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201612347

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IP - Hematology - Adult - Discharge [4943]

IP - Hematology - Adult - Discharge [4943] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


SmartSet: IP - HEMATOLOGY - ADULT - DISCHARGE (ID:4943)
General Information
Display name: IP - Hematology - Adult - Discharge
Type: General
Merge priority: 0
Version comment:
Content source:
Synonyms: 1. DC
2. D/C
3. GENERIC
4. .HEM
SmartSet notes:
Description:
Web information: Title URL
1.
Questionnaire:
Configuration
Skilled Nursing Facility Orders
Skilled Nursing Facility Certification Statement
Facility Certification Statement Routine
Skilled Nursing Facility Certification Statement
Facility Certification Statement Routine
Skilled Nursing Facility Admit Order
Admit to Skilled Nursing Facility Routine
Skilled Nursing Facility Admit Order
Admit to Skilled Nursing Facility Routine
Skilled Nursing Facility Patient Care Orders
Page 1 of 11
Printed by STRAKA, KEVIN F [KFS1] at 12/6/2016 5:11:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

For dyspnea, Oxygen at 2 L/minute per nasal
canula; If this is an acute change for the patient
call PCP with assessment ASAP after oxygen is
started. Suction PRN to clear airways.
Routine
DME - Home Oxygen Patient's O2 Requirements Assessed and Meets
Criteria for Home O2:
Delivery Device:
Equipment Needed:
Continuous (liters/min):
Continuous (FiO2):
With Activity (liters/min):
With Activity (FiO2):
With Sleep (liters/min):
With Sleep (FiO2):
Length of Need:
Vendor:
DME - CPAP Formal Sleep Study Completed:
Diagnosis:
CPAP Pressure (cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
DME - BiPAP (S) Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S):
Diagnosis:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Page 2 of 11
Printed by STRAKA, KEVIN F [KFS1] at 12/6/2016 5:11:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

DME - BiPAP (S/T) Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S/T):
Diagnosis:
Respiratory Rate:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Patient may self administer medication per RN
assessment
Routine
Patient medications (per Skilled Nursing Facility
policy) may be left at bedside
Routine
Facility Therapy Needs
Physical Therapy to Evaluate and Treat at Next
Facility
Routine
Occupational Therapy to Evaluate and Treat at
Next Facility
Routine
Speech Therapy to Evaluate and Treat at Next
Facility
Routine
Communicable Diseases
Patient has been screened for TB within the last
90 days prior to admission and does not have
any other clinically apparent communicable
diseases.
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
Routine
Communicable Diseases
Patient has been screened for TB within the last
90 days prior to admission and does not have
any other clinically apparent communicable
diseases.
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
Routine
Analgesics
acetaMINOPHEN (TYLENOL) tab 650 mg, 1 tab, 1, starting S, No Print
acetaMINOPHEN (TYLENOL) suppository 650 mg, 1 suppository, 1, starting S, No Print
Blood Glucose Management
glucagon 1 mg injection kit 1 mg, 1 each, 1, starting S, No Print
Glucose 40 % oral gel 10 g, 1 Tube, 1, starting S, No Print
Nursing Communication Routine, Notify {Notify for Blood Glucose:3004146} if
blood glucose is greater than 400 mg/dL or less than
40 mg/dL
Page 3 of 11
Printed by STRAKA, KEVIN F [KFS1] at 12/6/2016 5:11:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

Diabetes Care Instructions Routine, - Patient's blood glucose goal range before
meals is *** mg/dL.
- Monitor patient's blood glucose {Glucose Monitoring
Frequency:25242}.
- If your patient's blood glucoses are uncontrolled
contact provider.
- "Uncontrolled" blood glucoses mean:
* Blood glucose above 150 mg/dL more than half the
time during a week.
* Blood glucose over *** mg/dL.
* Blood glucose less than 70 mg/dL two or more
times per week (or if having signs/symptoms of low
blood glucose such as shaking, sweating, or light-
headedness).
Bowel Management
bisacodyl (DULCOLAX) rectal suppository 10 mg, 1 suppository, 1, starting S, No Print
Senna-Docusate Sodium 8.6-50 MG per tab 1-2 tab, 1 tab, 1, starting S, No Print
magnesium hydroxide (MILK OF MAGNESIA)
susp
30 mL, 1 Bottle, 1, starting S, No Print
polyethylene glycol (MIRALAX) oral powder 17 g, 1 Bottle, 1, starting S, No Print
Non-categorized Medications
guaifenesin-dextroMETHORPHAN
(ROBITUSSIN DM) syrup
10 mL, 1 Bottle, 1, starting S, No Print
carbamide peroxide (DEBROX) 6.5% otic soln 3 drop, 1 Bottle, 1, starting S until S+5, No Print
alum-mag-simeth (MYLANTA ES) susp 30 mL, 1 Bottle, 1, starting S, No Print
Patient Care Orders
Confirmed Discharge Date/Time
Confirmed Discharge Date/Time Confirmed Discharge Date:
Confirmed Discharge Time:
Conditions for Discharge:
Provider to be Present at Discharge?
Reason For Hospitalization
Why You Were Hospitalized Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Activity
Activity Routine
Discharge Activity: Up As Tolerated
Encourage walking daily. Balance activities with rest.
Driving Restrictions Routine, No driving while on narcotics.
Sexual Activity Routine, Consult with your doctor/NP before
resuming sexual activity.
Nutrition
Page 4 of 11
Printed by STRAKA, KEVIN F [KFS1] at 12/6/2016 5:11:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

Diet - General (No Modifications) Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
Follow a diet with emphasis on food safety. No raw
meats, foods should be washed and cleaned, peeled,
steamed and cooked. Avoid foods that can not be
washed well. Practice good handwashing to help
prevent infection. Reference HFFY #415: Cancer:
Graft vs. Host Disease Diet Recommendations
(GVHD), and HFFY #476 (#483-Spanish version):
Cancer: Healthy Eating for Adults and Children with
Low White Cell Counts (Low Microbial Diet)
Wound Care
Wound Care Routine
Line Care Routine, Perform dressing care and flushing of your
PICC or Hickman per Catheter Care Instruction
handout.
Bladder Care
Bladder Care Routine
Bowel Care
Bowel Care Routine
Other Patient Care Instructions
Other Discharge Patient Care Instructions Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, Please refer to your education
materials for further information and follow all
instructions until your doctor instructs you to stop.
Temperature: Take twice daily or if you are feeling ill.
Call IMMEDIATELY if your temperature is greater or
equal to 100.8 degrees F (38.2 degrees C).
Mask: Wear a mask when coming to your clinic
appointment. Avoid crowds.
Visitors: Ask friends/family who are ill to wait a few
days until they are better to visit you.
Home: Keep home environment as clean as
possible.
When to Call Your Doctor
Page 5 of 11
Printed by STRAKA, KEVIN F [KFS1] at 12/6/2016 5:11:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

When to Call Your Doctor Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Call your doctor if you have any of
these symptoms:
-Signs of Infection
1. Temperature greater than or equal to 100.8
degrees F or (38.2
degrees C).
2. Shaking chills.
3. Redness, soreness or pus-like discharge/fluid at
your central
line site or at any other open area/site of injury.
4. Pain or burning with urination.
5. Cough, especially if the cough is new.
6. Special Note: If you are on prednisone,
signs/symptoms of
infection may be minimal. You may notice
symptoms such as
weakness, fatigue, or increased tiredness.
-Extreme fatigue
-Headaches that are new
-Shortness of breath with or without activity
-Signs of bleeding: Nose bleeds, bleeding gums,
blood in urine or
stool, a cut on your skin that is difficult to stop
bleeding, bruising, or
petechiae (pinpoint red or purple flattened
spots/bruises)
-Nausea and/or vomiting that is not controlled with
medication or that
is a new symptom
-Constant or uncontrolled diarrhea
-Inability to urinate for more than 8 hours
-Increased pain or pain that is difficult to control or
manage.
Uncontrolled headaches not relieved by Tylenol,
chest discomfort,
pounding heart
-Central line is open to air, broken or leaking
-Any new symptom that concerns you
CALL 911 FOR EMERGENCIES
Call the Carbone Comprehensive Cancer Center
Hematology Clinic with questions or problems during
business hours - Monday through Friday - 8am-5pm
at 1-800-323-8942 or 608-265-1700. Follow the
prompts for the Hematology Clinic.
Contact the Hematology Fellow or Staff Physician on
Call at 1-800-323-8942 weekdays 5pm - 8am,
Page 6 of 11
Printed by STRAKA, KEVIN F [KFS1] at 12/6/2016 5:11:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

weekends and holidays. Ask for Hematology doctor
on call.
Heart Failure Recommended Care
Heart Failure Discharge Instructions
Weigh yourself daily or as directed Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
When to Call Your Doctor Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Call your doctor if you have any of
these symptoms as they may indicate worsening
Heart Failure:
- Increased shortness of breath
- Cough or chest congestion
- Swelling in your abdomen or legs
- Any increase or decrease in weight of more than 3
pounds in a day or 5 pounds total
If you do not have a scheduled return
appointment, please schedule an appointment
with your primary physician
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Core Measure Documentation - ACE Inhibitor/ARB
ACE Inhibitor/ARB Reason Not Ordered ONCE, Starting S For 1 Occurrences, Routine
Reason Not Ordered:
ACE Inhibitor/ARB Already Ordered ONCE, Starting S For 1 Occurrences, Routine
Reason Not Ordered: Other (Comments required for
not ordering BOTH an ACEI and an ARB)
Follow-Up Care
Follow-Up Apoointments
Schedule Appointment Reason for Hospital Follow Up Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
Schedule Appointment Reason for Hospital Follow Up Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
Page 7 of 11
Printed by STRAKA, KEVIN F [KFS1] at 12/6/2016 5:11:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

Schedule Appointment Reason for Hospital Follow Up Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
Patient to Schedule Appointment Routine
Purpose:
With whom:
For when:
Follow Up Appointments - Diabetes
No appointment: Patient does not have diabetes ONCE, Starting S For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
does not have diabetes
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with
a provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient
refusal, etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Appointment scheduled (with provider who can
manage diabetes)
ONCE, Starting S For 1 Occurrences, Routine
Documentation (required): Appointment scheduled
(with provider who can manage diabetes)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with
a provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient
refusal, etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 8 of 11
Printed by STRAKA, KEVIN F [KFS1] at 12/6/2016 5:11:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

Appointment scheduled per patient report
(ENTER DATE IN COMMENTS)
ONCE, Starting S For 1 Occurrences, Routine
Documentation (required): Appointment scheduled
per patient report (ENTER DATE IN COMMENTS)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with
a provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient
refusal, etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Appointment pending: patient discharged on
weekend; follow-up information provided
ONCE, Starting S For 1 Occurrences, Routine
Documentation (required): Appointment pending:
patient discharged on weekend; follow-up information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with
a provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient
refusal, etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Free clinic information provided ONCE, Starting S For 1 Occurrences, Routine
Documentation (required): Free clinic information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with
a provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient
refusal, etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 9 of 11
Printed by STRAKA, KEVIN F [KFS1] at 12/6/2016 5:11:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

No appointment: Patient discharging to a facility
(e.g., skilled nursing facility, correctional facility,
etc.)
ONCE, Starting S For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
discharging to a facility (e.g., skilled nursing facility,
correctional facility, etc.)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with
a provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient
refusal, etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
No appointment: Patient refusal ONCE, Starting S For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
refusal
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with
a provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient
refusal, etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Facility Therapy Needs
Discharge - Outpatient Therapy Routine
Type(Each Agency Requires a Separate Order):
Diagnosis:
Facility:
Facility City:
Facility Phone:
Facility Fax:
Discharge Labs
Recommended Discharge Labs Details
Labs
BUN Status: Standing, Expires:T+122 MANUAL,Count:1,
Normal, Routine
CALCIUM Status: Standing, Expires:T+122 MANUAL,Count:1,
Normal, Routine
CBC WITH DIFFERENTIAL Status: Standing, Expires:T+122 MANUAL,Count:1,
Normal, Routine
COMPREHENSIVE METABOLIC PANEL Status: Standing, Expires:T+122 MANUAL,Count:1,
Normal, Routine
CREATININE Status: Standing, Expires:T+397 MANUAL,Count:1,
Normal, Routine
Page 10 of 11
Printed by STRAKA, KEVIN F [KFS1] at 12/6/2016 5:11:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org

ELECTROLYTES Status: Standing, Expires:T+122 MANUAL,Count:1,
Normal, Routine
GLUCOSE Status: Standing, Expires:T+122 MANUAL,Count:1,
Normal, Routine
MAGNESIUM Status: Standing, Expires:T+122 MANUAL,Count:1,
Normal, Routine
Criteria
Suggestions: UWIP C DISCHARGE ORDER SET SUGGESTION - NON-LOGIN
DEPARTMENT SPECIFIC[3901755]
Filter: UWIP ORDER SET RESTRICTION - IP ONLY DISCHARGE[1754]
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Printed by STRAKA, KEVIN F [KFS1] at 12/6/2016 5:11:49 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2016CCKM@uwhealth.org