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/clinical/cckm-tools/content/order-sets/inpatient/bmtoncologyhematology/name-97855-en.cckm

201712349

page

100

UWHC,UWMF,

Tools,

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

IP - Neutropenic Fever - Adult - Admission [1604]

IP - Neutropenic Fever - Adult - Admission [1604] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


IP - Neutropenic Fever - Adult - Admission [1604]
for Adult Patients OnlyIntended
Management of Neutropenic Fever (NF) – Adult –
Inpatient/ Ambulatory CPG
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/oncology/name-97716-en.cckm
Admission Status
Level of Care (Single Response) [187515]
*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 [106407]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: BONE MARROW TRANSPLANT
Rationale for LOS greater than 2 midnights:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Page 1 of 15
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12/2017CCKM@uwhealth.org

Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [122711]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: BONE MARROW TRANSPLANT
Rationale for LOS greater than 2 midnights:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [130119]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis (Single Response) [150156]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
Page 2 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs [22214]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital Signs [NURMON0013] SEE COMMENTS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every *** hours
Activity [22218]
Ad Lib [NURACT0008] CONTINUOUS, Starting today For Until specified,
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:
Page 3 of 15
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Ambulate [NURACT0008] CONTINUOUS, Starting today For Until specified,
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 [NURACT0008] CONTINUOUS, Starting today For Until specified,
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 [22219]
Patient Approved for Additional Menu Items
[NURCOM0022]
CONTINUOUS
Patient may order food items from UWHC café or
Mendota Market? Yes
Patient may order regular soda or other sugar-
sweetened beverages? Yes
Neutropenic Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Neutropenic
Bedside Meal Instructions:
Room Service Class:
Respiratory [22221]
Oxygen Therapy [RT0032] CONTINUOUS, Starting today For Until specified,
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
Pulse Oximetry Evidence [NURMON0009] EVERY 8 HOURS, Starting today For Until specified,
Routine
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Intake and Output [22223]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today For Until specified,
Routine
BMT Transfusion Protocol [113191]
Page 4 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Initiate BMT Service Transfusion Protocol
[TRAN0001]
CONTINUOUS, Starting today, Routine
Analgesics to be Ordered:
Antihistamines to be Ordered:
Steroids to be Ordered:
Labs to be Ordered:
Total Volume (units) RBC (Pediatric):
Total Volume (mL) RBC (Pediatric):
Total Units Platelets (Pediatric) (1 random donor unit =
45-65 mL; Suggested dose = 1 RDU/12kg; 4 RDU=1
SDU):
Does patient require single donor platelets (If yes,
Blood Bank MD approval required): No
Platelet Threshold: 10,000/microliter
Hemoglobin Threshold: 8 grams/deciliter
Order blood products, premeds and/or post labs as
indicated using order set #4179 IP - BMT - Blood
Transfusion - Supplemental
Non-Categorized Patient Care Orders [22224]
Measure Weight Upon Admission
[NURMON0015]
ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
Measure weight upon admission
Measure Height Upon Admission [NURMON0052] ONCE For 1 Occurrences, Routine, Measure height
upon admission
Measure Weight [NURMON0015] 1X DAILY, Starting today For Until specified, Routine
Weigh With?
Weigh when?
Neutropenic Precautions [116356]
Protective Precautions [ISO0001] CONTINUOUS
Reason for Protective Precautions:
Protective - Positive Pressure Room
[NURCOM0109]
CONTINUOUS
Contingency Parameters [22225]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 100
If diastolic blood pressure < (mmHg): 50
If temperature > (C):
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Pain not controlled with ordered analgesics or
ordered interventions,Pain unrelieved by ordered
interventions
Intravenous Therapy
Premedications for Needle Insertion [106310]
Page 5 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is immediate.
lidocaine (LMX) 4% topical dressing kit [66882] 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
sodium chloride (bacteriostatic) 0.9 % injection
[50585]
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.
IV Fluids [22464]
sodium chloride 0.9% BOLUS [730003] 1,000 mL, Intravenous, ONCE PRN For 1 Doses,
systolic blood pressure less than 90 mmHg
sodium chloride 0.9% infusion [64367] Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.9% infusion [51641] Intravenous, CONTINUOUS
Medications - Anti-infectives For Fever
Broad Spectrum Coverage (Single Response) [106258]
Pharmacokinetic/ Pharmacodynamic Dose
Optimization of Antibiotics for the Treatment of
Gram Negative Infection
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/?path=/content/cpg/infection-and-
isolation/name-97543-en.cckm
Treatment of Patients with Reported Allergies to
Beta-Lactam Antibiotics – Adult – Inpatient clinical
practice guideline
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/?path=/content/cpg/infection-and-
isolation/name-97535-en.cckm
Cefepime [186245]
cefepime (MAXIPIME) 2 g vial + minibag [52163] 2 g, Intravenous, ONCE For 1 Doses, for .5 Hours
cefepime (MAXIPIME) 2 g vial + minibag [52163] 2 g, Intravenous
Start 6 hours after initial one-time order
for 4 Hours
Note: Run cefepime (MAXIPIME) over 4 hours
[950056]
EVERY 6 HOURS
For additional information please refer to
Pharmacokinetic/ Pharmacodynamic Dose
Optimization of Antibiotics for the Treatment of Gram
Negative Infection”
meropenem (MERREM) intraVENOUS - NOTE:
Choose meropenem when patient has received
both cefepime and piperacillin/ tazobactam in the
past 90 days [800055]
500 mg, Intravenous, EVERY 6 HOURS For 96 Hours
Administer every 6 hours per Pharmacokinetic/
Pharmacodynamic Dose Optimization of Antibiotics for
the Treatment of Gram Negative Infection for first
fever spike
aztreonam (AZACTAM) intraVENOUS - NOTE:
Choose when patient has severe or immediate
IgE mediated allergy to beta-lactam antibiotics.
Must order concurrent IV vancomycin [800013]
2 g, Intravenous, EVERY 8 HOURS For 96 Hours
See Treatment of Patients with Reported Allergies to
Beta-Lactam Antibiotics – Adult – Inpatient clinical
practice guideline
Gram-positive Coverage [105209]
Page 6 of 15
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vancomycin (VANCOCIN) intraVENOUS - NOTE:
Choose when there is conern for cellulitis, line
infection, or when patient has severe or
immediate IgE mediated allergy to beta-lactam
antibiotics [800084]
1 g, Intravenous, DOSE PER PHARMACY
Anaerobic Coverage (Single Response) [22500]
metRONIDazole (FLAGYL) intraVENOUS- NOTE:
Choose when there is concern for intra-abdominal
infection [800062]
500 mg, Intravenous, EVERY 8 HOURS
metRONIDazole (FLAGYL) tab - NOTE: Choose
when there is concern for intra-abdominal
infection [39639]
500 mg, Oral, 3 X DAILY
Medications - General
Analgesics - Acetaminophen - PRN [22436]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain/fever
First Line
Fever greater than 38.2 degrees Celcius or See Pain
Management Algorithm for the Selection of As-
Needed Analgesic
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Oral, EVERY 4 HOURS PRN, pain/fever
Administer second line if patient unable to tolerate
tablet or prefers suspension
Fever greater than 38.2 degrees Celcius or See Pain
Management Algorithm for the Selection of As-
Needed Analgesic
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Analgesics - Opioids - Oral - PRN [218562]
oxycodone tab RANGE [750032] 5-10 mg, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesic
Analgesics - Opioids - Intravenous - PRN [218561]
MORPHine PF injection RANGE [750057] 1-4 mg, Intravenous, EVERY 2 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesic
for 4 Minutes
Anti-emetics [22294]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
8 mg, Oral, EVERY 8 HOURS PRN, nausea/vomiting
Maximum 24 mg every 24 hours.
First line PRN nausea/ vomiting
ondansetron (ZOFRAN) injection [800202] 8 mg, Intravenous, EVERY 8 HOURS PRN,
nausea/vomiting
For first line therapy when unable to take orally
Maximum 24 mg every 24 hours.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting
Second line PRN nausea/ vomiting when there is no
response to first line therapy within 30 minutes
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Second line PRN nausea/ vomiting when there is no
response to first line therapy within 30 minutes and
unable to take orally
If ordered IV: push slowly, max rate 5 mg/minute
Bowel Management [22440]
Page 7 of 15
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY PRN, constipation
Dissolve in 240 mL of liquid
First line PRN constipation
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
2 tab, Oral, 2 X DAILY PRN, constipation
For second line therapy if there is no response to first
line therapy within 12 hours
Hypnotics (Single Response) [228331]
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
melatonin tab [119466] 3 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Trazodone - Melatonin [227992] "And" Linked Panel
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use first line.
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
melatonin tab [119466] 3 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use second line if failure to respond to trazodone
within 60 minutes
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Hypnotics (Single Response) [228334]
traZODONE (DESYREL) tab [720150] 25 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
If needed, give prior to midnight if possible. May
contribute to sedation the following day.
melatonin tab [119466] 1 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Non-Categorized [185857]
polyvinyl alcohol (ARTIFICIAL TEARS) 1.4 %
ophthalmic soln [64529]
1-2 drop, Eyes (Each), PRN, dry eyes
sodium chloride (SALINE) 0.65 % nasal spray
[41865]
2 spray, Nostril (Each), EVERY 4 HOURS PRN, nasal
dryness
May leave at bedside.
biotene calcium mouthwash RANGE [750070] 10-15 mL, Swish & Spit, EVERY 4 HOURS PRN, dry
mouth
Leave at bedside
Medications - Flushes/Catheter Maintenance
Flushes - Peripheral [22318]
sodium chloride 0.9% flush 10 mL injection
[785055]
Flush, PRN, flush/line care
Flush per Vascular Access Device guidelines
Flushes - CVC or Tunneled Hickman [22320]
heparin lock flush 10 units/mL 5 mL injection
[75031]
1-150 units, Flush, PRN, flush/line care
Flush per Vascular Access Device guidelines
Flushes - Triple Lumen PICC Line Flush [22321]
Page 8 of 15
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12/2017CCKM@uwhealth.org

heparin lock flush 10 units/mL 5 mL injection
[75031]
1-150 units, Flush, PRN, flush/line care
Flush per Vascular Access Device guidelines
Laboratory
On Admission [22227]
BLOOD GASES [HCBGAS] NEXT DRAW, Starting today For 1 Occurrences,
Routine
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
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?
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?
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?
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?
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?
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?
PROTEIN, TOTAL [TP] 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?
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?
Page 9 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

ALKALINE PHOSPHATASE [ALKP] 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?
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?
C. DIFF TOXIN B PCR, B6/6 SCREENING ONLY
[CDIFFS]
ONCE For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Prior to starting antibiotics [22228]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL, Starting today 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? Prior to starting
antibiotics
One sample from each port and Peripheral
Other: peripherally, if patient has existing central
venous catheter
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL, Starting today 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 Conditional, What Condition?
One sample from each port and Peripheral Other:
peripherally, if patient has existing central venous
catheter
Page 10 of 15
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL, Starting today 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 Conditional, What Condition? Prior to starting
antibiotics
One sample from each port and Peripheral
Other: peripherally, if patient has existing central
venous catheter
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL, Starting today 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 Conditional, What Condition? Prior to starting
antibiotics
One sample from each port and Peripheral
Other: peripherally, if patient has existing central
venous catheter
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, URINE [URC] CONDITIONAL, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Prior to starting
antibiotics
CULTURE, SPUTUM [SPT] CONDITIONAL, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Prior to starting
antibiotics
CULTURE, SURFACE WOUND, NO GRAM
STAIN [WDC]
CONDITIONAL, Routine
Indicate source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Prior to starting
antibiotics
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 [194450]
For First Fever Spike: [NURCOM0055] ONCE, Starting today 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.
Page 11 of 15
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL, Starting today 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 [UA] CONDITIONAL, Starting today 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 [URC] CONDITIONAL, Starting today For 14 Days, Routine
Does patient have an indwelling urinary catheter?
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.
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
CONDITIONAL, Starting today 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 [194451]
For First Fever Spike: [NURCOM0055] ONCE, Starting 12/23/17 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.
Page 12 of 15
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL, Starting 12/23/17 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 [UA] CONDITIONAL, Starting 12/23/17 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 [URC] CONDITIONAL, Starting 12/23/17 For 7 Days, Routine
Does patient have an indwelling urinary catheter?
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.
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
CONDITIONAL, Starting 12/23/17 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.
Diagnostic Tests and Imaging
Diagnostic Test and Imaging [22229]
X-RAY CHEST PA & LAT VIEWS [R71020] ONCE-RAD NEXT AVAILABLE, Starting today 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? Rule out infection
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Page 13 of 15
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CT SINUS W/ O IV CONTRAST [R70486B] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms? Neutropenic fever
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history. rule out infection
Last creatinine value? (will auto pull in date and value
in comment):
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
CT CHEST ABDOMEN PELVIS W IV
CONTRAST - UWH [241318]
CT CHEST ABDOMEN PELVIS W IV
CONTRAST [R07129]
ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms? Neutropenic fever
What specific question(s) would you like answered
by this exam? Please include relevant recent/past
history. Rule out infection
Last creatinine value? (will auto pull in date and
value in comment):
Last patient weight? (will auto pull in value and date
in comment):
Transport Method: Floor Determined/Entered
CT CHEST W IV CONTRAST [R71260] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms? Neutropenic fever
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history. Rule out infection
Last creatinine value? (will auto pull in date and value
in comment):
Last patient weight? (will auto pull in value and date in
comment):
Transport Method:
CT CHEST W/ O IV CONTRAST [R71250] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: CT
Current signs and symptoms? Neutropenic fever
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history. Rule out infection
Last creatinine value? (will auto pull in date and value
in comment):
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Consults
Consults [22231]
Consult Infectious Disease (Inpatient) [CON0037] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Page 14 of 15
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Consult Pulmonary Medicine (Inpatient)
[CON0065]
ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
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 15 of 15
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org