaMINOPHEN (TYLENOL) tab 650 mg, Oral, EVERY 4 HOURS PRN, pain/fever
No more than 4 grams acetaminophen per 24 hours
for adults or 15 mg/kg per dose for peds < 40 kg
Mild pain, multimodal therapy or temperature greater
than 38.2 C. Evaluate temperature before
administering
Hypnotics
traZODONE (DESYREL) tab 25 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see IPOC supplemental Sleep/Rest
Disturbance Adult)
Laboratory
Admission Labs
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?
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?
Page 7 of 14
Printed by STRAKA, KEVIN F [KFS1] at 12/21/2016 12:01:01 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

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?
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?
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?
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?
SMEAR TO ORDERING MD 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?
HLA Class I Typing (ABC), Pre-Tx
HLA HIGH RESOLUTION, A LOCUS NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 8 of 14
Printed by STRAKA, KEVIN F [KFS1] at 12/21/2016 12:01:01 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

HLA HIGH RESOLUTION, B LOCUS NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA HIGH RESOLUTION, C LOCUS NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA HIGH RESOLUTION, DR LOCUS NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA DQ LOCUS, PRE-TX NEXT DRAW For 1 Occurrences, Routine
Indicate organ for transplant:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
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
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, Starting S 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 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 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 9 of 14
Printed by STRAKA, KEVIN F [KFS1] at 12/21/2016 12:01:01 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

CULTURE, SPUTUM WITH GRAM STAIN CONDITIONAL - RN COLLECT, Starting S 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
For First Fever Spike: ONCE, Starting S+8 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, 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 8 through 14.
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 8-14
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 8 through 14.
Page 10 of 14
Printed by STRAKA, KEVIN F [KFS1] at 12/21/2016 12:01:01 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@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 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
For First Fever Spike: ONCE, Starting S+15 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, 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 15 through 21.
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 15-21
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 15 through 21.
Page 11 of 14
Printed by STRAKA, KEVIN F [KFS1] at 12/21/2016 12:01:01 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@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 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
For First Fever Spike: ONCE, Starting S+22 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, 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 22 through 28.
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 22-28
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 22 through 28.
Page 12 of 14
Printed by STRAKA, KEVIN F [KFS1] at 12/21/2016 12:01:01 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@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 22 through 28.
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging
X-RAY CHEST PA & LAT VIEWS ONCE-RAD NEXT AVAILABLE, Starting S For 1
Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Neutropenic fever
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Consults
Consults
Consult Social Work (Inpatient) ONCE, Starting S For 1 Occurrences, Routine
Reason for Consult: OTHER
Evaluate and follow during chemotherapy.
PICC Placement Request ONCE, Starting S For 1 Occurrences, Routine
PICC Line Placement Reason:
PICC Line Placement Duration:
Mastectomy?
Dialysis Graft/Shunt?
Thrombosis?
Existing Venous Access Device(s)?
Over 400 lbs?
Number of Lumens:
Do Not Use:
Do Not Use Reason:
Consult Venous Access Team (Inpatient) ONCE, Starting S For 1 Occurrences, Routine
Reason for consult:
Can this consult be done via video?
Consult Occupational Therapy (Inpatient) Eval
and Treat
ONCE, Starting S For 1 Occurrences, Routine
Reason for Consult:
Consult Physical Therapy (Inpatient) Eval and
Treat
ONCE, Starting S For 1 Occurrences, Routine
Reason for Physical Therapy Consult:
Page 13 of 14
Printed by STRAKA, KEVIN F [KFS1] at 12/21/2016 12:01:01 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

Consult Nutrition (Inpatient) ONCE, Starting S For 1 Occurrences, Routine
Reason for Consult: Nutrition Assessment w/
Recommendations
Delegate to Initiate and Manage Tube Feeding:
Delegate to Initiate Feeding Tube Placement Order
Set:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
BestPractice
No Hospital Problems have yet been identified.
Specify Hospital Problem(s) You will be prompted to specify a hospital problem on
signing.
Criteria
Suggestions: UWIP C LOGIN DEPT IP ONCOLOGY/HEMATOLOGY/BMT[3001756]
Filter: UWIP ORDER SET RESTRICTION - HOSPITAL ENCOUNTERS EXCEPT ED -
NOT IP DC[3000400]
Restrict SmartSet:
Settings
Discontinue action:
Deselect sections for
Pended/Held orders:
Pended/Held orders
display:
Release date: Use System Definitions Setting
Disallow user override:
Page 14 of 14
Printed by STRAKA, KEVIN F [KFS1] at 12/21/2016 12:01:01 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org