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/clinical/cckm-tools/content/order-sets/inpatient/bmtoncologyhematology/name-97858-en.cckm

20180129

page

100

UWHC,UWMF,

Tools,

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

IP - Sickle Cell Anemia - Pediatric - Admission [3351]

IP - Sickle Cell Anemia - Pediatric - Admission [3351] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


IP - Sickle Cell Anemia - Pediatric - Admission [3351]
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 Status (Single Response) [82665]
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:
Page 1 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [112140]
Admit To Inpatient Status [ADT0001] Attending:
Admitting Resident:
Requested Floor: P4
Service:
Rationale for LOS greater than 2 midnights:
Admit To Observation Status [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Patient Care Orders
Vital Signs [100658]
Pediatric Early Warning Signs [NURMON0060] SEE COMMENTS, Scheduled, Every 4 hours.
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Patient Monitoring [112142]
Assess Neurologic Status [NURMON0006] EVERY 8 HOURS, Starting today, Routine
Activity [112284]
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:
Patient to stay on unit if on PCA pump
[NURACT0011]
ONCE, Starting today For 1 Occurrences
Nutrition [101291]
Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Page 2 of 50
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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 [100660]
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, 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 [NURMON0009] EVERY 4 HOURS, Starting today, Routine
Pulse Oximetry [NURMON0009] ONCE, Starting today, Routine
Incentive Spirometry [NURTRT0018] EVERY 2 HOURS WHILE AWAKE, Starting today,
Routine
Intake and Output [100661]
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today For Until specified,
Routine
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine
Non-Categorized Patient Care Orders [100662]
Measure Weight Daily [NURMON0015] 1X DAILY, Starting today For Until specified, Routine
Weigh With?
Weigh when?
Measure Weight on Admission [NURMON0015] ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
Measure Height - On Admission [NURMON0052] ONCE, Routine, On Admission
Notify Sickle Cell Coordinator Upon Admission
[NURCOM0022]
ONCE, Starting today For 1 Occurrences, Pager 3191
or call 890-6581 and leave a message if pager is
unavailable.
Contingency Parameters for Patients Less than 6 Months of Age [129269]
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: Pain not controlled with ordered analgesics or
ordered interventions.
Contingency Parameters for Patients 7 Months to 2 years of Age [129270]
Page 3 of 50
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01/2018CCKM@uwhealth.org

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: Pain not controlled with ordered analgesics or
ordered interventions.
Contingency Parameters for Patients 3 to 6 Years of Age [129271]
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: Pain not controlled with ordered analgesics or
ordered interventions.
Contingency Parameters for Patients 7 to 10 Years of Age [129272]
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
Other: Pain not controlled with ordered analgesics or
ordered interventions.
Contingency Parameters for Patients 11 Years of Age and Greater [129273]
Page 4 of 50
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01/2018CCKM@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: Pain not controlled with ordered analgesics or
ordered interventions.
Intravenous Therapy
IV Fluids [101254]
sodium chloride 0.9% BOLUS [730003] 10 mL/kg, Intravenous
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion - NOTE: Suggested rate 1.0 x
maintenance [44910]
Intravenous, CONTINUOUS
NOTE: Suggested rate 1 x maintenance
Premedication for Needle Insertion [30232]
Lidocaine [152737] "And" Linked Panel
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
Analgesics - Scheduled - NOTE: Order for patients less than 50 kg [102895]
-Analgesia (PCA) Pediatric Intravenous Patient Controlled -controlled analgesia (PCA) see IP -patientFor
Infusion order set
ketOROLAC (TORADOL) injection - NOTE:
Suggested dose 0.5 mg/kg/dose (Maximum 15
mg/dose) [800050]
0.5 mg/kg, Intravenous, EVERY 6 HOURS For 5 Days
Analgesics - Scheduled - NOTE: Order for patients 50 kg or greater. Order BOTH if ordering from this
group [102896]
-Analgesia (PCA) Pediatric Intravenous Patient Controlled -controlled analgesia (PCA) see IP -patientFor
Infusion order set
ketOROLAC (TORADOL) injection - NOTE:
Loading dose [800050]
30 mg, Intravenous, ONCE For 1 Doses
Page 5 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
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01/2018CCKM@uwhealth.org

ketOROLAC (TORADOL) injection - 15 mg
[800050]
15 mg, Intravenous, EVERY 6 HOURS For 19 Doses
Analgesics - As Needed (Single Response) [102877]
-Analgesia (PCA) Pediatric Intravenous Patient Controlled -controlled analgesia (PCA) see IP -patientFor
Infusion order set
acetaMINOPHEN (TYLENOL) tab - NOTE:
Suggested dose 10-15 mg/kg/dose (Maximum
650 mg/dose) [34149]
Oral, EVERY 4 HOURS PRN, pain, temperature
greater than *** C or Mild to moderate pain
NOTE: Suggested dose 10-15 mg/kg/dose (Maximum
650 mg/dose)
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 10-15
mg/kg/dose (Maximum 650 mg/dose) [800005]
Oral, EVERY 4 HOURS PRN, pain/fever, temperature
greater than *** C or Mild to moderate pain
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
For patients unable to take tablets.
NOTE: Suggested dose 10-15 mg/kg/dose (Maximum
650 mg/dose)
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 10-15 mg/kg /dose
(Maximum 650 mg/dose) [43994]
Rectal, EVERY 4 HOURS PRN, pain/fever, pain or
temperature greater than *** Celsius Mild to moderate
pain i
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
For patients unable to take oral acetaminophen.
NOTE: Suggested dose 10-15 mg/kg/dose (Maximum
650 mg/dose)
ibuprofen (MOTRIN) susp -Do NOT order if
patient is receiving Ketorolac NOTE: Suggested
dose 10 mg/kg/dose (Maximum 600 mg/dose)
[45376]
10 mg/kg, Oral, EVERY 6 HOURS PRN, pain, Mild to
moderate pain if failure to acetaminophen
Pain or temperature greater than *** Celsius
For patients unable to take tablets.
Do NOT order if patient is receiving Ketorolac NOTE:
Suggested dose 10 mg/kg/dose (Maximum 600
mg/dose)
ibuprofen (MOTRIN) tab - Do NOT order if patient
is receiving Ketorolac NOTE: Suggested dose 10
mg/kg/dose (Maximum 600 mg/dose) [38353]
Oral, EVERY 6 HOURS PRN, pain, Mild to moderate
pain if failure to acetaminophen
Pain or temperature greater than *** Celsius
Do NOT order if patient is receiving Ketorolac NOTE:
Suggested dose 10 mg/kg/dose (Maximum 600
mg/dose)
Anti-emetics [81049]
ondansetron (ZOFRAN) injection - NOTE:
Suggested dose 0.1 mg/kg/dose (Maximum 4
mg/dose) [800202]
0.1 mg/kg, Intravenous, EVERY 8 HOURS PRN,
nausea/vomiting
NOTE: Suggested dose 0.1 mg/kg/dose (Maximum 4
mg/dose)
Anti-infectives [101640]
ceftriaxone (ROCEPHIN) intraVENOUS - NOTE:
Suggested dose 50 mg/kg (Maximum dose 2 g)
[800027]
50 mg/kg, Intravenous, EVERY 24 HOURS
NOTE: Suggested dose 50 mg/kg (Maximum dose 2
g)
azithromycin (ZITHROMAX) 200 mg/5 mL susp -
NOTE: Day 1 dose 10 mg/kg (Maximum 500
mg/dose) [51547]
10 mg/kg, Oral, ONCE For 1 Doses
NOTE: Day 1 dose 10 mg/kg (Maximum 500 mg/dose)
azithromycin (ZITHROMAX) 200 mg/5 mL susp -
NOTE: Day 2-5 dose 5 mg/kg (Maximum 250
mg/dose) [51547]
5 mg/kg, Oral, 1 X DAILY Starting tomorrow For 4
Days
NOTE: Day 2-5 dose 5 mg/kg (Maximum 250
mg/dose)
azithromycin (ZITHROMAX) tab - NOTE: Day 1
dose [57023]
500 mg, Oral, ONCE For 1 Doses
NOTE: Day 1 dose
azithromycin (ZITHROMAX) tab - NOTE: Day 2-5
dose [57023]
250 mg, Oral, 1 X DAILY For 4 Doses
NOTE: Day 2-5 dose
Page 6 of 50
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01/2018CCKM@uwhealth.org

penicillin V potassium (VEETID) 250 mg/5 mL
soln [40830]
125 mg, Oral, 2 X DAILY (AT MEALTIME)
penicillin V potassium (VEETID) 250 mg/5 mL
soln [40830]
250 mg, Oral, 2 X DAILY (AT MEALTIME)
penicillin V potassium (VEETID) tab [40831] 250 mg, Oral, 2 X DAILY (AT MEALTIME)
Antipruritics (Single Response) [101638]
diphenhydramine (BENADRYL) elixir - NOTE:
Suggested dose 0.5 mg/kg (Maximum 50
mg/dose) [36793]
0.5 mg/kg, Oral, EVERY 6 HOURS PRN, itching
NOTE: Suggested dose 0.5 mg/kg (Maximum 50
mg/dose)
diphenhydramine (BENADRYL) injection - NOTE:
Suggested dose 0.5 mg/kg (Maximum 50
mg/dose) [800106]
0.5 mg/kg, Intravenous, EVERY 6 HOURS PRN,
itching
NOTE: Suggested dose 0.5 mg/kg (Maximum 50
mg/dose)
diphenhydramine (BENADRYL) cap - NOTE:
Suggested dose 0.5 mg/kg (Maximum 25
mg/dose) [36791]
25 mg, Oral, EVERY 6 HOURS PRN, itching
NOTE: Suggested dose 0.5 mg/kg (Maximum 25
mg/dose)
hydrOXYzine (ATARAX) 10 MG/5ML syrup -
NOTE: Suggested dose 0.5 mg/kg (Maximum 25
mg/dose) [38281]
0.5 mg/kg, Oral, EVERY 6 HOURS PRN, itching
NOTE: Suggested dose 0.5 mg/kg (Maximum 25
mg/dose)
hydrOXYzine (ATARAX) tab - NOTE: Suggested
dose 0.5 mg/kg (Maximum 25 mg/dose) [38282]
Oral, EVERY 6 HOURS PRN, itching
NOTE: Suggested dose 0.5 mg/kg (Maximum 25
mg/dose)
Bowel Management (Single Response) [20816]
polyethylene glycol (MIRALAX) oral packet -
NOTE: Suggested dose for patients less than 25
kg is 8.5 g/dose [61829]
Oral, 2 X DAILY (AT MEALTIME)
Dissolve in 4 ounces of water. Hold for loose stools
NOTE: Suggested dose for patients less than 25 kg is
8.5 g/dose
polyethylene glycol (MIRALAX) oral packet -
NOTE: Suggested dose for patients 25 kg or
greater is 17 g/dose [61829]
17 g, Oral, 2 X DAILY (AT MEALTIME)
Dissolve in 8 ounces water. Hold for loose stools
NOTE: Suggested dose for patients 25 kg or greater is
17 g/dose
Bowel Management - As Needed - First Line (Single Response) [112268]
lactulose (CEPHULAC) soln - NOTE: Suggested
dose 5-10 mL/dose 3 times a day as needed
[75426]
Oral
Hold for loose stools
NOTE: Suggested dose 5-10 mL/dose 1-3 times a day
as needed
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
1-2 tab, Oral, 2 X DAILY PRN, constipation
Bowel Management - As Needed - Second Line (Single Response) [225311]
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal
Administer if first line agent fails
bisacodyl EC (DULCOLAX) delayed release tab
[49076]
10 mg, Oral, 1 X DAILY PRN, constipation
Administer if first line agent fails
glycerin (PEDIATRIC) rectal suppository [153728] 1 suppository, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails.
phosphate (FLEET PEDIATRIC) enema - NOTE:
Order for children 2-11 years [37522]
1 enema, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails
phosphate (FLEET) enema - NOTE: Order for
children 12 years or older [37517]
1 enema, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails
Gastric (Single Response) [101637]
famotidine (PEPCID) suspension - NOTE:
Suggested dose 0.5 mg/kg/dose (Maximum 40
mg/dose) [106408]
0.5 mg/kg, Oral, 2 X DAILY
famotidine (PEPCID) tab - NOTE: Suggested
dose 0.5 mg/kg/dose (Maximum 40 mg/dose)
[45134]
Oral, 2 X DAILY
Page 7 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
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01/2018CCKM@uwhealth.org

Deferoxamine - NOTE: Order for patients with ferritin greater than 1000 nanogram/mL [101639]
deferoxamine (DESFERAL) bag [700188] 15 mg/kg, Intravenous, ONCE
Max dose = 500 mg
Sucrose for Oral Analgesia [110384]
sucrose (SWEET-EASE) 24% buccal soln
[794009]
Oral, PRN, pain, mild pain or potentially painful
procedures. See Admin Instructions
Laboratory
Admission Labs [100668]
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?
RETICULOCYTE COUNT [RET] 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?
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?
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?
URINALYSIS, NO MICROSCOPY [UACHEM] 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?
CULTURE, URINE [URC] ONCE, Starting today For 1 Occurrences, 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?
Page 8 of 50
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01/2018CCKM@uwhealth.org

HEMOGLOBINAPATHY EVALUATION
[XHGBEV]
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 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
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01/2018CCKM@uwhealth.org

VITAMIN D, 25-HYDROXY BY HPLC [HCLCD25] NEXT DRAW, Starting today For 1 Occurrences,
Routine, Screening for Vitamin D deficiency is not
covered by Medicare. If this is the reason for the test,
please advise the patient of non-coverage via the ABN
process. Coverage is allowed in some other
circumstances. If one of these diagnoses is
appropriate for your patient, please associate the
corresponding code with this order.
252.00 (ICD-9); E21.3 (ICD-10) Hyperparathyroidism,
unspecified
252.01 (ICD-9); E21.0 (ICD-10) Primary
Hyperparathyroidism
252.02 (ICD-9); E21.1 (ICD-10) Secondary
Hyperparathyroidism, Non-Renal
252.08 (ICD-9); E21.2 (ICD-10) Other
Hyperparathyroidism
252.1 (ICD-9); E20.9 (ICD-10) Hypoparathyroidism
268.0 (ICD-9); E55.0 (ICD-10) Rickets Active
268.2 (ICD-9); M83.9 (ICD-10) Osteomalacia
Unspecified
268.9 (ICD-9); E55.9 (ICD-10) Established Vitamin D
Deficiency (monitoring efficacy of replacement
therapy)
275.3 (ICD-9); E83.30 (ICD-10) Disorders of
Phosphorus Metabolism
275.41 (ICD-9); E83.51 (ICD-10) Hypocalcemia
275.42 (ICD-9); E83.52 (ICD-10) Hypercalcemia
585.3 (ICD-9); N18.3 (ICD-10) Chronic Kidney
Disease, Stage III (Moderate)
585.4 (ICD-9); N18.4 (ICD-10) Chronic Kidney
Disease, Stage IV (Severe)
585.5 (ICD-9); N18.5 (ICD-10) Chronic Kidney
Disease, Stage V
585.6 (ICD-9); N18.6 (ICD-10) End Stage Renal
Disease
588.81 (ICD-9); N25.81 (ICD-10) Secondary
Hyperparathyroidism (of Renal Origin)
733.00 (ICD-9); M81.0 (ICD-10) Osteoporosis
Unspecified
Page 10 of 50
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733.01 (ICD-9); M81.0 (ICD-10) Senile Osteoporosis
733.02 (ICD-9); M81.8 (ICD-10) Idiopathic
Osteoporosis
733.03 (ICD-9); M81.8 (ICD-10) Disuse Osteoporosis
733.09 (ICD-9); M81.8 (ICD-10) Other Osteoporosis
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HCG, QUALITATIVE, URINE [UPREG] 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?
CALCIUM [CA] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FERRITIN [FER] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Daily Labs [101253]
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT AM, 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?
RETICULOCYTE COUNT [RET] NEXT AM, 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?
Every Other Day [101267]
ELECTROLYTES [LYTE] EVERY OTHER DAY, Starting 1/26/18 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 OTHER DAY, Starting 1/26/18 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 OTHER DAY, Starting 1/26/18 For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Blood Bank
Tests [94965]
Page 11 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

TYPE AND SCREEN [HCTS] STAT, Starting today For 1 Occurrences, Routine, 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.
Analgesics (Single Response) [12024]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, ONCE PRN For 1 Doses, pain,
premedication for blood product
Premedication for blood product
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Oral, ONCE PRN For 1 Doses, pain/fever,
premedication for blood product
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, ONCE PRN For 1 Doses, pain/fever,
Premedication for blood product
Premedication for blood product
NOTE: Suggested dose 15 mg/kg (Maximum 650
mg/dose)
Red Blood Cells - Adult (Single Response) [206670]
Select indication below. When appropriate, the system will automatically suggest the appropriate number
@BUCWTMSG@of units for this patient based on the indication.
For more information about the Blood Utilization
Calculator (BUC) click here
URL: https://uconnect.wisc.edu/clinical/references/laboratory-
services/transfusion-services-uwhc/resources/name-
101746-en.file
R1-Life-threatening hemorrhage or
anticipated/ongoing surgical blood loss [207820]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R1 Life-threatening hemorrhage
or anticipated/ongoing surgical blood loss
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Page 12 of 50
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:09:47 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R2-Suspected bleeding, symptomatic or drop in
Hemoglobin >= 3 g/dL or Hematocrit drop >= 10
[207821]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R2 Suspected bleeding,
symptomatic or drop in Hemoglobin >= 3 g/dL or
Hematocrit drop >= 10
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [NO RECENT
HEMOGLOBIN/HEMATOCRIT, UNABLE TO
CALCULATE VOLUME] [207822]
Page 13 of 50
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:09:47 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in acute upper GI bleeds
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [NO
HEMOGLOBIN/HEMATOCRIT RESULT SINCE
LAST BLOOD ORDER, UNABLE TO
CALCULATE VOLUME] [210389]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in acute upper GI bleeds
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 14 of 50
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:09:47 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [CALCULATED
VOLUME FOR THIS PATIENT=0 UNITS]
[207823]
NO ORDER RECOMMENDED: Based on this
indication, the patient does not require blood at
this time because they are already above the
target hemoglobin/hematocrit level. Select a
different indication or exit the order set.
[NURCOM0022]
ONCE
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [CALCULATED
VOLUME FOR THIS PATIENT=1 UNIT] [207824]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in acute upper GI bleeds
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [CALCULATED
VOLUME FOR THIS PATIENT=2 UNITS]
[207825]
Page 15 of 50
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:09:47 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 2 UNITS For 2 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in acute upper GI bleeds
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 2 UNITS For 2 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [CALCULATED
VOLUME FOR THIS PATIENT=3 UNITS]
[207826]
Red Blood Cells (Adult) [BLB0006] 3 UNITS For 3 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in acute upper GI bleeds
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 16 of 50
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:09:47 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 3 UNITS For 3 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [CALCULATED
VOLUME FOR THIS PATIENT=4 UNITS]
[207827]
Red Blood Cells (Adult) [BLB0006] 4 UNITS For 4 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in acute upper GI bleeds
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 4 UNITS For 4 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [CALCULATED
VOLUME FOR THIS PATIENT=5 UNITS]
[207828]
Page 17 of 50
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:09:47 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 5 UNITS For 5 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in acute upper GI bleeds
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 5 UNITS For 5 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients [NO
RECENT HEMOGLOBIN/HEMATOCRIT,
UNABLE TO CALCULATE VOLUME] [207829]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 18 of 50
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:09:47 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients [NO
HEMOGLOBIN/HEMATOCRIT RESULT SINCE
LAST BLOOD ORDER, UNABLE TO
CALCULATE VOLUME] [210435]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients
[CALCULATED VOLUME FOR THIS
PATIENT=0 UNITS] [207830]
NO ORDER RECOMMENDED: Based on this
indication, the patient does not require blood at
this time because they are already above the
target hemoglobin/hematocrit level. Select a
different indication or exit the order set.
[NURCOM0022]
ONCE
Page 19 of 50
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:09:47 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients
[CALCULATED VOLUME FOR THIS
PATIENT=1 UNIT] [207831]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients
[CALCULATED VOLUME FOR THIS
PATIENT=2 UNITS] [207832]
Page 20 of 50
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:09:47 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 2 UNITS For 2 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 2 UNITS For 2 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients
[CALCULATED VOLUME FOR THIS
PATIENT=3 UNITS] [207833]
Red Blood Cells (Adult) [BLB0006] 3 UNITS For 3 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 21 of 50
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:09:47 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 3 UNITS For 3 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients
[CALCULATED VOLUME FOR THIS
PATIENT=4 UNITS] [207834]
Red Blood Cells (Adult) [BLB0006] 4 UNITS For 4 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 4 UNITS For 4 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients
[CALCULATED VOLUME FOR THIS
PATIENT=5 UNITS] [207835]
Page 22 of 50
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:09:47 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 5 UNITS For 5 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 5 UNITS For 5 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina) [NO
RECENT HEMOGLOBIN/HEMATOCRIT,
UNABLE TO CALCULATE VOLUMEe] [207836]
Page 23 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina) [NO
HEMOGLOBIN/HEMATOCRIT RESULT SINCE
LAST BLOOD ORDER, UNABLE TO
CALCULATE VOLUME] [210436]
Page 24 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=0 UNITS] [207837]
NO ORDER RECOMMENDED: Based on this
indication, the patient does not require blood at
this time because they are already above the
target hemoglobin/hematocrit level. Select a
different indication or exit the order set.
[NURCOM0022]
ONCE
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=1 UNIT] [207838]
Page 25 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=2 UNITS] [207839]
Page 26 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 2 UNITS For 2 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 2 UNITS For 2 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=3 UNITS] [207846]
Page 27 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 3 UNITS For 3 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 3 UNITS For 3 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=4 UNITS] [207847]
calculation display removed
Page 28 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 4 UNITS For 4 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 4 UNITS For 4 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=5 UNITS] [207848]
Page 29 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 5 UNITS For 5 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 5 UNITS For 5 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R6 High risk patients (e.g., ECMO, TAAA,
stroke/cerebral vasospasm, Sickle Cell Disease)
[207849]
Page 30 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R6 High risk patients (e.g.,
ECMO, TAAA, stroke/cerebral vasospasm, Sickle
Cell Disease)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R7-Massive Transfusion Procedure [207850]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R7 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Page 31 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R8-Other [207851]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R8 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed: 1/24/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
Plasma - Adult (Single Response) [207852]
indication below.Select
F1-Active hemorrhage or correction of
coagulopathy for INR > 1.8 (NOT on warfarin)
[214319]
Plasma (Adult) [BLB0003] Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 32 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Transfuse Plasma (Adult) [NURTRT0031] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after final
plasma transfusion
F2-Invasive procedure that will begin in more
than 24 hours (on warfarin) [222319]
is not indicated.Plasma
Note: Discontinue [950016] ONCE For 1 Doses
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[239981]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
phytonadione (VITAMIN K1) intraVENOUS
[239982]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 12 hours after
phytonadione infusion
F3-Immediate reversal of warfarin [222321]
Plasma is not indicated.
Note: Discontinue [950016] ONCE
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[239981]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
phytonadione (VITAMIN K1) intraVENOUS
[239982]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
prothrombin complex PCC (KCENTRA) injection
kit [157782]
Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after PCC
administration
Page 33 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

F3-Immediate reversal of warfarin [222895]
Plasma is not indicated.
Note: Discontinue [950016] ONCE
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[239981]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
phytonadione (VITAMIN K1) intraVENOUS
[239982]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
prothrombin complex PCC (KCENTRA) injection
kit [157782]
25 Units/kg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after PCC
administration
F3-Immediate reversal of warfarin [222894]
Plasma is not indicated.
Note: Discontinue [950016] ONCE
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[239981]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
phytonadione (VITAMIN K1) intraVENOUS
[239982]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
prothrombin complex PCC (KCENTRA) injection
kit [157782]
35 Units/kg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after PCC
administration
F3-Immediate reversal of warfarin [222896]
Plasma is not indicated.
Note: Discontinue [950016] ONCE
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[239981]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
phytonadione (VITAMIN K1) intraVENOUS
[239982]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
prothrombin complex PCC (KCENTRA) injection
kit [157782]
50 Units/kg, Intravenous, ONCE For 1 Doses
Page 34 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after PCC
administration
F4-Plasmapheresis [214323]
Plasma (Adult) [BLB0003] Routine
Reason for Order: F4 Plasmapheresis
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
F5-Massive Transfusion Procedure [214326]
Plasma (Adult) [BLB0003] Routine
Reason for Order: F5 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
F6-Other [214328]
Plasma (Adult) [BLB0003] Routine
Reason for Order: F6 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 35 of 50
Printed by TAYLOR, ELAINE [ECT2] at 1/24/2018 4:09:47 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Transfuse Plasma (Adult) [NURTRT0031] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
Red Blood Cells - Pediatric (Single Response) [214402]
indication below.Select
PR1-(Patient younger than 4 months) Acute
blood loss or anticipated surgical blood loss
[214359]
Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR1 (Patient younger than 4
months) Acute blood loss or anticipated surgical
blood loss
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR2-(Patient younger than 4 months) Target
Hemoglobin > 7 g/dL or Hematocrit > 21% in
stable patient with signs of anemia (RA or nasal
cannula with FiO2 < 25%, and reticulocyte count
< 4%) [214360]
Page 36 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR2 (Patient younger than 4
months) Target Hemoglobin > 7 g/dL or Hematocrit >
21% in stable patient with signs of anemia (RA or
nasal cannula with FiO2 < 25%, and reticulocyte
count < 4%)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR3-(Patient younger than 4 months) Target
Hemoglobin > 8 g/dL or Hematocrit > 24% with
mild lung disease, NC/CPAP/NIPPV with FiO2 <
40%, and signs of poor oxygenation [214361]
Page 37 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR3 (Patient younger than 4
months) Target Hemoglobin > 8 g/dL or Hematocrit >
24% with mild lung disease, NC/CPAP/NIPPV with
FiO2 < 40%, and signs of poor oxygenation
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR4-(Patient younger than 4 months) Target
Hemoglobin > 10 g/dL or Hematocrit > 30% with
severe lung disease, intubated or on
nasopharyngeal synchronized intermittent
mandatory ventilation with FiO2 > 40%,
congenital heart disease, and/or prematurity
[214362]
Page 38 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR4 (Patient younger than 4
months) Target Hemoglobin > 10 g/dL or Hematocrit
> 30% with severe lung disease, intubated or on
nasopharyngeal synchronized intermittent
mandatory ventilation with FiO2 > 40%, congenital
heart disease, and/or prematurity
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR5-Acute blood loss or anticipated surgical
blood loss [214364]
Page 39 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR5 Acute blood loss or
anticipated surgical blood loss
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR6-Target Hemoglobin > 7 g/dL or Hematocrit >
21% [214365]
Page 40 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR6 Target Hemoglobin > 7 g/dL
or Hematocrit > 21%
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR7-Signs of poor oxygen delivery or target
Hemoglobin > 10 g/dL or Hematocrit > 30% in
patients with severe pulmonary disease requiring
assisted ventilation or congenital heart disease
[214363]
Page 41 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR7 Signs of poor oxygen
delivery or target Hemoglobin > 10 g/dL or
Hematocrit > 30% in patients with severe pulmonary
disease requiring assisted ventilation or congenital
heart disease
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR8-Chronic transfusions in selected patients
with Sickle Cell or thalassemia syndromes OR
partial exchange or exchange transfusion
[214366]
Page 42 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR8 Chronic transfusions in
selected patients with Sickle Cell or thalassemia
syndromes OR partial exchange or exchange
transfusion
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR9-Massive Transfusion Procedure [214367]
Page 43 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR9 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR10-Other [214368]
Page 44 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR10 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Plasma - Pediatric (Single Response) [214403]
indication below.Select
PF1-Elevated INR with active bleeding or
anticipated major surgery/invasive procedure
[214369]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF1 Elevated INR with active
bleeding or anticipated major surgery/invasive
procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 45 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF2-Pump prime in pediatric open heart surgery
as appropriate for neonates and lower weight
pediatric patients [214371]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF2 Pump prime in pediatric open
heart surgery as appropriate for neonates and lower
weight pediatric patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF3-Replacement therapy for hemostatic factor
deficiencies if concentrate not available [214373]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF3 Replacement therapy for
hemostatic factor deficiencies if concentrate not
available
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 46 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF4-Disseminated intravascular coagulation with
active bleeding [214374]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF4 Disseminated intravascular
coagulation with active bleeding
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF5-Immediate reversal of warfarin effect for
emergency surgery or active bleeding (in
combination with vitamin K) [214375]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF5 Immediate reversal of
warfarin effect for emergency surgery or active
bleeding (in combination with vitamin K)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 47 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF6-Massive Transfusion Procedure [214376]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF6 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF7-Other [214377]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF7 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 48 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Diagnostic Test and Imaging
Diagnostic Tests and Imaging [237933]
ECG - 12 Lead (PEDS) Without Rhythm
[EKG0014]
ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
X-RAY CHEST 2 VIEWS [R71046] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area:
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
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
X-RAY ABDOMEN SINGLE VIEW [R74018] ONCE-RAD NEXT AVAILABLE, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history? Sickle Cell Anemia
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
US DOPPLER TRANSCRANIAL COMPLETE
[R93886]
ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
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.
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Consults
Consults [100669]
Page 49 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

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 Pediatric Pain Management (Inpatient)
[CON0165]
ONCE, Starting today For 1 Occurrences, Routine
Pain Problem:
Reason for Consult:
Can this consult be done via video?
Pediatric Patient
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Consult Child Life Specialist (Inpatient)
[CON0014]
ONCE, Starting today For 1 Occurrences, Routine
Activity Level:
Reason for Consult: OTHER (Work with patient to
encourage incentive spirometry)
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult:
Consult to Peds Nutrition - INSIDE UW Health
[1009221]
Details
CONSULT TO PALLIATIVE CARE MEDICINE
[1009427]
Details
Consult Pediatric Pulmonary (Inpatient)
[CON0098]
ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Patient with history of
pneumonia/asthma
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 50 of 50
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org