/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-97853-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 - Hematology/Oncocology - Pediatric - Discharge [5061]

IP - Hematology/Oncocology - Pediatric - Discharge [5061] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


IP - Hematology/Oncology - Pediatric - Discharge [5061]
Patient Care Orders
Confirmed Discharge Date/Time [151653]
Confirmed Discharge Date/Time [ADT0013] Confirmed Discharge Date:
Confirmed Discharge Time:
Conditions for Discharge:
Provider to be Present at Discharge?
Reason For Hospitalization [135304]
Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Activity [135306]
Activity - Up As Tolerated [NURACT0008] Routine
Discharge Activity: Up As Tolerated
Encourage walking daily. Balance activities with rest.
Diet [135308]
Diet [NUT8888] Routine
General: General (No Modifications)
Diet Modifications: Neutropenic
Other Diet Modifications:
Follow a diet with emphasis on food safety. Foods
should be washed and cleaned and well cooked.
Practice good handwashing to help prevent infection.
Wound Care [135309]
Wound Care [NURWND0015] Routine
Line Care [NURWND0015] Routine, Perform dressing care and flushing of your
PICC or Hickman per Catheter Care Instruction
handout.
Bladder Care [135314]
Bladder Care [NURELM0067] Routine
Bowel Care [135315]
Bowel Care [NURELM0068] Routine
When to Call Your Doctor - Hematology/Oncology - General [135317]
Page 1 of 16
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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

When to Call Your Doctor - Hematology/Oncology
- General [NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, If you have a NON-URGENT medical
concern or a request for an appointment, prescription,
lab or test result call 608-263-6420 and your call will
be directed to a clinic scheduler or nurse.
If you have an URGENT medical concern, call the
page operator at 608-262-0486, and ask the operator
to page your nurse practitioner {PEDS HEM/ONC
NPS:19991},
or your physician {PEDS HEM/ONC MDS:19755}.
If it is the EVENING, WEEKEND, OR HOLIDAY, call
the page operator at 608-262-0486, and ask the
operator to page the pediatric hematologist-oncologist
on call.
Symptoms to be reported immediately are:
Temperature greater than 100.4
Shaking Chills
Excessive vomiting and/or no urine output for 12 hours
or more
A severe nosebleed or any other prolonged bleeding
Significant head injury
Extreme lethargy or dramatic change in your child’s
behavior
Excessive diarrhea (greater than 3 times in 24 hours)
No bowel movement/stool for 3 days
If you do not receive a call back within 20 minutes,
please call again
Information to have ready to tell to the on call
physician
Your child’s name and diagnosis
Type and date of most recent chemotherapy
Your child’s most recent blood count
Your main concern now
Your local pharmacy and number
Home Health Agency: @UWIPFLOW2(330601)@
@UWIPFLOW2(330607)@
@UWIPFLOW2(330609)@
@UWIPFLOW2(330615)@
@UWIPFLOW2(304040)@
@UWIPFLOW2(304046)@
Home Health Agency Equipment: ***
Primary Hem/Onc NP: {PEDS HEM/ONC
NPS:19991}
Primary Hem/Onc MD: {PEDS HEM/ONC
MDS:19755}
Next clinic visit: ***
Page 2 of 16
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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

Next labs: ***
Follow-up tests: ***
The above have been explained to: {UWIP
INSTRUCTIONS EXPLAINED TO:3000500}
Discharge Instructions Given to: *** M/D/Y *** Time
***
When to Call Your Doctor - Metaiodobenzylguanidine [135318]
Page 3 of 16
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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

When to Call Your Doctor -
Metaiodobenzylguanidine [NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, MIBG treatment uses radioactive
iodine (I-131) for treatment of neuroblastoma. The
radioactive iodine is bound to a compound (MIBG) that
is infused into the patient through an IV.
The radioactive iodine used to treat your child is not
volatile, meaning it does not evaporate into the air, so
there is no risk of inhaling the radioactivity. A
significant amount of the radioactivity is absorbed by
the tumor; the remainder is eliminated in the urine.
During the first eight hours after the MIBG is given,
approximately 20-25% of the radioactive iodine will be
excreted in the urine. Within twenty-four hours, 25-
60% will be excreted.
The greater distance you are away from the MIBG
treated patient, the less radioactive exposure you will
have. By doubling your distance from the patient, you
will reduce your radiation exposure to a quarter of the
original amount.
After being discharged from the hospital
1. Continue to give your child potassium iodide (SSKI)
and potassium perchlorate as instructed, and continue
until the stop date.
2. Flush toilet twice after urination for the next 5-7
days.
3. Use disposable diapers and be sure to place in
outdoor garbage can at least once a day.
4. Use disposable gloves while changing diapers.
5. Wash hands carefully with soap and water after
changing diapers or handling urine, vomitus or stool
(even though you wore gloves).
6. Bathe the child daily.
7. Avoid close contact (closer than arm’s length) for
longer than fifteen minutes per day for the first week
after treatment. (Do not nap with the child, or hold
them on your lap if possible).
8. Patients may not hold infants for one month after
the treatment to prevent undue radiation exposure.
Guidelines for Public Travel after Treatment
Avoid close contact with members of the public, and
as practical, maintain a minimum distance of 1-meter
(approximately 3 feet) between your child and the
general public. The general public are those
Page 4 of 16
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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

individuals other than the Caregiver(s).
Minimize the items or surfaces that your child will be
touching.
Flush the toilet five-times after use.
Do not allow your child to sit on your lap.
During transport, minimize the number of individuals
that will be seated adjacent to your child, i.e. first row
or last row window seat with yourself seated adjacent
to your child.
Once you arrive home, follow the instructions provided
to you for home care treatment of your child.
Phone Call Instructions for Pediatric Hematology-
Oncology Families
If you have a NON-URGENT medical concern or a
request for an appointment, prescription, lab or test
result call 608-263-6420 and your call will be directed
to a clinic scheduler or nurse.
If you have an URGENT medical concern, call the
page operator at 608-262-0486, and ask the operator
to page your nurse practitioner {PEDS HEM/ONC
NPS:19991},
or your physician {PEDS HEM/ONC MDS:19755}.
If it is the EVENING, WEEKEND, OR HOLIDAY, call
the page operator at 608-262-0486, and ask the
operator to page the pediatric hematologist-oncologist
on call.
Symptoms to be reported immediately are:
Temperature greater than 100.4
Shaking Chills
Excessive vomiting and/or no urine output for 12 hours
or more
A severe nosebleed or any other prolonged bleeding
Significant head injury
Extreme lethargy or dramatic change in your child’s
behavior
Excessive diarrhea (greater than 3 times in 24 hours)
No bowel movement/stool for 3 days
If you do not receive a call back within 20 minutes,
please call again
Information to have ready to tell to the on call
physician
Your child’s name and diagnosis
Type and date of most recent chemotherapy
Your child’s most recent blood count
Your main concern now
Page 5 of 16
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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

Your local pharmacy and number
Home Health Agency: @UWIPFLOW2(330601)@
@UWIPFLOW2(330607)@
@UWIPFLOW2(330609)@
@UWIPFLOW2(330615)@
@UWIPFLOW2(304040)@
@UWIPFLOW2(304046)@
Home Health Agency Equipment: ***
Primary Heme/Onc NP: {PEDS HEM/ONC
NPS:19991}
Primary Heme/Onc MD: {PEDS HEM/ONC
MDS:19755}
Next clinic visit: ***
Next labs: ***
Follow-up tests: ***
The above have been explained to: {UWIP
INSTRUCTIONS EXPLAINED TO:3000500}
Discharge Instructions Given to: *** M/D/Y *** Time
***
When to Call Your Doctor - Sickle Cell [135338]
Page 6 of 16
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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

When to Call Your Doctor - Sickle Cell
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, Continue the following "pain control
plan" for 3-4 days: ***
If pain worsens re-initiate scheduled narcotic(s) and
scheduled ibuprofen and increase oral fluids to {2x
maintenance:19931}.
Continue laxative/stool softener until 2 days after the
final narcotic dose.
Restart prior home medications.
Take {1.25 maintenance:19751} of fluid daily for one
week following discharge.
Avoid getting chilled or overheated
Phone Call Instructions
If you have a NON-URGENT medical concern or a
request for an appointment, prescription, lab or test
result call 608-263-6420 and your call will be directed
to a clinic scheduler or nurse.
If you have an URGENT medical concern, call the
page operator at 608-262-0486, and ask the operator
to page your nurse practitioner {PEDS HEM/ONC
NPS:19991},
or your physician {PEDS HEM/ONC MDS:19755}.
If it is the EVENING, WEEKEND, OR HOLIDAY, call
the page operator at 608-262-0486, and ask the
operator to page the pediatric hematologist-oncologist
on call.
Symptoms to be reported immediately are:
Temperature greater than 100.4
Shaking Chills
Excessive vomiting and/or no urine output for 12 hours
or more
A severe nosebleed or any other prolonged bleeding
Significant head injury
Extreme lethargy or dramatic change in your child’s
behavior
Excessive diarrhea (greater than 3 times in 24 hours)
No bowel movement/stool for 3 days
If you do not receive a call back within 20 minutes,
please call again
Information to have ready to tell to the on call
physician
Your child’s name and diagnosis
Type and date of most recent chemotherapy
Your child’s most recent blood count
Your main concern now
Page 7 of 16
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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

Your local pharmacy and number
Home Health Agency: @UWIPFLOW2(330601)@
@UWIPFLOW2(330607)@
@UWIPFLOW2(330609)@
@UWIPFLOW2(330615)@
@UWIPFLOW2(304040)@
@UWIPFLOW2(304046)@
Home Health Agency Equipment: ***
Primary Heme/Onc NP: {PEDS HEM/ONC
NPS:19991}
Primary Heme/Onc MD: {PEDS HEM/ONC
MDS:19755}
Next clinic visit: ***
Next labs: ***
Follow-up tests: ***
The above have been explained to: {UWIP
INSTRUCTIONS EXPLAINED TO:3000500}
Discharge Instructions Given to: *** M/D/Y *** Time
***
When to Call Your Doctor - HSCT [135377]
Page 8 of 16
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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

When to Call Your Doctor - HSCT
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, Clinic Follow-Up
Clinic visits will focus on:
•How your child has been feeling and address any
problems.
•Discuss any coping, financial, or family issues.
•Review your child’s progress.
•Height/weight/vital signs are checked.
•Review laboratory results.
•Review medications.
•Perform a complete physical examination.
•Adjust any medications or home care.
•Immunoglobulin Infusion
-Allogeneic – will continue immunoglobulin monthly
until 3 months post transplant
-Autologous – will discontinue immunoglobulin infusion
at discharge from hospital
•Blood transfusions may be necessary after discharge.
•Special procedures may be performed.
Medications
It is important to know all of your child’s medications,
dosage, schedule, and potential side effects. These
will be reviewed with you prior to your child’s
discharge. Remember:
•Please bring your child’s medications or written
schedule with you to clinic. The clinic nurse can
provide a carrying case for all medications.
•Inform MD or Nurse which medications need to be
refilled.
•If your child takes Cyclosporin A, tacrolimus, or
sirolimus be sure to discuss how to best obtain blood
levels with your provider. Your child may be asked to
hold morning dose on day of clinic in order for blood
levels to be obtained.
Preparing your home for your child’s discharge.
•Good home cleaning, including carpet cleaning
(required).
•Avoid any home construction prior to your child’s
discharge.
•Do not need to remove household plants.
•Weekly cleaning (vacuuming carpets and dusting
strongly recommended).
Reporting Symptoms
If your child has any of the following symptoms, report
them immediately to the MD or Nurse:
•Fever to 100.4
•Shaking chills
•Increased fatigue
•Body aches or pain
•Cough, shortness of breath
•Diarrhea or loose stools
•Loss of appetite, weight loss
Page 9 of 16
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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

•Nausea and vomiting
•New or different rash
•Redness or drainage at any body part
•Bleeding or bruising
•Burning with urination
•Changes in personality or level of alertness
•Catheter problems of any kind
Preventing Infection
•Avoid crowds and sick persons
•Have your child wear a respiratory mask when
leaving the home and in an area where there are
crowds, sick people or construction. Do not need to
wear a mask in the home or car.
•Have your child wash hands frequently with
antibacterial soap in pump dispenser, (i.e., after
toileting, after playing with toys or pets, after outside
play, before preparing food or eating).
•Daily bath – observe your child for any rash or skin
changes.
•Mouth care – 3 times daily. Avoid flossing. Report
changes in mouth, redness, oral thrush, etc. Notify
your physician before any dental visit.
•Avoid people with chicken pox or shingles.
Immediately report to physician if your child is
exposed to anyone with chicken pox or shingles.
•Child should avoid cleaning up animal waste. Check
with physician or NP which before obtaining any new
pets. Exotic pets should be avoided. All household
pets should have shots up to date.
•Avoid activities that may produce dust exposure such
as chopping wood, gardening, playing in leaves, dirt,
or sand box, or construction work.
•Do not restart any vaccinations or receive a flu shot
without physician permission.
Eating Well
See handout “Healthy Eating After Blood/Marrow
Stem Cell Transplant”
Daily Activities
•Resume normal activities slowly and progress over
time.
•Your child may need additional help to build up
strength with physical therapy/occupational therapy
sessions.
•Check with your physician or NP about your child’s
activity plan, especially swimming, weight use or
contact sports.
•Young children may benefit from a Birth to 3 or Early
Childhood Intervention services. Ask your NP about a
consult for these services.
School and Friends
•Attending school should be avoided until your child’s
immune system recovers. Your NP will assist in
setting up a home-tutoring program.
Page 10 of 16
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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

•Friends and classmates may visit your child if they
are healthy.
Driving
•Adolescents should not drive if taking any
medications that affects your alertness or cause
drowsiness.
Avoid Sun Exposure
•Wear SPF 15 or stronger sunscreen on exposed skin
in bright sunlight.
•Wear a hat and other clothing that provide protection.
Phone Call Instructions for Pediatric Hematology-
Oncology Families
If you have a NON-URGENT medical concern or a
request for an appointment, prescription, lab or test
result call 608-263-6420 and your call will be directed
to a clinic scheduler or nurse.
If you have an URGENT medical concern, call the
page operator at 608-262-0486, and ask the operator
to page your nurse practitioner {PEDS HEM/ONC
NPS:19991}, or your physician {PEDS HEM/ONC
MDS:19755}.
If it is the EVENING, WEEKEND, OR HOLIDAY, call
the page operator at 608-262-0486, and ask the
operator to page the pediatric hematologist-oncologist
on call.
Symptoms to be reported immediately are:
Temperature greater than 100.4
Shaking Chills
Excessive vomiting and/or no urine output for 12 hours
or more
A severe nosebleed or any other prolonged bleeding
Significant head injury
Extreme lethargy or dramatic change in your child’s
behavior
Excessive diarrhea (greater than 3 times in 24 hours)
No bowel movement/stool for 3 days
If you do not receive a call back within 20 minutes,
please call again
Information to have ready to tell to the on call
physician
Your child’s name and diagnosis
Type and date of most recent chemotherapy
Your child’s most recent blood count
Your main concern now
Your local pharmacy and number
Home Health Agency: @UWIPFLOW2(330601)@
@UWIPFLOW2(330607)@
Page 11 of 16
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 3:34:08 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

@UWIPFLOW2(330609)@
@UWIPFLOW2(330615)@
@UWIPFLOW2(304040)@
@UWIPFLOW2(304046)@
Home Health Agency Equipment: ***
Primary Heme NP: {PEDS HEM/ONC
NPS:19991}
Primary Heme MD: {PEDS HEM/ONC
MDS:19755}
Next clinic visit: ***
Next labs: ***
Follow-up tests: ***
The above have been explained to: {UWIP
INSTRUCTIONS EXPLAINED TO:3000500}
Discharge Instructions Given to: *** M/D/Y *** Time
***
Follow-Up Care
Follow-Up Appointments [135378]
Schedule Appointment With Physical Therapy
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty: Physical Therapy
Schedule Appointment With Occupational
Therapy [NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty: Occupational Therapy
Schedule Appointment With Speech Therapy
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty: Speech Therapy
Patient to Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Follow Up Appointments - Diabetes (Single Response) [148552]
*** RESPONSE REQUIRED *** This order facilitates documentation (only) about follow-up
appointments for patients with diabetes. 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., discharge to a skilled nursing facility, patient refusal, etc.). Only select “Appointment
Scheduled” if an appointment has already been scheduled, and use the Schedule Appointment
order as needed to request assistance in scheduling
Page 12 of 16
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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

No appointment: Patient does not have diabetes
[COR0064]
ONCE, Starting today 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) [COR0064]
ONCE, Starting today 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.
Appointment scheduled per patient report
(ENTER DATE IN COMMENTS) [COR0064]
ONCE, Starting today 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.
Page 13 of 16
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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

Appointment pending: patient discharged on
weekend; follow-up information provided
[COR0064]
ONCE, Starting today 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 [COR0064] ONCE, Starting today 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.
No appointment: Patient discharging to a facility
(e.g., skilled nursing facility, correctional facility,
etc.) [COR0064]
ONCE, Starting today 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.
Page 14 of 16
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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

No appointment: Patient refusal [COR0064] ONCE, Starting today 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.
Discharge Labs [134929]
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Please use the table below to determine what type of order to use to place discharge lab
orders.
Discharge Labs Workflow URL: https://uconnect.wisc.edu/growth/training--
education/health-link/10-minutes/inpatient-
discharge-consult/resources/name-82993-en.file
Recommended Discharge Labs [NURCOM0075] Details
Who is Responsible for the
Result?
Where Will Labs be
Completed?
What Order Should You
Use?
Current Attending Provider UW Health Lab Specific lab orders (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
(B)
Current Consulting Provider
UW Health Lab
Specific lab orders with
AUTHORIZING PROVIDER
CHANGED TO
CONSULTANT (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
and AUTHORIZING
PROVIDER CHANGED TO
CONSULTANT (B)
Another Provider
UW Health Lab
Recommended Discharge
Labs (C)
Non-UW Health Lab
Recommended Discharge
Labs (C)
(A) SPECIFIC LAB ORDERS:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have the labs completed at a
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient's care will be responsible for the
result, you must change the AUTHORIZING PROVIDER on the order to the CONSULTING
PROVIDER before signing the order. To do this, click the Providers button near the top of the
Review, Sign & Hold tab of the discharge navigator. Update the authorizing provider to the
consulting provider.
(B) SPECIFIC LAB ORDER WITH ORDER CLASS CHANGED TO OUTSIDE:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have labs completed at a NON-
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient’s care will be responsible for the
result, you must change the AUTHORIZING PROVIDER on the order to the CONSULTING
PROVIDER before signing the order. To do this, click the Providers button near the top of the
Review, Sign & Hold tab of the discharge navigator. Update the authorizing provider to the
consulting provider.
The patient will receive a paper order to take to the lab.
(C) RECOMMENDED DISCHARGE LABS:
This order should be used to recommend to another provider labs that a patient should have
completed after discharge. The provider designated in the 'Send Recommendations To' field is
responsible for PLACING the lab orders AND will be responsible for the RESULTS of any
ordered labs.
Page 16 of 16
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 3:34:08 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org