/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/bmtoncologyhematology/,

/clinical/cckm-tools/content/order-sets/inpatient/bmtoncologyhematology/name-97868-en.cckm

201711310

page

100

UWHC,UWMF,

Tools,

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

IP - Beacon Supplemental Hematopoietic Stem Cell Transplant - Pediatric - Admission [5102]

IP - Beacon Supplemental Hematopoietic Stem Cell Transplant - Pediatric - Admission [5102] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


IP - BEACON SUPPLEMENTAL HEMATOPOIETIC STEM CELL TRANSPLANT
- PEDIATRIC - ADMISSION [5102]
Admission Status
Level of Care (Single Response) [187515]
*An admit patient order has already been written, but the level of care at which the patient
should be placed still needs to be identified.
Place Patient on General Care [ADT0018] General Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Place Patient on Intermediate Care (IMC)
[ADT0018]
Intermediate Care, has already been signed. This
order will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intensive Care (ICU) [ADT0018] Intensive Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Admit to Inpatient (Single Response) [188296]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-
only surgery, or a previously-authorized inpatient
stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [27585]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor: P4
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.
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Page 1 of 30
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Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [109990]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor: P4
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.
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Patient Care Orders
Vital Signs [24569]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Pediatric Early Warning Signs [NURMON0060] SEE COMMENTS, Starting today, Every 4 hours.
Patient Monitoring [136613]
Assess Neurologic Status [NURMON0006] EVERY 8 HOURS, Routine
Activity [24571]
Ad Lib [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Encourage out of bed in room or HSCT hallway 4
times daily as tolerated.
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10/2017CCKM@uwhealth.org

Nutrition [24572]
SetSupplemental" Order -Pediatric -to "Parenteral Nutrition Refer
Low Microbial Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: Diet Modifications
Diet Modifications: Neutropenic
Bedside Meal Instructions:
Room Service Class:
Patient Approved for Additional Menu Items
[DIE0010]
Patient may order food items from UWHC café or
Mendota Market?
Patient may order regular soda or other sugar-
sweetened beverages?
Routine, CONTINUOUS
Skin Care [137686]
Skin Care [NURCOM0022] ONCE, Starting today For 1 Occurrences, Use Aloe
Vesta Foam Cleanser with OB sponges to wipe after
using the bathroom. Apply sensicare protective barrier
after cleansing to any area that may come in contact
with stool.
nystatin topical powder 100000 unit/g [103228] Topical, PRN, Skin Care
Apply to peri area after stools
Chlorhexidine Gluconate (CHG) treatment
[NURCOM0022]
1X DAILY
Oral Care [129501]
Oral Care [NURCOM0022] CONTINUOUS, Starting today, Brush teeth with
Biotene toothpaste on a soft toothbrush for 90
seconds twice a day. Replace toothbrush weekly.
Rinse mouth with 15-30 mL of normal saline after
brushing. Swish and spit vigorously four times a day.
Give new bottle of saline every day. If patient unable
to tolerate normal saline, may use sterile water.
Perform lip care twice per day.
Central Line Care [24574]
Maintain PICC [NURVAD0050] CONTINUOUS, Routine
Device Status: Ready For Use
Site:
PICC Secured With:
Flush With(Must also enter separate medication order
to obtain drug): Heparinized Saline
Site Assessment Frequency: EVERY 8 HOURS
Maintain Tunneled Central Venous Catheter
[NURVAD0003]
CONTINUOUS, Routine
Device Status: Ready For Use
Type: Hickman
Site:
Location:
Flush With(Must also enter separate medication order
to obtain drug): Heparinized Saline (Every 24 hours or
after each use)
Site Assessment Frequency: EVERY 8 HOURS
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10/2017CCKM@uwhealth.org

Maintain Central Implanted Port [NURVAD0005] CONTINUOUS, Routine
Device Status: Ready For Use
Type:
Site:
Maintain catheter, site, and dressing per Nursing and
Patient Care Policy, 1.56 AP - Central Vascular
Access Device Use, Maintenance and Removal (Adult
& Pediatric).
Respiratory [137685]
Pulse Oximetry [NURMON0009] EVERY 4 HOURS, Starting today, Routine, With vital
signs.
Intake and Output [24576]
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today, Routine
BMT Transfusion Protocol [113193]
Initiate BMT Service Transfusion Protocol
[TRAN0001]
CONTINUOUS, Starting today, Routine
Analgesics to be Ordered:
Antihistamines to be Ordered:
Steroids to be Ordered:
Labs to be Ordered: None
Total Volume (units) RBC (Pediatric):
Total Volume (mL) RBC (Pediatric):
Does patient require single donor platelets (If yes,
Blood Bank MD approval required):
Total Units Platelets (Pediatric) (1 random donor unit =
45-65 mL; Suggested dose = 1 RDU/12kg; 4 RDU=1
SDU):
Platelet Threshold: 20,000/microliter
Hemoglobin Threshold: 8 grams/deciliter
Order blood products, premeds and/or post labs as
indicated using order set #4179 IP - BMT - Blood
Transfusion - Supplemental
Non-Categorized Patient Care Orders [233856]
Measure Height [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine,
Upon admission.
Measure Weight [NURMON0015] 2X DAILY, Starting today, Routine
Weigh With?
Weigh when?
All Blood Products Should be Leukopoor and
Irradiated Except for Stem Cell Product
[NURCOM0022]
CONTINUOUS, Starting today
Contingency Parameters [233857]
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10/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
If diastolic blood pressure > (mmHg): 65
If diastolic blood pressure < (mmHg): 45
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 180
If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
Pulse Oximetry < (%): 95
Other: Hemoglobin is less than or equal to 8.0
g/dL,Platelet count is less than or equal to
20K/uL,Voids are positive for hematuria greater than
trace,Patient has more than 3 diarrheal stools per
day,Pain not controlled with ordered analgesics or
ordered interventions.
Contingency Parameters [233858]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 85
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 160
If heart rate < (bpm): 80
If respiratory rate >: 40
If respiratory rate <: 20
Pulse Oximetry < (%): 93
Other: Hemoglobin is less than or equal to 8.0
g/dL,Platelet count is less than or equal to
20K/uL,Voids are positive for hematuria greater than
trace,Patient has mroe than 3 diarrheal stools per
day,Pain not controlled with ordered analgesics or
ordered interventions.
Contingency Parameters [233859]
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10/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 118
If systolic blood pressure < (mmHg): 87
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 140
If heart rate < (bpm): 75
If respiratory rate >: 30
If respiratory rate <: 18
Pulse Oximetry < (%): 93
If urine output < (mL):
Other: Hemoglobin is less than or equal to 8.0
g/dL,Platelet count is less than or equal to
20K/uL,Voids are positive for hematuria greater than
trace,Patient has more than 3 diarrheal stools per
day,Pain not controlled with ordered analgesics or
ordered interventions.
Contingency Parameters [233860]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 125
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 120
If heart rate < (bpm): 70
If respiratory rate >: 24
If respiratory rate <: 14
Pulse Oximetry < (%): 93
Other: Hemoglobin is less than or equal to 8.0
g/dL,Platelet count is less than or equal to
20K/uL,Voids are positive for hematuria greater than
trace,Patient has more than 3 diarrheal stools per
day,Pain not controlled with ordered analgesics or
ordered interventions.
Contingency Parameters [233862]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 140
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 110
If heart rate < (bpm): 60
If respiratory rate >: 22
If respiratory rate <: 12
Pulse Oximetry < (%): 93
Other: Hemoglobin is less than or equal to 8.0
g/dL,Platelet count is less than or equal to
20K/uL,Voids are positive for hematuria greater than
trace,Patient has more than 3 diarrheal stools per
day,Pain not controlled with ordered analgesics or
ordered interventions.
Page 6 of 30
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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10/2017CCKM@uwhealth.org

Intravenous Therapy
Premedication for Needle Insertion [30232]
Lidocaine [152737]
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, prior to needle sticks
to reduce pain. See "LMX Use Instructions" order in
Active Orders report or the Admin Instructions for
application details
FOR PATIENTS 5 Kg OR LESS: Do NOT apply to
area greater than 100 square centimeters.
(maximum 1 g/site; maximum 1 site per hour, 6
times per day).
FOR PATIENTS 5.1-10 Kg: Do NOT apply to area
greater than 100 square centimeters. (maximum 1
g/site; maximum 2 sites per hour, 6 times per day).
FOR PATIENTS GREATER THAN 10 Kg: Do NOT
apply to area greater than 200 square centimeters.
(maximum 2.5 g/site; maximum 4 sites per hour, 6
times per day).
For patients less than 1 year old do NOT leave on
longer than 1 hour. For patients 1 year or older do
NOT leave on longer than 2 hours
LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Details
Medications - General
Management of Fever and Neutropenia - Pediatric
- Inpatient/Ambulatory/Emergency Department -
Clinical Practice Guideline
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/oncology/name-116777-
en.cckm
Anti-Infectives - For Fever [132700]
NOTE: Initiate cefepime (MAXIPIME) 50
mg/kg/dose, Intravenously, EVERY 8 HOURS
(Maximum of 2000 mg/dose) for first temperature
spike greater than 38 C in patients as empiric
anti-pseudomonal therapy. Administer after blood
cultures are obtained. [950018]
PRN - NOTIFY PHARMACY WHEN NEEDED, fever
NOTE: Initiate vancomycin 15 mg/kg/dose,
Intravenously, EVERY 6 HOURS (Maximum of
2000 mg/dose) for first temperature spike greater
than 38 C if patient is clinically unstable, has
acute myeloid leukemia, has a history of
methicillin-resistant Staphylococcus aureus or
beta-lactam-resistant Streptococcus spp. or has
received high-dose cytarabine. Administer after
blood cultures are obtained [950018]
PRN - NOTIFY PHARMACY WHEN NEEDED, fever
NOTE: Initiate meropenem (MERREM) 20
mg/kg/dose, Intravenously, EVERY 8 HOURS
(Maximum of 1000 mg/dose) for first temperature
spike greater than 38 C in patients with a history
of multidrug-resistant organisms. Administer after
blood cultures are obtained [950018]
PRN - NOTIFY PHARMACY WHEN NEEDED, fever
Immune Globulin - For all Haploidentical and Allogenic Transplants patients with IGG level <400 mg/dL
[139462]
Page 7 of 30
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10/2017CCKM@uwhealth.org

Notify Attending for IgG Level Less Than 400
mg/dL [NURCOM0001]
Provider to Notify: Attending
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: IgG level less than 400 mg/dL
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 10
mg/kg/dose (Maximum 650 mg/dose) [800005]
10 mg/kg, Oral, EVERY 7 DAYS
Give 30 minutes prior to infusion of immune globulin
NOTE: Suggested dose 10 mg/kg/dose (Maximum
650 mg/dose)
diphenhydramine (BENADRYL) injection 0.5
mg/kg - NOTE: Suggested dose 0.5 mg/kg/dose
(Maximum 50 mg/dose) [800106]
0.5 mg/kg, Intravenous, EVERY 7 DAYS
Give 30 minutes prior to immune globulin
NOTE: Suggested dose 0.5 mg/kg/dose (Maximum 50
mg/dose)
immune globulin 10% (GAMMAGARD LIQ) bag
[143798]
250 mg/kg, Intravenous, EVERY 7 DAYS
IMMUNOGLOBULIN G [XIGG] EVERY TUESDAY, Starting 11/6/17 with First
Occurrence As Scheduled For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 2
IMMUNOGLOBULIN G [XIGG] EVERY TUESDAY, Starting 11/13/17 with First
Occurrence As Scheduled For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 3
IMMUNOGLOBULIN G [XIGG] EVERY TUESDAY, Starting 11/20/17 with First
Occurrence As Scheduled For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 4
IMMUNOGLOBULIN G [XIGG] EVERY TUESDAY, Starting 11/27/17 with First
Occurrence As Scheduled For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 5
IMMUNOGLOBULIN G [XIGG] EVERY TUESDAY, Starting 12/4/17 with First
Occurrence As Scheduled For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 6
Page 8 of 30
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10/2017CCKM@uwhealth.org

IMMUNOGLOBULIN G [XIGG] EVERY TUESDAY, Starting 12/11/17 with First
Occurrence As Scheduled For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 7
IMMUNOGLOBULIN G [XIGG] EVERY TUESDAY, Starting 12/18/17 with First
Occurrence As Scheduled For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 8
Menses Cessation [24720]
medroxyprogesterone (PROVERA) tab [39462] 10 mg, Oral, 1 X DAILY
Discontinue when platelet count is greater than 100K
post-Bone Marrow Transplant
medroxyprogesterone (DEPO-PROVERA) susp
prefilled syringe - first order [172349]
150 mg, Intramuscular, ONCE For 1 Doses
Stress Ulcer Prophylaxis [27613]
ranitidine (ZANTAC) syrup - NOTE: (Maximum
150 mg/dose) [41612]
2 mg/kg, Oral, 2 X DAILY
NOTE: Suggested dose 1-2 mg/kg/dose (Maximum
150 mg/dose)
ranitidine (ZANTAC) tab [46455] 150 mg, Oral, 2 X DAILY
pantoprazole (PROTONIX) susp CUSTOM -
NOTE: Suggested dose 1 mg/kg/dose (Maximum
40 mg/dose) [780113]
1 mg/kg, Oral, 1 X DAILY
NOTE: Suggested dose 1 mg/kg/dose (Maximum 40
mg/dose)
pantoprazole (PROTONIX) injection - NOTE:
Suggested dose 1 mg/kg/dose (Maximum 40
mg/dose) [800119]
1 mg/kg, Intravenous, 2 X DAILY
NOTE: Suggested dose 1 mg/kg/dose (Maximum 40
mg/dose)
Sucrose for Oral Analgesia [110384]
sucrose (SWEET-EASE) 24% buccal soln
[794009]
Oral, PRN, pain, mild pain or potentially painful
procedures. See Admin Instructions
Laboratory
Collect On Admission [24580]
COMPREHENSIVE METABOLIC PANEL [METB] NEXT DRAW, Starting today For 1 Occurrences,
Routine, Test includes Sodium; Potassium; Chloride;
Carbon Dioxide, Total; Anion Gap; Glucose; BUN;
Creatinine; Calcium; Albumin; Protein, Total; Alkaline
Phosphatase; AST/SGOT; ALT/ SGPT; and Bilirubin,
Total.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITH DIFFERENTIAL [CBC] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PTT [PTT] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 9 of 30
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10/2017CCKM@uwhealth.org

MAGNESIUM [MAG] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CMV QUANTITATIVE BY PCR [HCCMVDNA] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GGT [GGT] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
IMMUNOGLOBULIN G [XIGG] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
NEXT DRAW For 1 Occurrences, Routine, For
optimum diagnosis of sepsis, sample 3-4 sites only on
the first day of a septic episode. Cultures on
subsequent days are of minimal diagnostic value.
Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
NEXT DRAW For 1 Occurrences, Routine, For
optimum diagnosis of sepsis, sample 3-4 sites only on
the first day of a septic episode. Cultures on
subsequent days are of minimal diagnostic value.
Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
URINALYSIS WITH MICROSCOPY [UA] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC - Draw Daily [110585]
Page 10 of 30
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10/2017CCKM@uwhealth.org

CBC WITH DIFFERENTIAL [CBC] NEXT AM, Starting tomorrow at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 1
CBC WITH DIFFERENTIAL [CBC] NEXT AM, Starting 11/7/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 2
CBC WITH DIFFERENTIAL [CBC] NEXT AM, Starting 11/14/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 3
CBC WITH DIFFERENTIAL [CBC] NEXT AM, Starting 11/21/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 4
CBC WITH DIFFERENTIAL [CBC] NEXT AM, Starting 11/28/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 5
CBC WITH DIFFERENTIAL [CBC] NEXT AM, Starting 12/5/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 6
CBC WITH DIFFERENTIAL [CBC] NEXT AM, Starting 12/12/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 7
CBC WITH DIFFERENTIAL [CBC] NEXT AM, Starting 12/19/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 8
Draw Every Monday and Thursday - Week 1 [24582]
Page 11 of 30
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

COMPREHENSIVE METABOLIC PANEL [METB] EVERY MONDAY AND THURSDAY, Starting today
with First Occurrence As Scheduled For 7 Days,
Routine, Test includes Sodium; Potassium; Chloride;
Carbon Dioxide, Total; Anion Gap; Glucose; BUN;
Creatinine; Calcium; Albumin; Protein, Total; Alkaline
Phosphatase; AST/SGOT; ALT/ SGPT; and Bilirubin,
Total.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 1.
BILIRUBIN, DIRECT [DBIL] EVERY MONDAY AND THURSDAY, Starting today
with First Occurrence As Scheduled For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 1.
MAGNESIUM [MAG] EVERY MONDAY AND THURSDAY, Starting today
with First Occurrence As Scheduled For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 1.
PHOSPHATE [PHOS] EVERY MONDAY AND THURSDAY, Starting today
with First Occurrence As Scheduled For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 1.
Draw Every Monday and Thursday - Week 2 [28080]
COMPREHENSIVE METABOLIC PANEL [METB] EVERY MONDAY AND THURSDAY, Starting 11/6/17
with First Occurrence As Scheduled For 7 Days,
Routine, Test includes Sodium; Potassium; Chloride;
Carbon Dioxide, Total; Anion Gap; Glucose; BUN;
Creatinine; Calcium; Albumin; Protein, Total; Alkaline
Phosphatase; AST/SGOT; ALT/ SGPT; and Bilirubin,
Total.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 2.
BILIRUBIN, DIRECT [DBIL] EVERY MONDAY AND THURSDAY, Starting 11/6/17
with First Occurrence As Scheduled For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 2.
Page 12 of 30
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

MAGNESIUM [MAG] EVERY MONDAY AND THURSDAY, Starting 11/6/17
with First Occurrence As Scheduled For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 2.
PHOSPHATE [PHOS] EVERY MONDAY AND THURSDAY, Starting 11/6/17
with First Occurrence As Scheduled For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 2.
Draw Every Monday and Thursday - Week 3 [28081]
COMPREHENSIVE METABOLIC PANEL [METB] EVERY MONDAY AND THURSDAY, Starting
11/13/17 with First Occurrence As Scheduled For 7
Days, Routine, Test includes Sodium; Potassium;
Chloride; Carbon Dioxide, Total; Anion Gap; Glucose;
BUN; Creatinine; Calcium; Albumin; Protein, Total;
Alkaline Phosphatase; AST/SGOT; ALT/ SGPT; and
Bilirubin, Total.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 3.
BILIRUBIN, DIRECT [DBIL] EVERY MONDAY AND THURSDAY, Starting
11/13/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 3.
MAGNESIUM [MAG] EVERY MONDAY AND THURSDAY, Starting
11/13/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 3.
PHOSPHATE [PHOS] EVERY MONDAY AND THURSDAY, Starting
11/13/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 3.
Draw Every Monday and Thursday - Week 4 [28082]
Page 13 of 30
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

COMPREHENSIVE METABOLIC PANEL [METB] EVERY MONDAY AND THURSDAY, Starting
11/20/17 with First Occurrence As Scheduled For 7
Days, Routine, Test includes Sodium; Potassium;
Chloride; Carbon Dioxide, Total; Anion Gap; Glucose;
BUN; Creatinine; Calcium; Albumin; Protein, Total;
Alkaline Phosphatase; AST/SGOT; ALT/ SGPT; and
Bilirubin, Total.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 4.
BILIRUBIN, DIRECT [DBIL] EVERY MONDAY AND THURSDAY, Starting
11/20/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 4.
MAGNESIUM [MAG] EVERY MONDAY AND THURSDAY, Starting
11/20/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 4.
PHOSPHATE [PHOS] EVERY MONDAY AND THURSDAY, Starting
11/20/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 4.
Draw Every Monday and Thursday - Week 5 [28083]
COMPREHENSIVE METABOLIC PANEL [METB] EVERY MONDAY AND THURSDAY, Starting
11/27/17 with First Occurrence As Scheduled For 7
Days, Routine, Test includes Sodium; Potassium;
Chloride; Carbon Dioxide, Total; Anion Gap; Glucose;
BUN; Creatinine; Calcium; Albumin; Protein, Total;
Alkaline Phosphatase; AST/SGOT; ALT/ SGPT; and
Bilirubin, Total.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 5.
BILIRUBIN, DIRECT [DBIL] EVERY MONDAY AND THURSDAY, Starting
11/27/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 5.
Page 14 of 30
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

MAGNESIUM [MAG] EVERY MONDAY AND THURSDAY, Starting
11/27/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 5.
PHOSPHATE [PHOS] EVERY MONDAY AND THURSDAY, Starting
11/27/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 5.
Draw Every Monday and Thursday - Week 6 [28085]
COMPREHENSIVE METABOLIC PANEL [METB] EVERY MONDAY AND THURSDAY, Starting 12/4/17
with First Occurrence As Scheduled For 7 Days,
Routine, Test includes Sodium; Potassium; Chloride;
Carbon Dioxide, Total; Anion Gap; Glucose; BUN;
Creatinine; Calcium; Albumin; Protein, Total; Alkaline
Phosphatase; AST/SGOT; ALT/ SGPT; and Bilirubin,
Total.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 6.
BILIRUBIN, DIRECT [DBIL] EVERY MONDAY AND THURSDAY, Starting 12/4/17
with First Occurrence As Scheduled For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 6.
MAGNESIUM [MAG] EVERY MONDAY AND THURSDAY, Starting 12/4/17
with First Occurrence As Scheduled For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 6.
PHOSPHATE [PHOS] EVERY MONDAY AND THURSDAY, Starting 12/4/17
with First Occurrence As Scheduled For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 6.
Draw Every Monday and Thursday - Week 7 [28086]
Page 15 of 30
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 1:05:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

COMPREHENSIVE METABOLIC PANEL [METB] EVERY MONDAY AND THURSDAY, Starting
12/11/17 with First Occurrence As Scheduled For 7
Days, Routine, Test includes Sodium; Potassium;
Chloride; Carbon Dioxide, Total; Anion Gap; Glucose;
BUN; Creatinine; Calcium; Albumin; Protein, Total;
Alkaline Phosphatase; AST/SGOT; ALT/ SGPT; and
Bilirubin, Total.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 7.
BILIRUBIN, DIRECT [DBIL] EVERY MONDAY AND THURSDAY, Starting
12/11/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 7.
MAGNESIUM [MAG] EVERY MONDAY AND THURSDAY, Starting
12/11/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 7.
PHOSPHATE [PHOS] EVERY MONDAY AND THURSDAY, Starting
12/11/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 7.
Draw Every Monday and Thursday - Week 8 [28087]
COMPREHENSIVE METABOLIC PANEL [METB] EVERY MONDAY AND THURSDAY, Starting
12/18/17 with First Occurrence As Scheduled For 7
Days, Routine, Test includes Sodium; Potassium;
Chloride; Carbon Dioxide, Total; Anion Gap; Glucose;
BUN; Creatinine; Calcium; Albumin; Protein, Total;
Alkaline Phosphatase; AST/SGOT; ALT/ SGPT; and
Bilirubin, Total.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 8.
BILIRUBIN, DIRECT [DBIL] EVERY MONDAY AND THURSDAY, Starting
12/18/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 8.
Page 16 of 30
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 1:05:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

MAGNESIUM [MAG] EVERY MONDAY AND THURSDAY, Starting
12/18/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 8.
PHOSPHATE [PHOS] EVERY MONDAY AND THURSDAY, Starting
12/18/17 with First Occurrence As Scheduled For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 8.
Basic Metabolic Panel - Draw Every Tuesday, Wednesday, Friday, Saturday, and Sunday [110070]
BASIC METABOLIC PANEL [BMET] EVERY TUESDAY, WEDNESDAY, FRIDAY,
SATURDAY AND SUNDAY, Starting today with First
Occurrence As Scheduled For 7 Days, Routine, Test
includes Sodium; Potassium; Chloride; Carbon
Dioxide, Total; Anion Gap; Glucose; BUN; Creatinine;
and Calcium.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 1
BASIC METABOLIC PANEL [BMET] EVERY TUESDAY, WEDNESDAY, FRIDAY,
SATURDAY AND SUNDAY, Starting 11/6/17 with First
Occurrence As Scheduled For 7 Days, Routine, Test
includes Sodium; Potassium; Chloride; Carbon
Dioxide, Total; Anion Gap; Glucose; BUN; Creatinine;
and Calcium.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 2
BASIC METABOLIC PANEL [BMET] EVERY TUESDAY, WEDNESDAY, FRIDAY,
SATURDAY AND SUNDAY, Starting 11/13/17 with
First Occurrence As Scheduled For 7 Days, Routine,
Test includes Sodium; Potassium; Chloride; Carbon
Dioxide, Total; Anion Gap; Glucose; BUN; Creatinine;
and Calcium.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 3
BASIC METABOLIC PANEL [BMET] EVERY TUESDAY, WEDNESDAY, FRIDAY,
SATURDAY AND SUNDAY, Starting 11/20/17 with
First Occurrence As Scheduled For 7 Days, Routine,
Test includes Sodium; Potassium; Chloride; Carbon
Dioxide, Total; Anion Gap; Glucose; BUN; Creatinine;
and Calcium.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 4
Page 17 of 30
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

BASIC METABOLIC PANEL [BMET] EVERY TUESDAY, WEDNESDAY, FRIDAY,
SATURDAY AND SUNDAY, Starting 11/27/17 with
First Occurrence As Scheduled For 7 Days, Routine,
Test includes Sodium; Potassium; Chloride; Carbon
Dioxide, Total; Anion Gap; Glucose; BUN; Creatinine;
and Calcium.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 5
BASIC METABOLIC PANEL [BMET] EVERY TUESDAY, WEDNESDAY, FRIDAY,
SATURDAY AND SUNDAY, Starting 12/4/17 with First
Occurrence As Scheduled For 7 Days, Routine, Test
includes Sodium; Potassium; Chloride; Carbon
Dioxide, Total; Anion Gap; Glucose; BUN; Creatinine;
and Calcium.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 6
BASIC METABOLIC PANEL [BMET] EVERY TUESDAY, WEDNESDAY, FRIDAY,
SATURDAY AND SUNDAY, Starting 12/11/17 with
First Occurrence As Scheduled For 7 Days, Routine,
Test includes Sodium; Potassium; Chloride; Carbon
Dioxide, Total; Anion Gap; Glucose; BUN; Creatinine;
and Calcium.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 7
BASIC METABOLIC PANEL [BMET] EVERY TUESDAY, WEDNESDAY, FRIDAY,
SATURDAY AND SUNDAY, Starting 12/18/17 with
First Occurrence As Scheduled For 7 Days, Routine,
Test includes Sodium; Potassium; Chloride; Carbon
Dioxide, Total; Anion Gap; Glucose; BUN; Creatinine;
and Calcium.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 8
CMV Quantitative - Draw Every Tuesday [110054]
CMV QUANTITATIVE BY PCR [HCCMVDNA] EVERY TUESDAY, Starting 11/27/17 with First
Occurrence As Scheduled For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 4
CMV QUANTITATIVE BY PCR [HCCMVDNA] EVERY TUESDAY, Starting 12/4/17 with First
Occurrence As Scheduled For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 5.
Page 18 of 30
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

CMV QUANTITATIVE BY PCR [HCCMVDNA] EVERY TUESDAY, Starting 12/11/17 with First
Occurrence As Scheduled For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 6
CMV QUANTITATIVE BY PCR [HCCMVDNA] EVERY TUESDAY, Starting 12/18/17 with First
Occurrence As Scheduled For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 7
CMV QUANTITATIVE BY PCR [HCCMVDNA] EVERY TUESDAY, Starting 12/25/17 with First
Occurrence As Scheduled For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 8
Conditional Labs - General
Draw if Temperature is Equal to or Greater than 38 Degrees Celsius and no Culture Drawn Within last 24
Hours - Week 1 [27583]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting today For 7
Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 1.
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting today For 7
Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 1.
Page 19 of 30
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 1:05:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

CULTURE, URINE [URC] CONDITIONAL - RN COLLECT, Starting today For 7
Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 1
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL - RN COLLECT, Starting today For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 1
Draw if Temperature is Equal to or Greater than 38 Degrees Celsius and no Culture Drawn Within last 24
Hours - Week 2 [28104]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 11/6/17 For
7 Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 2.
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 11/6/17 For
7 Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 2.
Page 20 of 30
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 1:05:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

CULTURE, URINE [URC] CONDITIONAL - RN COLLECT, Starting 11/6/17 For
7 Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 2
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL - RN COLLECT, Starting 11/6/17 For
7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 2
Draw if Temperature is Equal to or Greater than 38 Degrees Celsius and no Culture Drawn Within last 24
Hours - Week 3 [28105]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 11/13/17 For
7 Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 3.
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 11/13/17 For
7 Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 3.
Page 21 of 30
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 1:05:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

CULTURE, URINE [URC] CONDITIONAL - RN COLLECT, Starting 11/13/17 For
7 Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 3
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL - RN COLLECT, Starting 11/13/17 For
7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 3
Draw if Temperature is Equal to or Greater than 38 Degrees Celsius and no Culture Drawn Within last 24
Hours - Week 4 [28106]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 11/20/17 For
7 Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 4.
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 11/20/17 For
7 Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 4.
Page 22 of 30
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

CULTURE, URINE [URC] CONDITIONAL - RN COLLECT, Starting 11/20/17 For
7 Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 4
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL - RN COLLECT, Starting 11/20/17 For
7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 4
Draw if Temperature is Equal to or Greater than 38 Degrees Celsius and no Culture Drawn Within last 24
Hours - Week 5 [28107]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 11/27/17 For
7 Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 5.
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 11/27/17 For
7 Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 5.
Page 23 of 30
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

CULTURE, URINE [URC] CONDITIONAL - RN COLLECT, Starting 11/27/17 For
7 Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 5
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL - RN COLLECT, Starting 11/27/17 For
7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 5
Draw if Temperature is Equal to or Greater than 38 Degrees Celsius and no Culture Drawn Within last 24
Hours - Week 6 [28108]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 12/4/17 For
7 Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 6.
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 12/4/17 For
7 Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 6.
Page 24 of 30
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 1:05:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

CULTURE, URINE [URC] CONDITIONAL - RN COLLECT, Starting 12/4/17 For
7 Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 6
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL - RN COLLECT, Starting 12/4/17 For
7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 6
Draw if Temperature is Equal to or Greater than 38 Degrees Celsius and no Culture Drawn Within last 24
Hours - Week 7 [28109]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 12/11/17 For
7 Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 7.
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 12/11/17 For
7 Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 7.
Page 25 of 30
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 1:05:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

CULTURE, URINE [URC] CONDITIONAL - RN COLLECT, Starting 12/11/17 For
7 Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL - RN COLLECT, Starting 12/11/17 For
7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Draw if Temperature is Equal to or Greater than 38 Degrees Celsius and no Culture Drawn Within last 24
Hours - Week 8 [28110]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 12/18/17 For
7 Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 8.
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 12/18/17 For
7 Days, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic
episode. Cultures on subsequent days are of minimal
diagnostic value. Culture detects bacteria, Candida
and Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 8.
Page 26 of 30
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 1:05:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

CULTURE, URINE [URC] CONDITIONAL - RN COLLECT, Starting 12/18/17 For
7 Days, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 8
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL - RN COLLECT, Starting 12/18/17 For
7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if temperature is
greater than 38.2 degrees Celsius or 38.0 if sustained
for greater than one hour
Week 8
Engraftment Lab
Engraftment Lab [30006]
STR ENGRAFTMENT SEPARATED LINEAGES,
POST-TX [116722]
individually. tests must be ordered at same time and should NOT be ordered Both
STR ENGRAFTMENT POPULATION 1
[HCSTRCD3]
NEXT AM For 1 Occurrences, Routine
Indicate if donor or recipient:
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
STR ENGRAFTMENT POPULATION 2
[HCSTRCD33]
NEXT AM For 1 Occurrences, Routine
Indicate if donor or recipient:
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
Blood Bank
Tests [108626]
TYPE AND SCREEN - Week 1 [HCTS] CONDITIONAL - RN COLLECT, Starting tomorrow
For 7 Days, 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., Week 1.
Page 27 of 30
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

TYPE AND SCREEN - Week 2 [HCTS] CONDITIONAL - RN COLLECT, Starting 11/7/17 at
5:00 AM For 7 Days, 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., Week 2.
TYPE AND SCREEN - Week 3 [HCTS] CONDITIONAL - RN COLLECT, Starting 11/14/17 at
5:00 AM For 7 Days, 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., Week 3.
TYPE AND SCREEN - Week 4 [HCTS] CONDITIONAL - RN COLLECT, Starting 11/21/17 at
5:00 AM For 7 Days, 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., Week 4.
TYPE AND SCREEN - Week 5 [HCTS] CONDITIONAL - RN COLLECT, Starting 11/28/17 at
5:00 AM For 7 Days, 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., Week 5.
TYPE AND SCREEN - Week 6 [HCTS] CONDITIONAL - RN COLLECT, Starting 12/5/17 at
5:00 AM For 7 Days, 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., Week 6.
Page 28 of 30
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

TYPE AND SCREEN - Week 7 [HCTS] CONDITIONAL - RN COLLECT, Starting 12/12/17 at
5:00 AM For 7 Days, 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., Week 7.
TYPE AND SCREEN - Week 8 [HCTS] CONDITIONAL - RN COLLECT, Starting 12/19/17 at
5:00 AM For 7 Days, 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., Week 8.
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [24601]
X-RAY CHEST PA & LAT VIEWS [R71020] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Pre-stem cell transplant
What specific question(s) would you like answered by
this exam? Pre-stem cell transplant
Relevant recent/past history? Pre-stem cell transplant
Is patient pregnant? No
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Consults
Consults [24603]
Consult Spiritual Care (Inpatient) [CON0056] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Evaluate and Treat
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: OTHER (Evaluate and treat)
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult: Activity
Tolerance
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Activity
Tolerance
Consult Pediatric Health Psychology (Inpatient)
[CON0202]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-Friday)
or if special assessment needs.
Reason for Consult: Pre-stem cell translant
Consult Child Life Specialist (Inpatient)
[CON0014]
ONCE, Starting today For 1 Occurrences, Routine
Activity Level: ABLE TO PLAY IN ROOM OR HSCT
HALLWAY
Reason for Consult: OTHER (Evaluate and treat)
Page 29 of 30
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org

Consult Radiation Oncology (Inpatient)
[CON0066]
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:
Notify Hospital School of New Admission
[NURCOM0022]
ONCE, Starting today For 1 Occurrences, Notify
Hospital School of New Admission
Notify Vocational Education Services, School
Reintegration of New Admission [NURCOM0022]
ONCE, Starting today For 1 Occurrences, Notify
Vocational Education Services, School Reintegration
of New Admission
Consult Palliative Care - Pediatric (Inpatient)
[CON0172]
ONCE For 1 Occurrences, Routine
Reason For Consult:
Can this consult be done via video?
BestPractice
No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
Page 30 of 30
Printed by TAYLOR, ELAINE [ECT2] at 10/30/2017 1:05:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2017CCKM@uwhealth.org