/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-97856-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 - Oncology - New Diagnosis - Pediatric - Admission [1517]

IP - Oncology - New Diagnosis - Pediatric - Admission [1517] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


IP - Oncology - New Diagnosis - Pediatric - Admission [1517]
Admission Status
Level of Care (Single Response) [186484]
*An admit patient order has already been written, but the level of care at which the patient
should be placed still needs to be identified.
Place Patient on General Care [ADT0018] General Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Place Patient on Intermediate Care (IMC)
[ADT0018]
Intermediate Care, has already been signed. This
order will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intensive Care (ICU) [ADT0018] Intensive Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Admit to Inpatient (Single Response) [188296]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-
only surgery, or a previously-authorized inpatient
stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission [129499]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor: P4
Service:
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:
Admission (Single Response) [129500]
Page 1 of 14
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor: P4
Service:
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:
Patient Care Orders
Vital Signs [20353]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Pediatric Early Warning Signs [NURMON0060] SEE COMMENTS, Starting today with First
Occurrence As Scheduled, Every 4 hours.
Patient Monitoring [20354]
Assess Neurologic Status [NURMON0006] EVERY 4 HOURS, Starting today, Routine
Activity [20355]
Ad Lib [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition [20356]
Order Set"Supplemental -Parenteral Nutrition Orders, Refer to "Parenteral Nutrition For
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Patient Approved for Additional Menu Items
[DIE0010]
Patient may order food items from UWHC café or
Mendota Market?
Patient may order regular soda or other sugar-
sweetened beverages?
Routine, CONTINUOUS
Respiratory [20357]
Note: If ordering patient on oxygen, also order Respiratory Therapy consult.
Pulse Oximetry [NURMON0009] SEE COMMENTS, Starting today with First
Occurrence As Scheduled, Routine, Every *** hours.
Page 2 of 14
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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

Intake and Output [20614]
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today, Routine
Skin Care [225309]
Chlorhexidine Gluconate (CHG) treatment
[NURCOM0022]
1X DAILY
Oral Care [129501]
Oral Care [NURCOM0022] CONTINUOUS, Starting today, Brush teeth with
Biotene toothpaste on a soft toothbrush for 90
seconds twice a day. Replace toothbrush weekly.
Rinse mouth with 15-30 mL of normal saline after
brushing. Swish and spit vigorously four times a day.
Give new bottle of saline every day. If patient unable
to tolerate normal saline, may use sterile water.
Perform lip care twice per day.
Central Line Care [24574]
Maintain PICC [NURVAD0050] CONTINUOUS, Routine
Device Status: Ready For Use
Site:
PICC Secured With:
Flush With(Must also enter separate medication order
to obtain drug): Heparinized Saline
Site Assessment Frequency: EVERY 8 HOURS
Maintain Tunneled Central Venous Catheter
[NURVAD0003]
CONTINUOUS, Routine
Device Status: Ready For Use
Type: Hickman
Site:
Location:
Flush With(Must also enter separate medication order
to obtain drug): Heparinized Saline (Every 24 hours or
after each use)
Site Assessment Frequency: EVERY 8 HOURS
Maintain Central Implanted Port [NURVAD0005] CONTINUOUS, Routine
Device Status: Ready For Use
Type:
Site:
Maintain catheter, site, and dressing per Nursing and
Patient Care Policy, 1.56 AP - Central Vascular
Access Device Use, Maintenance and Removal (Adult
& Pediatric).
Non-Categorized Patient Care Orders [20616]
Measure Weight [NURMON0015] ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
On admission.
Measure Height [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine, On
admission.
Order Protective Precautions if Absolute
Neutrophil Count (ANC) is Less Than 500 cells/uL
[NURCOM0022]
CONTINUOUS, Starting today
Suspected Leukemia or Lymphoma [217291]
Suspected Leukemia/Lymphoma [NURCOM0034] CONTINUOUS, Starting today For 5 Days
Is patient suspected of leukemia or lymphoma:
Contingency Parameters (< 6 months) [129621]
Page 3 of 14
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 2:31:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
If diastolic blood pressure > (mmHg): 65
If diastolic blood pressure < (mmHg): 45
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 180
If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
Pulse Oximetry < (%): 95
Other: Hemoglobin is less than or equal to 7
g/dL,Platelet count is less than or equal to 10
K/uL,Absolute neutrophil count (ANC) is less than
500/uL,Voids are positive for hematuria greater than
trace,Patient has more than 3 diarrheal stools per
day,Patient has more than 3 emesis per 24 hour
period
Contingency Parameters (7 months thru 2 years) [129622]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 85
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 160
If heart rate < (bpm): 80
If respiratory rate >: 40
If respiratory rate <: 20
Pulse Oximetry < (%): 93
Other: Hemoglobin is less than or equal to 7
g/dL,Platelet count is less than or equal to 10
K/uL,Absolute neutrophil count (ANC) is less than
500/uL,Voids are positive for hematuria greater than
trace,Patient has more than 3 emesis per 24 hour
period
Contingency Parameters (3 years thru 6 years) [129623]
Page 4 of 14
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 87
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 140
If heart rate < (bpm): 75
If respiratory rate >: 30
If respiratory rate <: 18
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: Hemoglobin is less than or equal to 7
g/dL,Platelet count is less than or equal to 10
K/uL,Absolute neutrophil count (ANC) is less than
500/uL,Voids are positive for hematuria greater than
trace,Patient has more than 3 emesis per 24 hour
period
Contingency Parameters (7 years thru 10 years) [129675]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 125
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 120
If heart rate < (bpm): 70
If respiratory rate >: 24
If respiratory rate <: 14
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: Hemoglobin is less than or equal to 7
g/dL,Platelet count is less than or equal to 10
K/uL,Absolute neutrophil count (ANC) is less than
500/uL,Voids are positive for hematuria greater than
trace,Patient has more than 3 emesis per 24 hour
period
Contingency Parameters (11 years and older) [129681]
Page 5 of 14
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 2:31:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 140
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 110
If heart rate < (bpm): 60
If respiratory rate >: 22
If respiratory rate <: 12
Pulse Oximetry < (%): 93
Other: Hemoglobin is less than or equal to 7
g/dL,Platelet count is less than or equal to 10
K/uL,Absolute neutrophil count (ANC) is less than
500/uL,Voids are positive for hematuria greater than
trace,Patient has more than 3 emesis per 24 hour
period
Intravenous Therapy
Hydration [127370]
dextrose 5%-NaCl 0.2% infusion - at 1.5 X
Maintenance Dose [51615]
Intravenous, CONTINUOUS
at 1.5 X Maintenance Dose
Premedication for Needle Insertion [30232]
Lidocaine [152737]
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, prior to needle sticks
to reduce pain. See "LMX Use Instructions" order in
Active Orders report or the Admin Instructions for
application details
FOR PATIENTS 5 Kg OR LESS: Do NOT apply to
area greater than 100 square centimeters.
(maximum 1 g/site; maximum 1 site per hour, 6
times per day).
FOR PATIENTS 5.1-10 Kg: Do NOT apply to area
greater than 100 square centimeters. (maximum 1
g/site; maximum 2 sites per hour, 6 times per day).
FOR PATIENTS GREATER THAN 10 Kg: Do NOT
apply to area greater than 200 square centimeters.
(maximum 2.5 g/site; maximum 4 sites per hour, 6
times per day).
For patients less than 1 year old do NOT leave on
longer than 1 hour. For patients 1 year or older do
NOT leave on longer than 2 hours
LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Details
Medications - General
Tumor Lysis [127374]
allopurinol (ZYLOPRIM) susp - Maximum Dose
800 mg/day [780008]
5 mg/kg, Oral, 2 X DAILY
Maximum Dose 800 mg/day
rasburicase (ELITEK) in sodium chloride 0.9 % 50
mL bag - Maximum of 3 mg/dose [700369]
0.15 mg/kg, Intravenous, ONCE For 1 Doses
Can ONLY be ordered by Attending Physician or
Fellow
Bowel Management - Scheduled [19347]
polyethylene glycol (MIRALAX) oral packet -
NOTE: Suggested dose 8.5 or 17 g/dose one or
two times a day [61829]
Oral, 1 X DAILY
Hold for loose stools
NOTE: Suggested dose 8.5 or 17 g/dose one or two
times a day
Page 6 of 14
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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

senna-docusate (SENOKOT-S) 8.6-50 mg per tab
- NOTE: Suggested dose 1 or 2 tablets one or two
times a day [60530]
Oral
Hold for loose stools
NOTE: Suggested dose 1 or 2 tablets one or two
times a day
lactulose (CEPHULAC) soln - NOTE: Suggested
dose 2.5-10 mL/dose one to three times a day
[75426]
Oral, 1 X DAILY
Hold for loose stools
NOTE: Suggested dose 2.5-10 mL/dose one to three
times a day
Bowel Management - As Needed [19348]
polyethylene glycol (MIRALAX) oral packet -
NOTE: Suggested dose 8.5 or 17 g/dose one or
two times a day as needed [61829]
Oral
Hold for loose stools
NOTE: Suggested dose 8.5 or 17 g/dose one or two
times a day as needed
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
- NOTE: Suggested dose 1 or 2 tablets one to two
times a day as needed [60530]
Oral
Hold for loose stools
NOTE: Suggested dose 1 or 2 tablets one to two times
a day as needed
lactulose (CEPHULAC) soln - NOTE: Suggested
dose 2.5-10 mL/dose one to three times a day as
needed [75426]
Oral
Hold for loose stools
NOTE: Suggested dose 2.5-10 mL/dose one to three
times a day as needed
Antifungals (Single Response) [20698]
fluconazole (DIFLUCAN) susp - NOTE:
Suggested dose 4-6 mg/kg/dose (Maximum 400
mg/dose) [800222]
Oral, 1 X DAILY Starting today
NOTE: Suggested dose 4-6 mg/kg/dose (Maximum
400 mg/dose)
fluconazole (DIFLUCAN) tab - NOTE: Suggested
dose 4-6 mg/kg/dose (Maximum 400 mg/dose)
[45168]
Oral, 1 X DAILY Starting today
NOTE: Suggested dose 4-6 mg/kg/dose (Maximum
400 mg/dose)
fluconazole (DIFLUCAN) intraVENOUS - NOTE:
Suggested dose 4-6 mg/kg/dose (Maximum 400
mg/dose) [800044]
Intravenous, 1 X DAILY
Anti-infectives (Single Response) [20214]
sulfamethoxazole-trimethoprim (BACTRIM) 200-
40 mg per half-tab - NOTE: Suggested dose 2.5
mg trimethoprim/kg/dose [720141]
Oral, 2 X DAILY SAT, SUN
NOTE: Suggested dose 2.5 mg trimethoprim/kg/dose
(Maximum 160 mg of trimethoprim/dose)
sulfamethoxazole-trimethoprim (BACTRIM) 400-
80 MG per tab - NOTE: Suggested dose 2.5 mg
trimethoprim/kg/dose [42457]
Oral, 2 X DAILY SAT, SUN
NOTE: Suggested dose 2.5 mg trimethoprim/kg/dose
(Maximum 160 mg of trimethoprim/dose)
sulfamethoxazole-trimethoprim (BACTRIM)
intraVENOUS - NOTE: Suggested dose 2.5 mg
trimethoprim/kg/dose (Maximum 160 mg of
trimethoprim/dose) [800114]
2.5 mg/kg, Intravenous, 2 X DAILY SAT, SUN
Give if patient unable to tolerate oral formulation
NOTE: Suggested dose 2.5 mg trimethoprim/kg/dose
(Maximum 160 mg of trimethoprim/dose)
atovaquone (MEPRON) 750 MG/5ML susp -
NOTE: Order for patients < 4 months and greater
than 2 years allergic to sulfamethoxazole
Maximum Dose = 1500 mg [50620]
30 mg/kg, Oral, 1 X DAILY
atovaquone (MEPRON) 750 MG/5ML susp -
NOTE: Order for patients 4 to 24 months of age
allergic to sulfamethoxazole - Maximum Dose =
1500 mg [50620]
45 mg/kg, Oral, 1 X DAILY
Sucrose for Oral Analgesia [110384]
sucrose (SWEET-EASE) 24% buccal soln
[794009]
Oral, PRN, pain, mild pain or potentially painful
procedures. See Admin Instructions
Non-categorized [20216]
heparin lock flush 10 units/mL 5 mL injection
[75031]
1-150 units, Flush, PRN, flush/line care
Flush per VAD guidelines
Page 7 of 14
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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

heparin lock flush 100 units/mL 5 mL injection
[64978]
500 units, Flush, PRN, flush/line care
Implanted port use ONLY to be used when de-
accessing port. Flush per VAD guidelines
sodium chloride flush 0.9% 10 mL injection
[785055]
Flush, PRN, flush/line care
Laboratory
Admission Labs [20620]
CBC WITH DIFFERENTIAL [CBC] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GLUCOSE [GLU] STAT - RN COLLECT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM [CA] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALBUMIN [ALB] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTEIN, TOTAL [TP] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, DIRECT [DBIL] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 8 of 14
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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

AST/SGOT [AST] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALKALINE PHOSPHATASE [ALKP] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LD, TOTAL [LDH] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR [PT] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PTT [PTT] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
TYPE AND SCREEN [HCTS] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT, As good clinical practice and for
patient safety, the Transfusion Service will
automatically crossmatch 2 packed RBCs on all
patients with antibodies to ensure blood would be
available in the event it is needed. If you would like to
opt out of this automatic order for this patient please
contact the UWHC Blood Bank at (608) 263-8367 or
The American Center Lab at (608) 234-6600 as
appropriate.
URIC ACID [URIC] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 9 of 14
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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

URINALYSIS WITH MICROSCOPY [UA] STAT - RN COLLECT, 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?
CMV ABS, IGG/IGM [XCMVC] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE CLEARANCE [HCCCLR] Panel
CREATININE [CRET] NEXT AM For 1 Occurrences, Routine
CREATININE, URINE (FOR CLEARANCE)
[HCUCCR]
NEXT AM For 1 Occurrences, Routine
VOLUME AND PERIOD, URINE [HCVP] NEXT AM For 1 Occurrences, Routine
CREATININE CLEARANCE [UCRCL] ONCE, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FIBRINOGEN [GM1320] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HCG, QUALITATIVE, URINE [UPREG] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
If post-pubescent female.
HERPES SIMPLEX TYPE 1 AND 2 AB, IGG
[XHSVCG]
STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
RUBEOLA AB, IGG (MEASLES) [RUBO] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
VARICELLA ZOSTER AB, IGG/IGM [HCVZVGM] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS B SURFACE AB [HBSABI] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS B SURFACE AG [HBSAG] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 10 of 14
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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

PH, URINE [HCUPH] STAT - RN COLLECT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
SPECIFIC GRAVITY, URINE [HCSG] STAT - RN COLLECT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Laboratory - Draw Every 8 Hours [127369]
POTASSIUM [K] EVERY 8 HOURS For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM, IONIZED, WHOLE BLOOD
[HCWBICA]
EVERY 8 HOURS For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] EVERY 8 HOURS For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
URIC ACID [URIC] EVERY 8 HOURS For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] EVERY 8 HOURS For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] EVERY 8 HOURS For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] EVERY 8 HOURS For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
URIC ACID [URIC] EVERY 8 HOURS For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
For patients on rasburicase
Tests Needing Consent [20622]
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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

HIV AB/AG COMBO [HIVABAG] NEXT DRAW, Starting today For 1 Occurrences,
Routine, I, the ordering provider, have verified that the
patient/patient's authorized representative was:
1. Notified that the patient will be subjected to an HIV
test unless the patient/rep declines the test;
2. Given educational materials on HIV and HIV testing;
3. Notified that they may decline the test and health
care providers may not use the fact that the
patient/rep declined an HIV test as a basis for denying
other services; and
4. Provided an opportunity to ask questions and to
decline the HIV test.
The ordering provider verifies:
5. The patient/patient's authorized representative
understands that an HIV test will be performed; and
6. The decision of the patient/rep regarding whether to
have an HIV test performed was not coerced or
involuntary.
Pt/Pt's Rep did not opt out. Steps listed in instructions
taken. If test is declined, type ".HIVTESTDECLINE" in
progress note.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [20623]
X-RAY CHEST PA & LAT VIEWS [R71020] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Rule out mediastinal mass prior to line
placement
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Page 12 of 14
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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

CT ABDOMEN W IV CONTRAST [R74160] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Can pt be given oral contrast?
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
Allergies to IV contrast or iodine?
Last creatinine value? (will auto pull in date and value
in comment):
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
Transport Method:
CT PELVIS W IV CONTRAST [R72193] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
Allergies to IV contrast or iodine?
Last creatinine value? (will auto pull in date and value
in comment):
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
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 For 1 Occurrences,
Routine
Radiology Specialty Area: CT
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
Allergies to IV contrast or iodine?
Last creatinine value? (will auto pull in date and value
in comment):
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
Transport Method:
Page 13 of 14
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 2:31:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

ECG - 12 Lead (PEDS) [EKG0014] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
Transthoracic Resting Echocardiogram (PEDS)
[ECH0012]
ONCE, Starting today For 1 Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
To whom can we send the results of the study?
(include clinician and location):
Do you want Agitated Bubble Study?
Last patient height? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
Consults
Consults [20625]
Consult Spiritual Care (Inpatient) [CON0056] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Newly-diagnosed pediatric
oncology patient
Can this consult be done via video?
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: OTHER
Newly-diagnosed pediatric oncology patient.
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult:
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult:
Consult Pediatric Health Psychology (Inpatient)
[CON0202]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-Friday)
or if special assessment needs.
Reason for Consult:
Can this consult be done via video?
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Can this consult be done via video?
Consult Child Life Specialist (Inpatient)
[CON0014]
ONCE, Starting today For 1 Occurrences, Routine
Activity Level:
Reason for Consult: OTHER
Evaluate and treat.
Consult School [CON0153] ONCE, Starting today For 1 Occurrences, Routine,
The consulting provider needs to be verbally notified
of this order. A link to Web Paging is available below.
Reason for Consult:
Can this consult be done via video?
Consult Vocational Services (Inpatient)
[CON0085]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: School Re-Integration
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 14 of 14
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 2:31:36 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org