/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/burn/,

/clinical/cckm-tools/content/order-sets/inpatient/burn/name-97815-en.cckm

201709272

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Burn

IP – Burn – Discharge [4925]

IP – Burn – Discharge [4925] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Burn


IP - Burn - Discharge [4925]
Skilled Nursing Facility Orders
This Patient is going to a skilled nursing facilty, directly below is a group of orders commonly
associated with this patient population. Please review the orders below and select the appropriate
ones for this patient. If this patient is not going to a SNF, contact Case Management to update the
discharge plan. Updating the discharge plan will remove this set of SNF orders from the order set.
Skilled Nursing Facility Certification Statement [114940]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Certification Statement [118260]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Admit Order [114941]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Admit Order [118261]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Patient Care Orders [111713]
For dyspnea, Oxygen at 2 L/minute per nasal
canula; If this is an acute change for the patient
call PCP with assessment ASAP after oxygen is
started. Suction PRN to clear airways.
[NURCOM0022]
Routine
DME - Home Oxygen [1009468] Patient's O2 Requirements Assessed and Meets
Criteria for Home O2:
Delivery Device:
Equipment Needed:
Continuous (liters/min):
Continuous (FiO2):
With Activity (liters/min):
With Activity (FiO2):
With Sleep (liters/min):
With Sleep (FiO2):
Length of Need:
Vendor:
DME - CPAP [1009443] Formal Sleep Study Completed:
Diagnosis:
CPAP Pressure (cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Page 1 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 9/28/2017 1:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

DME - BiPAP (S) [1009441] Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S):
Diagnosis:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
DME - BiPAP (S/T) [1009442] Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S/T):
Diagnosis:
Respiratory Rate:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Patient may self administer medication per RN
assessment [NURCOM0022]
Routine
Patient medications (per Skilled Nursing Facility
policy) may be left at bedside [NURCOM0022]
Routine
Facility Therapy Needs [113391]
Physical Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Occupational Therapy to Evaluate and Treat at
Next Facility [NURCOM0022]
Routine
Speech Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Communicable Diseases [111717]
State Law requires at least one of the following statements be checked for your patient. May check both if
applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have any
other clinically apparent communicable diseases.
[NURCOM0022]
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Page 2 of 14
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Communicable Diseases [118262]
State Law requires at least one of the following statements be checked for your patient. May check both if
applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have any
other clinically apparent communicable diseases.
[NURCOM0022]
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Analgesics [111708]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, 1 tab, 1, starting 9/28/17, No Print
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, 1 suppository, 1, starting 9/28/17, No Print
Blood Glucose Management [111710]
glucagon 1 mg injection kit [107799] 1 mg, 1 each, 1, starting 9/28/17, No Print
Glucose 40 % oral gel [118089] 10 g, 1 Tube, 1, starting 9/28/17, No Print
Nursing Communication [NURCOM0022] Routine, Notify {Notify for Blood Glucose:3004146} if
blood glucose is greater than 400 mg/dL or less than
40 mg/dL
Diabetes Care Instructions [NURCOM0112] Routine, - Patient's blood glucose goal range before
meals is *** mg/dL.
- Monitor patient's blood glucose {Glucose Monitoring
Frequency:25242}.
- If your patient's blood glucoses are uncontrolled
contact provider.
- "Uncontrolled" blood glucoses mean:
* Blood glucose above 150 mg/dL more than half the
time during a week.
* Blood glucose over *** mg/dL.
* Blood glucose less than 70 mg/dL two or more times
per week (or if having signs/symptoms of low blood
glucose such as shaking, sweating, or light-
headedness).
Bowel Management [111709]
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, 1 suppository, 1, starting 9/28/17, No Print
Senna-Docusate Sodium 8.6-50 MG per tab
[70181]
1-2 tab, 1 tab, 1, starting 9/28/17, No Print
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, 1 Bottle, 1, starting 9/28/17, No Print
polyethylene glycol (MIRALAX) oral powder
[61353]
17 g, 1 Bottle, 1, starting 9/28/17, No Print
Non-categorized Medications [111711]
guaifenesin-dextroMETHORPHAN (ROBITUSSIN
DM) syrup [51568]
10 mL, 1 Bottle, 1, starting 9/28/17, No Print
carbamide peroxide (DEBROX) 6.5% otic soln
[35545]
3 drop, 1 Bottle, 1, starting 9/28/17 until 10/3/17, No
Print
alum-mag-simeth (MYLANTA ES) susp [44073] 30 mL, 1 Bottle, 1, starting 9/28/17, No Print
Patient Care Orders
Confirmed Discharge Date/Time [209896]
Page 3 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 9/28/2017 1:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Confirmed Discharge Date/Time [ADT0013] Confirmed Discharge Date:
Confirmed Discharge Time:
Conditions for Discharge:
Provider to be Present at Discharge?
Reason For Hospitalization [131727]
Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Activity [131728]
Activity [NURACT0008] Routine
Discharge Activity:
Activity [131747]
Return to Work [NURACT0011] Routine, {Return to Work:3022290}
If your employer has specific work related forms that
need to be filled out, please bring them with you to
your next clinic visit or have them faxed to 608-252-
0923.
Pediatric - After Sedation Instructions
[NURACT0011]
Routine, * For the rest of the day after sedation, your
child may be uncoordinated and may be at risk for
injuring themselves.
* Do not leave your child alone.
* Do not send your child to school or daycare.
* AVOID activities that require coordination and
balance such as bike riding, swimming and other
physical activities.
QUESTIONS OR CONCERNS
If you have any questions or concerns, please call us
at 608-263-1490.
Adult - After Sedation Instructions [NURACT0011] Routine, * For the rest of the day after sedation, you
may be uncordinated and may be at risk for injuring
yourself.
* You should have someone stay with you until you
are behaving normal.
* Do Not drive
* Do Not operate machinary
* Do Not go to work on the day of sedation.
* Avoid activities that require coordination and balance
such as bike riding, swimming and other physical
activities.
QUESTIONS OR CONCERNS
If you have any questions or concerns, please call us
at 608-263-1490.
Nutrition [131729]
Diet [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
Respiratory [131730]
Page 4 of 14
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Home Oxygen [DC0006] This order should NOT be used for Home Oxygen,
CPAP, BiPAP, Nebulizers, or Cough Assist Machines.
There are separate orders available for these items.,
Routine
Type (Each Agency Requires a Separate Order):
Oxygen
Diagnosis:
Supplies:
Vendor:
Schedule Appointment With Sleep Lab
[NURCOM0026]
Reason for Hospital Follow Up Appointment: To
determine if patient has sleep apnea which needs to
be treated with night CPAP
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Sleep Lab
Wound Care [131731]
Wound Care - Basic [NURWND0015] Routine, - If necessary, take your pain medicine 1
hour prior to starting your wound care.
- Remove your dressings before stepping into the tub
or shower.
- Shower Daily.
- Change your dressings {dressing change
frequency:3022294}.
- Wash your wounds with soap and water.
- Remove any loose scabs or drainage.
- Leave open to air to dry out thoroughly for {dry
time:3022295}.
- Apply lotion to healed areas.
- Apply *** to open areas on ***. Secure in place with
*** and *** for compression.
Wound Care - Wet to Dry [NURWND0015] Routine, - If necessary, take your pain medicine 1
hour prior to starting your wound care.
- Remove your dressings before stepping into the tub
or shower.
- Shower Daily.
- Change your dressings {dressing change
frequency:3022294}.
- Wash your wounds with soap and water.
- Remove any loose scabs or drainage.
- Moisten your gauze with {moisten with:3022306}.
- Loosely pack your wound with {dry/moist:3022307}
gauze.
- Cover packed wound with {cover with:3022308}.
- Secure dressings with {secure with:3022309}.
Wound Care - Mepilex Ag Dressing
[NURWND0015]
Routine, - Do not remove your dressings.
- Keep your dressing clean and dry.
- Keep the skin around your dressings clean by
sponge bathing with soap and water.
- Take your pain medicine 1 hour prior to your follow
up clinic appointment for wound care.
Wound Care - Skin Graft With Cotton or Spandex
Bolster [NURWND0015]
Routine, - Do not remove your dressings.
- Keep your bolster clean and dry.
- Keep the skin around your bolster clean by sponge
bathing around the site with soap and water.
- Take your pain medicine 1 hour prior to your follow
up clinic appointment for wound care.
Page 5 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 9/28/2017 1:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Wound Care - Compression Boot
[NURWND0015]
Routine
Wound Care - VAC [NURWND0015] Routine
No additional wound care needed
[NURCOM0052]
Routine, - No additional wound care needed
Bladder Care [131732]
Bladder Care [NURELM0067] Routine
Bowel Care [131733]
Bowel Care [NURELM0068] Routine, Narcotic pain medications can cause
constipation. We recommend that you take a stool
softener (i.e. Docusate with Senna, or Lactulose) and
Miralax while you are taking pain medication.
Other Patient Care Instructions [138001]
Other Discharge Patient Care Instructions
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, - Take all medications as directed.
- Please do not drive or operate heavy machinery
while taking narcotic pain medication.
- Most narcotic pain medications cannot be called in to
your pharmacy, so please be sure to bring your pain
medication bottles with you to every clinic appointment
and discuss any refill needs at your clinic visit.
- Stop Smoking including second hand smoke.
Smoking decreases blood flow and oxygen to wounds
and it slows healing.
When to Call Your Doctor [131735]
Page 6 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 9/28/2017 1:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

When to Call Your Doctor [NURCOM0079] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Call your doctor if you have any
signs and symptoms of infection:
- Increased redness (about 1 inch in width) and
swelling around burn area.
- Foul smelling drainage or pus around the burn area.
- Flu-like symptoms (fever more than 101.5 F, chills,
nausea or vomiting, muscle aches) and/or increased
pain.
Call your doctor if your pain is not controlled with the
medications that you are prescribed.
Contact Numbers:
CALL 911 FOR EMERGENCIES
If you have questions Monday through Friday 8am-
5pm please call the Burn and Wound Clinic at 608-
264-8040.
If you have urgent questions or needs after hours or
on weekends, please call the Burn Unit Nurses at 608-
263-1490 or call 608-263-6400 and ask to have the
Burn resident paged.
If you live out of the area, you can call toll free at
1-800-323-8942.
Heart Failure Recommended Care
documented or order groups are showing because either your patient has an EF < 40% These
list.has Heart Failure on their problem
UW Health HF guildeline URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/cardiovascular/name-97485-
en.cckm
Heart Failure Discharge Instructions [190359]
Weigh yourself daily or as directed
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Page 7 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 9/28/2017 1:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

When to Call Your Doctor [NURCOM0079] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Call your doctor if you have any of
these symptoms as they may indicate worsening
Heart Failure:
- Increased shortness of breath
- Cough or chest congestion
- Swelling in your abdomen or legs
- Any increase or decrease in weight of more than 3
pounds in a day or 5 pounds total
If you do not have a scheduled return
appointment, please schedule an appointment
with your primary physician [NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Core Measure Documentation - ACE Inhibitor/ARB (Single Response) [150651]
Core Measures - This Does NOT Generate A Medication Order (Use Med Reconciliation To
Prescribe Medications)
ACE Inhibitor/ARB Reason Not Ordered
[COR0001]
ONCE, Starting today For 1 Occurrences, Routine
Reason Not Ordered:
ACE Inhibitor/ARB Already Ordered [COR0001] ONCE, Starting today For 1 Occurrences, Routine
Reason Not Ordered: Other (Comments required for
not ordering BOTH an ACEI and an ARB)
Follow-Up Care
Follow-Up Apoointments [131738]
complete OSS for scheduling appointment for OSS for Moderate Sedation and Wound Care, If
orders.Moderate Sedation and Wound Care Supplemental
Schedule Appointment With Physical Therapy
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty: Physical Therapy
Schedule Appointment With Occupational
Therapy [NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty: Occupational Therapy
Schedule Appointment With Speech Therapy
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty: Speech Therapy
Schedule Appointment - Follow Up
Burns/Wounds [NURCOM0026]
Reason for Hospital Follow Up Appointment: Follow
up burns/wounds
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Burn Clinic 608-264-8040
Burn/wound Clinic appointment date***.
PT/OT required with appointment? {Yes/No:3000057}
Page 8 of 14
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Schedule Appointment - OSS for Moderate
Sedation and Wound Care [NURCOM0026]
Reason for Hospital Follow Up Appointment: OSS for
Moderate Sedation and Wound Care
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Burn Unit (608) 263-1490
Next OSS in Burn Center- date*** and time***
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Patient to Schedule Appointment [NURCOM0056] Purpose:
With whom:
For when:
Discharge Appointment Instructions
[NURCOM0083]
Details
Follow Up Appointments - Diabetes (Single Response) [148552]
*** RESPONSE REQUIRED *** This order facilitates documentation (only) about follow-up
appointments for patients with diabetes. Scheduling an appointment before discharge with a
provider who will manage a patient’s diabetes care (e.g., primary care physician, endocrinologist,
etc.) is a Joint Commission requirement. Exclusions are allowed based upon patient situation
(e.g., discharge to a skilled nursing facility, patient refusal, etc.). Only select “Appointment
Scheduled” if an appointment has already been scheduled, and use the Schedule Appointment
order as needed to request assistance in scheduling
No appointment: Patient does not have diabetes
[COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
does not have diabetes
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Appointment scheduled (with provider who can
manage diabetes) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment scheduled
(with provider who can manage diabetes)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 9 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 9/28/2017 1:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Appointment scheduled per patient report
(ENTER DATE IN COMMENTS) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment scheduled per
patient report (ENTER DATE IN COMMENTS)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Appointment pending: patient discharged on
weekend; follow-up information provided
[COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment pending:
patient discharged on weekend; follow-up information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Free clinic information provided [COR0064] ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Free clinic information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 10 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 9/28/2017 1:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

No appointment: Patient discharging to a facility
(e.g., skilled nursing facility, correctional facility,
etc.) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
discharging to a facility (e.g., skilled nursing facility,
correctional facility, etc.)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
No appointment: Patient refusal [COR0064] ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
refusal
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Facility Therapy Needs [131739]
Continue Physical Therapy at Next Facility
[NURCOM0022]
Routine
Continue Occupational Therapy at Next Facility
[NURCOM0022]
Routine
Continue Speech Therapy at Next Facility
[NURCOM0022]
Routine
Discharge Labs [134929]
Page 11 of 14
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Please use the table below to determine what type of order to use to place discharge lab
orders.
Discharge Labs Workflow URL: https://uconnect.wisc.edu/growth/training--
education/health-link/10-minutes/inpatient-
discharge-consult/resources/name-82993-en.file
Recommended Discharge Labs [NURCOM0075] Details
Who is Responsible for the
Result?
Where Will Labs be
Completed?
What Order Should You
Use?
Current Attending Provider UW Health Lab Specific lab orders (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
(B)
Current Consulting Provider
UW Health Lab
Specific lab orders with
AUTHORIZING PROVIDER
CHANGED TO
CONSULTANT (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
and AUTHORIZING
PROVIDER CHANGED TO
CONSULTANT (B)
Another Provider
UW Health Lab
Recommended Discharge
Labs (C)
Non-UW Health Lab
Recommended Discharge
Labs (C)
(A) SPECIFIC LAB ORDERS:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have the labs completed at a
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient's care will be responsible for the
result, you must change the AUTHORIZING PROVIDER on the order to the CONSULTING
PROVIDER before signing the order. To do this, click the Providers button near the top of the
Review, Sign & Hold tab of the discharge navigator. Update the authorizing provider to the
consulting provider.
(B) SPECIFIC LAB ORDER WITH ORDER CLASS CHANGED TO OUTSIDE:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have labs completed at a NON-
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient’s care will be responsible for the
result, you must change the AUTHORIZING PROVIDER on the order to the CONSULTING
PROVIDER before signing the order. To do this, click the Providers button near the top of the
Review, Sign & Hold tab of the discharge navigator. Update the authorizing provider to the
consulting provider.
The patient will receive a paper order to take to the lab.
(C) RECOMMENDED DISCHARGE LABS:
This order should be used to recommend to another provider labs that a patient should have
completed after discharge. The provider designated in the 'Send Recommendations To' field is
responsible for PLACING the lab orders AND will be responsible for the RESULTS of any
ordered labs.
Page 12 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 9/28/2017 1:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Sedation and Wound Care [136685]
to find out when 1490 -263Provider: please call the Burn Unit at
sedation.this patient is scheduled to return for wound care with
Pediatric - Sedation and Wound Care
Appointment Instructions [NURCOM0022]
Routine, SEDATION AND WOUND CARE
APPOINTMENT
Your child will have sedation and wound care on
[DATE *** ] at *** {AM/PM:11534}
WHAT TO DO BEFORE THE SEDATION AND
WOUND CARE VISIT
Your child cannot have food or drink in their stomach
at the time of their sedation. If they eat or drink after
the times listed below, we will have to postpone the
sedation. You must begin your child's preparation 6
hours prior to their scheduled treatment.
YOUR SEDATION SCHEDULE
* *** {AM/PM:11534} (6 hours prior to sedation) - Stop
eating all solids. Stop drinking milk or any cloudy
liquids.
* *** {AM/PM:11534} (4 hours prior to sedation) - Stop
breastfeeding
* *** {AM/PM:11534} (2 hours prior to sedation) - Stop
drinking all clear liquids such as broth, apple juice,
water or popsicles.
* *** {AM/PM:11534} (1 hour prior to sedation) - Give
one dose of {Pain Med List:3022681} to pre-medicate
your child, even if @HE@ is not having pain. The
wound care that is going to be done may cause pain,
so pain medication is necessary.
* *** {AM/PM:11534} (1 hour prior to sedation) - Check
in at the Patient Registration desk on the 2nd floor.
This is 1 hour before your procedure time so that we
have time to safely prepare your child for @HIS@
sedation and procedure. Your parking ticket can also
be validated at this time.
AFTER SEDATION
* For the rest of the day after sedation, your child may
be uncoordinated and may be at risk for injuring
themselves.
* Do not leave your child alone.
* Do not send your child to school or daycare
* Avoid activities that require coordination and balance
such as bike riding, swimming and other physical
activities.
QUESTIONS OR CONCERNS
If you have any questions or concerns, please call us
at 608-263-1490.
Page 13 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 9/28/2017 1:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Adult - Sedation and Wound Care Appointment
Instructions [NURCOM0022]
Routine, You will have sedation and wound care on
[DATE *** ] at *** {AM/PM:11534}
WHAT TO DO BEFORE THE SEDATION AND
WOUND CARE VISIT
You cannot have food or drink in your stomach at the
time of sedation. If you eat or drink after the times
listed below, we will have to postpone the sedation.
You must begin preparation 6 hours prior to your
scheduled treatment.
YOUR SEDATION SCHEDULE
* *** {AM/PM:11534} (6 hours prior to sedation) -
Stop eating all solids. Stop drinking milk or any cloudy
liquids.
* *** {AM/PM:11534} (2 hours prior to sedation) -
Stop drinking all clear liquids such as broth, apple
juice, water or popsicles.
* *** {AM/PM:11534} (1 hour prior to sedation) -
Take one dose of {Pain Med List:3022681} to pre-
medicate, even if you are not having pain. The wound
care that is going to be done may cause pain, so pain
medication is necessary.
* *** {AM/PM:11534} (1 hour prior to sedation) -
Check in at the Patient Registration desk on the 2nd
floor. This is 1 hour before your procedure time so
that we have time to safely prepare you for your
sedation and procedure. Your parking ticket can also
be validated at this time.
Consults
Consults [136683]
CONSULT TO PHYSICAL THERAPY [9095] Request Type: Consultation(opinion/advise) plus
procedure if needed
Reason for this request: Evaluate and Treat Sizeable
Burns
CONSULT TO OCC THERAPY [9094] Request Type: Consultation(opinion/advise) plus
procedure if needed
Reason for this request: Evaluate and Treat Sizeable
Burns
CONSULT TO HEALTH PSYCHOLOGY
(OUTPT) [9138]
Request Type: Consultation(opinion/advise) plus
procedure if needed
Reason for this request: Evaluate and Treat Sizeable
Burns
Page 14 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 9/28/2017 1:29:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org