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/clinical/cckm-tools/content/order-sets/inpatient/bmtoncologyhematology/name-97860-en.cckm

20170102

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100

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

IP - Spinal Cord Compression - Adult - Admission [1621]

IP - Spinal Cord Compression - Adult - Admission [1621] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


SmartSet: IP - SPINAL CORD COMPRESSION - ADULT - ADMISSION
(ID:1621)
General Information
Display name: IP - Spinal Cord Compression - Adult - Admission
Type: General
Merge priority: 0
Version comment:
Content source:
Synonyms: 1. .HEM
SmartSet notes:
Description: Intended for Adult Patients Only
Web information: Title URL
1.
Questionnaire:
Configuration
Admission Status
Level of Care
Place Patient on General Care 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) 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) 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)
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Admit To Inpatient 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)
Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response)
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status
Admit To Inpatient Attending:
Admitting Resident:
Requested Floor:
Service: HEMATOLOGY
Rationale for LOS greater than 2 midnights:
Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status
Admit To Inpatient 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:
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Admit To Observation Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay Attending:
Admitting Resident:
Requested Floor:
Service:
Isolation Status
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis
Moderate VTE Risk
Sequential Compression Device (SCD)
(TREATMENT)
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY)
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis
VTE Prophylaxis - Reason Not Ordered ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis
Moderate VTE Risk
Sequential Compression Device (SCD)
(TREATMENT)
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY)
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis
VTE Prophylaxis - Reason Not Ordered ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs
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Vital Signs EVERY 4 HOURS, Starting S For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital Signs EVERY 8 HOURS, Starting S For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Activity
Bedrest CONTINUOUS, Starting S For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: other (comment)
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Logroll CONTINUOUS, Starting S For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: strict logroll
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Chair CONTINUOUS, Starting S For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR: ad lib
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
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Ambulate with assistance CONTINUOUS, Starting S For Until specified,
Routine
AD LIB:
AMBULATE: with assistance
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Ad lib CONTINUOUS, Starting S For Until specified,
Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition
Strict NPO EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
NPO Except Medications EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Clear Liquid Diet EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Clear Liquid
No Red or Purple Dye:
Liquid Thickness: Thin
Bedside Meal Instructions:
Room Service Class:
Full Liquid Diet EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Full Liquid
No Red or Purple Dye:
Liquid Thickness: Thin
Bedside Meal Instructions:
Room Service Class:
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General Diet EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Neutropenic Diet EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Neutropenic
Bedside Meal Instructions:
Room Service Class:
Diabetes Meal Plan EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Diabetes
Bedside Meal Instructions:
Room Service Class:
Mechanical Soft Diet EFFECTIVE NOW, Starting S, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Consistency
Solid Consistency: Mechanical Soft
Liquid Thickness:
Bedside Meal Instructions:
Room Service Class:
Patient Approved for Additional Menu Items CONTINUOUS
Patient may order food items from UWHC café or
Mendota Market? Yes
Patient may order regular soda or other sugar-
sweetened beverages? Yes
Respiratory
Pulse Oximetry ONCE, Starting S For Until specified, Routine
Respiratory Therapy per Protocol CONTINUOUS, Starting S For Until specified,
Routine
Protocol Type:
Oxygen Therapy CONTINUOUS, Starting S For Until specified,
Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device:
Attempt to Wean Off Oxygen?
Intake and Output
Measure Intake And Output EVERY 8 HOURS, Starting S For Until specified,
Routine
Non-Categorized Patient Care Orders
Measure Weight 1X DAILY For Until specified, Routine
Weigh With?
Weigh when?
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Maintain Urinary Catheter CONTINUOUS, Starting S For Until specified,
Routine, To discontinue this order, enter a new order
for "Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes
in the new order.
Type: Indwelling Single Lumen
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Isolation - Protective Precautions - Panel
Protective Precautions CONTINUOUS
Reason for Protective Precautions:
Protective - Positive Pressure Room CONTINUOUS
Contingency Parameters
Notify Provider Provider to Notify: Provider
If systolic blood pressure > (mmHg): ***
If systolic blood pressure < (mmHg): ***
If diastolic blood pressure > (mmHg): ***
If diastolic blood pressure < (mmHg): ***
If temperature > (C): ***
If temperature < (C):
If heart rate > (bpm): ***
If heart rate < (bpm): ***
If respiratory rate >: ***
If respiratory rate <: ***
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Intravenous Therapy
Premedications for Needle Insertion
lidocaine (LMX) 4% topical dressing kit Topical, EVERY 1 HOUR PRN, peripheral line
insertion - see Admin Instructions
Do NOT apply to area greater than 200 square
centimeters (maximum 2.5 g/site; maximum 4 sites
per hour, 6 times per day). Do NOT leave on longer
than 2 hours. Use for stable patient, no allergies to
lidocaine, with at least 30 minutes time prior to IV use
lidocaine (XYLOCAINE) 1% injection 0.1-0.4 mL, Intradermal, PRN, peripheral line
insertion - see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into
center of wheal. Use if IV is needed within 30
minutes. Choice of medication should be based on
patient’s previous experience/preference, history of
lidocaine allergy and ease of access
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sodium chloride (bacteriostatic) 0.9 % injection 0.05-0.1 mL, Intradermal, PRN, peripheral line
insertion - see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into
center of wheal. Use if IV is needed within 30
minutes. Choice of medication should be based on
patient’s previous experience/preference, history of
lidocaine allergy and ease of access
IV Fluids
Insert and Maintain Peripheral IV CONTINUOUS, Starting S For Until specified,
Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
sodium chloride 0.9 % infusion Intravenous, CONTINUOUS
sodium chloride 0.9% BOLUS Intravenous, ONCE For 1 Doses
Infuse over 1 hour
sodium chloride 0.9% with KCl 20 mEq/L
infusion
Intravenous, CONTINUOUS
sodium chloride 0.9% with KCl 20 mEq/L
infusion
Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.9% infusion Intravenous, CONTINUOUS
dextrose 5%- NaCl 0.9% with KCl 20 mEq/L
infusion
Intravenous, CONTINUOUS
dextrose 5%- NaCl 0.9% with KCl 20 mEq/L
infusion
Intravenous, CONTINUOUS
Medications
Analgesics
acetaMINOPHEN (TYLENOL) tab 650 mg, Oral, EVERY 4 HOURS PRN, pain/fever,
PRN mild pain, multimodal therapy or temperature
greater than 38.2 C
Anti-emetics
ondansetron (ZOFRAN ODT) disintegrating tab 4 mg, Oral, EVERY 8 HOURS PRN, nausea/vomiting
First line as needed for nausea/vomiting
ondansetron (ZOFRAN) injection 4 mg, Intravenous, EVERY 8 HOURS PRN,
nausea/vomiting
First line as needed for nausea/vomiting when unable
to take orally
prochlorperazine (COMPAZINE) tab 10 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Second line as needed for nausea/vomiting when
there is no response to first line therapy within 30
minutes
prochlorperazine (COMPAZINE) injection 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Second line as needed for nausea/vomiting when
there is no response to first line therapy within 30
minutes and unable to take orally
Bowel Management - Scheduled
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senna-docusate (SENOKOT-S) 8.6-50 mg per
tab
2 tab, Oral, 2 X DAILY
Hold for loose stools
Bowel Managment - As Needed - First Line
magnesium hydroxide (MILK OF MAGNESIA)
susp
30 mL, Oral, 2 X DAILY PRN, constipation
Use as first line therapy
polyethylene glycol (MIRALAX) oral powder 17 g, Oral, 1 X DAILY PRN, constipation
Dissolve in 8 ounces of water, Use as first line
therapy
bisacodyl (DULCOLAX) EC tab 10 mg, Oral, 1 X DAILY PRN, constipation
Use as first line therapy
phosphate (FLEET) enema 1 enema, Rectal, 1 X DAILY PRN, constipation
Use as first line therapy
magnesium citrate soln 148-296 mL, Oral, 1 X DAILY PRN, constipation
Use as first line therapy
Bowel Management - As Needed - Second Line
magnesium citrate soln 296 mL, Oral, 1 X DAILY PRN, constipation
sorbitol 70% soln 30 mL, Oral, 1 X DAILY PRN, constipation
Hypnotics
traZODONE (DESYREL) tab 25 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see IPOC supplemental Sleep/Rest
Disturbance Adult)
Steroids
dexamethasone (DECADRON) intraVENOUS 10 mg, Intravenous, ONCE For 1 Doses
dexamethasone (DECADRON) intraVENOUS 4 mg, Intravenous, EVERY 6 HOURS Starting H+6
Hours
Administer first 4 mg dexamethasone IV dose 6 hours
after the 10 mg "once" dose.
Supplemental Orders
Laboratory
Admission Labs
CBC WITH DIFFERENTIAL NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
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CREATININE NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GLUCOSE NEXT DRAW, Starting S 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 NEXT DRAW, Starting S 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 NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTEIN, TOTAL NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALBUMIN NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALKALINE PHOSPHATASE NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
AST/SGOT NEXT DRAW, Starting S 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 NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LD, TOTAL NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
URIC ACID NEXT DRAW, Starting S 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, IONIZED, WHOLE BLOOD NEXT DRAW, Starting S For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
C REACTIVE PROTEIN NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
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PHOSPHATE NEXT DRAW, Starting S 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 WITH MICROSCOPY ONCE, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR NEXT DRAW, Starting S For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Laboratory (Post Infusion)
HEMATOCRIT CONDITIONAL - RN COLLECT, Starting S+1 For 1
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Release 1 hour post-
infusion of red blood cells
PLATELET COUNT CONDITIONAL - RN COLLECT, Starting S+1 For 1
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Release 1 hour post-
infusion of platelets
PROTHROMBIN TIME/INR CONDITIONAL - RN COLLECT, Starting S+1 For 1
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Release 1 hour post-
infusion of plasma
Blood Bank
Tests
TYPE AND SCREEN STAT - RN COLLECT, Starting S+1 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
acetaMINOPHEN (TYLENOL) tab 650 mg, Oral, ONCE PRN For 1 Doses, pain,
premedication for blood product
Premedication for blood product
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension
650 mg, Oral, ONCE PRN For 1 Doses, pain/fever,
premedication for blood product
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acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose)
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)
Antihistamines
diphenhydramine (BENADRYL) cap 25 mg, Oral, ONCE For 1 Doses
Premedication for blood product
diphenhydramine (BENADRYL) cap 50 mg, Oral, ONCE For 1 Doses
Premedication for blood product
diphenhydramine (BENADRYL) injection 25 mg 25 mg, Intravenous, ONCE For 1 Doses
Premedication of blood product
diphenhydramine (BENADRYL) injection 50 mg 50 mg, Intravenous, ONCE For 1 Doses
Premedication for blood products
Red Blood Cells - Adult
R1-Life-threatening hemorrhage or
anticipated/ongoing surgical blood loss
Red Blood Cells (Adult) 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): NON-
SURGICAL USE
Date Product Needed: 12/28/2016
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) 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
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Red Blood Cells (Adult) 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): NON-
SURGICAL USE
Date Product Needed: 12/28/2016
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) 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]
Red Blood Cells (Adult) 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: 12/28/2016
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 13 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult) 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 WEIGHT
ON FILE, UNABLE TO CALCULATE VOLUME]
Red Blood Cells (Adult) 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: 12/28/2016
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) 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 AND NO
WEIGHT ON FILE, UNABLE TO CALCULATE
VOLUME]
Page 14 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Red Blood Cells (Adult) 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: 12/28/2016
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 15 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult) 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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
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.
ONCE
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds
[CALCULATED VOLUME FOR THIS
PATIENT=1 UNIT]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Red Blood Cells (Adult) 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: 12/28/2016
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) 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:
Page 16 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds
[CALCULATED VOLUME FOR THIS
PATIENT=2 UNITS]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Page 17 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Red Blood Cells (Adult) 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: 12/28/2016
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 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult) 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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Page 19 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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: 12/28/2016
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) 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
WEIGHT ON FILE, UNABLE TO CALCULATE
VOLUME]
Red Blood Cells (Adult) 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: 12/28/2016
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 20 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult) 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
RECENT HEMOGLOBIN/HEMATOCRIT AND
NO WEIGHT ON FILE, UNABLE TO
CALCULATE VOLUME]
Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Page 21 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
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.
ONCE
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients
[CALCULATED VOLUME FOR THIS
PATIENT=1 UNIT]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Page 22 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Red Blood Cells (Adult) 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: 12/28/2016
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 23 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult) 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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Page 24 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Red Blood Cells (Adult) 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: 12/28/2016
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 25 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult) 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]
Red Blood Cells (Adult) 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: 12/28/2016
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) 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
WEIGHT ON FILE, UNABLE TO CALCULATE
VOLUME]
Page 26 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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: 12/28/2016
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) 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
RECENT HEMOGLOBIN/HEMATOCRIT AND
NO WEIGHT ON FILE, UNABLE TO
CALCULATE VOLUME]
Page 27 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Page 28 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
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.
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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Page 29 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Page 30 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Page 31 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Page 32 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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: 12/28/2016
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) 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]
Calculation used: (Target Hemoglobin - Actual Hemoglobin) * (Weight (kg)/80)
If no hemoglobin in last 24 hours, hematocrit/3 will be used.
Page 33 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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: 12/28/2016
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) 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)
Red Blood Cells (Adult) 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): NON-
SURGICAL USE
Date Product Needed: 12/28/2016
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 34 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult) 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
Red Blood Cells (Adult) 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): NON-
SURGICAL USE
Date Product Needed: 12/28/2016
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) 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
Page 35 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Adult) 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): NON-
SURGICAL USE
Date Product Needed: 12/28/2016
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) 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
F1-Active hemorrhage and multifactor
coagulopathy (INR > 1.8)
Plasma (Adult) Routine
Reason for Order: F1 Active hemorrhage and
multifactor coagulopathy (INR > 1.8)
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) Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
F2-Invasive procedure planned within six hours
and multifactorial coagulopathy (INR > 1.8)
Page 36 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Plasma (Adult) Routine
Reason for Order: F2 Invasive procedure planned
within six hours and multifactorial coagulopathy
(INR > 1.8)
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) Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
F3-Immediate reversal of warfarin effect for
emergency surgery or active bleeding (in
combination with vitamin K)
Plasma (Adult) Routine
Reason for Order: F3 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:
Transfuse Plasma (Adult) Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
F4-Plasmapheresis
Plasma (Adult) 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:
Page 37 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Plasma (Adult) Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
F5-Thrombotic thrombocytopenic purpura (TTP)
Plasma (Adult) Routine
Reason for Order: F5 Thrombotic
thrombocytopenic purpura (TTP)
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) Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
F6-Massive Transfusion Procedure
Plasma (Adult) Routine
Reason for Order: F6 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) Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
F7-Other
Plasma (Adult) Routine
Reason for Order: F7 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 38 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Plasma (Adult) Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
Platelets - Adult
P1-Target Platelets > 10 K/µL
Platelets (Adult) 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P1 Target Platelets > 10 K/µL
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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Platelets (Adult) TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Each Unit Over:
P2-Target Platelets >= 20 K/µL and central
venous catheter placement within 6 hours or
minor bleeding in BMT/leukemia-induction
patients
Page 39 of 74
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Platelets (Adult) 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P2 Target Platelets >= 20 K/µL
and central venous catheter placement within 6
hours or minor bleeding in BMT/leukemia-
induction 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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Platelets (Adult) TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Each Unit Over:
P3-Target Platelets > 50 K/µL and significant
bleeding or invasive procedure/surgery planned
within six hours (e.g., lumbar puncture,
nonneuraxial surgery)
Platelets (Adult) 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P3 Target Platelets > 50 K/µL
and significant bleeding or invasive
procedure/surgery planned within six hours (e.g.,
lumbar puncture, nonneuraxial surgery)
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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Page 40 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Platelets (Adult) TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Each Unit Over:
P4-Target Platelets > 100 K/µL with major
CNS/eye surgery, for up to 48 hrs. post op,
epidural catheters and lumbar drains
Platelets (Adult) 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P4 Target Platelets > 100 K/µL
with major CNS/eye surgery, for up to 48 hrs. post
op, epidural catheters and lumbar drains
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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Platelets (Adult) TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Each Unit Over:
P5-Platelet dysfunction and ongoing bleeding
Page 41 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Platelets (Adult) 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P5 Platelet dysfunction and
ongoing 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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Platelets (Adult) TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Each Unit Over:
P6-Massive Transfusion Procedure
Platelets (Adult) 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P6 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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Platelets (Adult) TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Each Unit Over:
P7-Other
Page 42 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Platelets (Adult) 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P7 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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Platelets (Adult) TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Each Unit Over:
Cryoprecipitate - Adult
C1-Fibrinogen deficiency (< 100 mg/dL)
Cryoprecipitate (Adult) Routine
Reason for Order: C1 Fibrinogen deficiency (<
100 mg/dL)
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:
Fibrin Glue, mLs Needed:
Transfuse Cryoprecipitate (Adult) Routine, Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units
(approx 120mL). Standard adult dose = 10 units.
Suggested dose = 1 unit/10 kg.
Individual cryoprecipitate units are also available
for fibrin glue (approx 10-15 mL each).
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
Fibrin Glue, mLs Needed:
C2-Factor XIII deficiency
Page 43 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Cryoprecipitate (Adult) Routine
Reason for Order: C2 Factor XIII deficiency
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:
Fibrin Glue, mLs Needed:
Transfuse Cryoprecipitate (Adult) Routine, Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units
(approx 120mL). Standard adult dose = 10 units.
Suggested dose = 1 unit/10 kg.
Individual cryoprecipitate units are also available
for fibrin glue (approx 10-15 mL each).
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
Fibrin Glue, mLs Needed:
C3-Massive Transfusion Procedure
Cryoprecipitate (Adult) Routine
Reason for Order: C3 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:
Fibrin Glue, mLs Needed:
Transfuse Cryoprecipitate (Adult) Routine, Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units
(approx 120mL). Standard adult dose = 10 units.
Suggested dose = 1 unit/10 kg.
Individual cryoprecipitate units are also available
for fibrin glue (approx 10-15 mL each).
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
Fibrin Glue, mLs Needed:
C4-Other
Cryoprecipitate (Adult) Routine
Reason for Order: C4 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:
Fibrin Glue, mLs Needed:
Page 44 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Cryoprecipitate (Adult) Routine, Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units
(approx 120mL). Standard adult dose = 10 units.
Suggested dose = 1 unit/10 kg.
Individual cryoprecipitate units are also available
for fibrin glue (approx 10-15 mL each).
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
Fibrin Glue, mLs Needed:
Red Blood Cells - Pediatric
PR1-(Patient younger than 4 months) Acute
blood loss or anticipated surgical blood loss
Red Blood Cells (Pediatric) 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) 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):
Page 45 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

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%)
Red Blood Cells (Pediatric) 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) 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
Page 46 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Pediatric) 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) 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
Page 47 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Pediatric) 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) 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
Page 48 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Pediatric) 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) 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%
Page 49 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Pediatric) 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) 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
Page 50 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Pediatric) 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) 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
Page 51 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Pediatric) 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) 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
Page 52 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Pediatric) 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) 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
Page 53 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Pediatric) 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) 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
PF1-Elevated INR with active bleeding or
anticipated major surgery/invasive procedure
Plasma (Pediatric) 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 54 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Plasma (Pediatric) Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 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
Plasma (Pediatric) 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) Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 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
Plasma (Pediatric) 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 55 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Plasma (Pediatric) Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 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
Plasma (Pediatric) 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) Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 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)
Plasma (Pediatric) 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 56 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Plasma (Pediatric) Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 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
Plasma (Pediatric) 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) Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF7-Other
Plasma (Pediatric) 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 57 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Plasma (Pediatric) Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank
at (608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Platelets - Pediatric
PP1-Target Platelets > 20 K/µL in a stable
premature infant (GA < 37 weeks)
Platelets (Pediatric) Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP1 Target Platelets > 20 K/µL
in a stable premature infant (GA < 37 weeks)
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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Platelets (Pediatric) Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested
dose = 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP2-Target Platelets > 30 K/µL in a sick
premature infant (GA < 37 weeks) or minor signs
of bleeding
Page 58 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Platelets (Pediatric) Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP2 Target Platelets > 30 K/µL
in a sick premature infant (GA < 37 weeks) or
minor signs of 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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Platelets (Pediatric) Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested
dose = 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP3-Target Platelets > 50 K/µL and extreme
prematurity (GA < 37 weeks) at high risk for IVH
or neonatal encephalopathy
Platelets (Pediatric) Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP3 Target Platelets > 50 K/µL
and extreme prematurity (GA < 37 weeks) at high
risk for IVH or neonatal encephalopathy
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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Page 59 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Platelets (Pediatric) Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested
dose = 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP4-Target Platelets > 10 K/µL in a non-
bleeding patient with failure of platelet
production
Platelets (Pediatric) Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP4 Target Platelets > 10 K/µL
in a non-bleeding patient with failure of platelet
production
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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Platelets (Pediatric) Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested
dose = 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP5-Target Platelets > 20 K/µL in a non-
bleeding patient with failure of platelet
production and risk factors (sepsis, fever,
coagulopathy, etc.)
Page 60 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Platelets (Pediatric) Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP5 Target Platelets > 20 K/µL
in a non-bleeding patient with failure of platelet
production and risk factors (sepsis, fever,
coagulopathy, etc.)
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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Platelets (Pediatric) Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested
dose = 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP6-Target Platelets > 50 K/µL with failure of
platelet production AND active bleeding OR
need for an invasive procedure
Platelets (Pediatric) Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP6 Target Platelets > 50 K/µL
with failure of platelet production AND active
bleeding OR need for an 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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Page 61 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Platelets (Pediatric) Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested
dose = 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP7-Significant bleeding in a patient with a
qualitative platelet defect, regardless of platelet
count
Platelets (Pediatric) Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP7 Significant bleeding in a
patient with a qualitative platelet defect,
regardless of platelet count
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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Platelets (Pediatric) Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested
dose = 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP8-Target Platelets > 75 K/µL in a non-
bleeding patient on ECMO
Page 62 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Platelets (Pediatric) Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP8 Target Platelets > 75 K/µL
in a non-bleeding patient on ECMO
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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Platelets (Pediatric) Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested
dose = 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP9-Target Platelets > 100 K/µL with major
CNS/eye/cardiac surgery (for up to 48 hrs. post-
operatively)
Platelets (Pediatric) Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP9 Target Platelets > 100
K/µL with major CNS/eye/cardiac surgery (for up
to 48 hrs. post-operatively)
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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Page 63 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Platelets (Pediatric) Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested
dose = 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP10-Massive Transfusion Procedure
Platelets (Pediatric) Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP10 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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Platelets (Pediatric) Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested
dose = 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP11-Other
Page 64 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Platelets (Pediatric) Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP11 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:
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):
HLA Matched (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Platelets (Pediatric) Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested
dose = 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Cryoprecipitate - Pediatric
PC1-Active bleeding OR anticipated major
surgery/invasive procedure (e.g., ECMO) with
fibrinogen < 100 mg/dL or dysfibrinogenemia
Cryoprecipitate (Pediatric) Routine
Reason for Order: PC1 Active bleeding OR
anticipated major surgery/invasive procedure
(e.g., ECMO) with fibrinogen < 100 mg/dL or
dysfibrinogenemia
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 65 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Cryoprecipitate (Pediatric) Routine, Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested
dose: 1 Unit/10 kg body weight. If patient weighs
less than 10 kg give 1 unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
PC2-Factor XIII deficiency
Cryoprecipitate (Pediatric) Routine
Reason for Order: PC2 Factor XIII deficiency
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 Cryoprecipitate (Pediatric) Routine, Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested
dose: 1 Unit/10 kg body weight. If patient weighs
less than 10 kg give 1 unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
PC3-Massive Transfusion Procedure
Cryoprecipitate (Pediatric) Routine
Reason for Order: PC3 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 Cryoprecipitate (Pediatric) Routine, Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested
dose: 1 Unit/10 kg body weight. If patient weighs
less than 10 kg give 1 unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
PC4-Other
Page 66 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Cryoprecipitate (Pediatric) Routine
Reason for Order: PC4 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:
Transfuse Cryoprecipitate (Pediatric) Routine, Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested
dose: 1 Unit/10 kg body weight. If patient weighs
less than 10 kg give 1 unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging
Page 67 of 74
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

MRI & MRA HEAD W & W/ O CONTRAST ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Study Needed Within:
Is patient pregnant?
Does patient have a pacemaker or defibrillator?
Allergy to Gadolinium (MRI) contrast?
For Scheduling purposes, is the patient
claustrophobic or require any form of sedation? Note:
ordering provider is responsible for prescribing oral
anxiolytic or ordering sedation services.
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.
Relevant Surgical History (Select all applicable or
None):
Implanted Devices? (Select all applicable or None):
History of Metal in Body? (Select all applicable or
None):
Has patient had a colonoscopy/endoscopy in the last
8 weeks?
Last creatinine value? (will auto pull in date and value
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date
in comment):
Last patient height? (will auto pull in value and date in
comment):
Transport Method:
Page 68 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

MRI CERVICAL SPINE W & W/ O CONTRAST ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Study Needed Within:
Is patient pregnant?
Does patient have a pacemaker or defibrillator?
Allergy to Gadolinium (MRI) contrast?
For Scheduling purposes, is the patient
claustrophobic or require any form of sedation? Note:
ordering provider is responsible for prescribing oral
anxiolytic or ordering sedation services.
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.
Relevant Surgical History (Select all applicable or
None):
Implanted Devices? (Select all applicable or None):
History of Metal in Body? (Select all applicable or
None):
Has patient had a colonoscopy/endoscopy in the last
8 weeks?
Last creatinine value? (will auto pull in date and value
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date
in comment):
Last patient height? (will auto pull in value and date in
comment):
Transport Method:
Page 69 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

MRI THORACIC SPINE W & W/ O CONTRAST ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Study Needed Within:
Is patient pregnant?
Does patient have a pacemaker or defibrillator?
Allergy to Gadolinium (MRI) contrast?
For Scheduling purposes, is the patient
claustrophobic or require any form of sedation? Note:
ordering provider is responsible for prescribing oral
anxiolytic or ordering sedation services.
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.
Relevant Surgical History (Select all applicable or
None):
Implanted Devices? (Select all applicable or None):
History of Metal in Body? (Select all applicable or
None):
Has patient had a colonoscopy/endoscopy in the last
8 weeks?
Last creatinine value? (will auto pull in date and value
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date
in comment):
Last patient height? (will auto pull in value and date in
comment):
Transport Method:
Page 70 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

MRI LUMBAR SPINE W & W/ O CONTRAST ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Study Needed Within:
Is patient pregnant?
Does patient have a pacemaker or defibrillator?
Allergy to Gadolinium (MRI) contrast?
For Scheduling purposes, is the patient
claustrophobic or require any form of sedation? Note:
ordering provider is responsible for prescribing oral
anxiolytic or ordering sedation services.
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.
Relevant Surgical History (Select all applicable or
None):
Implanted Devices? (Select all applicable or None):
History of Metal in Body? (Select all applicable or
None):
Has patient had a colonoscopy/endoscopy in the last
8 weeks?
Last creatinine value? (will auto pull in date and value
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date
in comment):
Last patient height? (will auto pull in value and date in
comment):
Transport Method:
Page 71 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

MRI PELVIS W & W/ O CONTRAST ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Study Needed Within:
Is patient pregnant?
Does patient have a pacemaker or defibrillator?
Allergy to Gadolinium (MRI) contrast?
For Scheduling purposes, is the patient
claustrophobic or require any form of sedation? Note:
ordering provider is responsible for prescribing oral
anxiolytic or ordering sedation services.
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.
Relevant Surgical History (Select all applicable or
None):
Implanted Devices? (Select all applicable or None):
History of Metal in Body? (Select all applicable or
None):
Has patient had a colonoscopy/endoscopy in the last
8 weeks?
Last creatinine value? (will auto pull in date and value
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date
in comment):
Last patient height? (will auto pull in value and date in
comment):
Transport Method:
Consults
Consults
Consult Radiation Oncology (Inpatient) ONCE
Intent:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Consult Interventional Radiology (Inpatient) ONCE
Reason for Consult:
Modality Type:
Call back number:
Intent:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Page 72 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

PICC Placement Request ONCE, Starting S For 1 Occurrences, Routine
PICC Line Placement Reason:
PICC Line Placement Duration:
Mastectomy?
Dialysis Graft/Shunt?
Thrombosis?
Existing Venous Access Device(s)?
Over 400 lbs?
Number of Lumens:
Do Not Use:
Do Not Use Reason:
Consult Palliative Care (Inpatient) ONCE, Starting S For 1 Occurrences, Routine
Reason For Consult:
Can this consult be done via video?
Behavioral Health Consults (select below)
Health Psychology - adjustment, protocol (eg. burn, trauma, rehab, pre-amp,
transplant), noncompliance, grief, pain
Addictive Disorders - alcohol or drug related problems (eg. treatment recommendations,
withdrawal mgmt)
Psychiatry - safety, agitation, capacity, med mgmt, psychotropic SE
ACE - 60 and older - delirium, dementia, depression, decisional capacity, sleep (also for
non-behavioral geriatric syndromes; overall geriatric evaluation, mobility/falls, functional
decline, social/caregiver issues, disposition, medication management)
Consult Health Psychology (Inpatient) ONCE, Routine, Please notify consulting provider
if patient needs to be seen same day (Monday-
Friday) or if special assessment needs.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Addictive Disorders (Inpatient) ONCE, Routine, This order is for ADULT patients.
Please use the Consult Adolescent/Pediatric
AODA Counselor order for adolescent/pediatric
patients instead.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Psychiatry (Inpatient) ONCE
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Consult Ace/Geriatric (Inpatient) ONCE, Routine
Reason for Consult:
Can this consult be done via video?
Consult Nutrition (Inpatient) ONCE, Starting S For 1 Occurrences, Routine
Reason for Consult: Nutrition Assessment w/
Recommendations
Delegate to Initiate and Manage Tube Feeding:
Delegate to Initiate Feeding Tube Placement Order
Set:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Page 73 of 74
Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Consult Physical Therapy (Inpatient) Eval and
Treat
ONCE, Starting S For 1 Occurrences, Routine
Reason for Physical Therapy Consult:
Consult Occupational Therapy (Inpatient) ONCE, Starting S For 1 Occurrences, Routine
Reason for Occupational Therapy Consult:
Consult Neurosurgery (Inpatient) ONCE
Intent:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis): Evaluate
for decompression
Consult Orthopedics (Inpatient) ONCE
Intent:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis): Evaluate
for decompression
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Printed by STRAKA, KEVIN F [KFS1] at 12/28/2016 10:44:17 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org