/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/cardiologyct-surgery/,

/clinical/cckm-tools/content/order-sets/inpatient/cardiologyct-surgery/name-109849-en.cckm

201707191

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Cardiology/CT Surgery

IP - Percutaneous Mitral Valve Repair - Adult - Postprocedure [6237]

IP - Percutaneous Mitral Valve Repair - Adult - Postprocedure [6237] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Cardiology/CT Surgery


IP - Percutaneous Mitral Valve Repair - Adult - Postprocedure [6237]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [187519]
*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 [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:
Post-Op/Phase II
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admission Status [120283]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: CARDIOLOGY
Rationale for LOS greater than 2 midnights:
Post-Op/Phase II
Admission Status [119046]
Page 1 of 13
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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.
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Post-Op/Phase II
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [131999]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Post-Op/Phase II
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS, Post-
Op/Phase II
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
High Bleed Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Page 2 of 13
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Post-Op/Phase II
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Post-Op/Phase II
VTE Prophylaxis (Single Response) [150176]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Post-Op/Phase II
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS,
Post-Op/Phase II
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
High Bleed Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Post-Op/Phase II
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Post-Op/Phase II
PACU
PACU Post-Procedure [219056]
Page 3 of 13
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Vital Signs [NURMON0013] SEE COMMENTS, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Postprocedure: Every 15 minutes x 4, every 30
minutes x 4, every 1 hour x 4 and then every 2 hours
while in ICU. Every 8 hours while in general care.,
PACU
Neurovascular Assessment [NURMON0045] SEE COMMENTS, Routine, Postprocedure: Every 15
minutes x 4, every 30 minutes x 4, every 1 hour x 4
and then every 4 hours while in ICU. Every 8 hours
while in general care., PACU
Wound Care [NURWND0015] CONTINUOUS, Routine
Wound Type:
Wound Site:
Wound Location:
Assess Frequency: SEE COMMENTS
Care Frequency: 1X DAILY
Wash With: Soap and Water
Irrigate/Rinse With: Other (Comment) (Water)
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing: Gauze
Secondary Dressing:
Postprocedure: Assess frequency every 15 minutes x
4, then every 30 minutes x 4, then every 1 hour x 4,
then every 4 hours., PACU
Patient Care Orders
Vital Signs [219057]
Vital Signs [NURMON0013] SEE COMMENTS, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Postprocedure: Every 15 minutes x 4, every 30
minutes x 4, every 1 hour x 4 and then every 2 hours
while in ICU. Every 8 hours while in general care.,
Post-Op/Phase II
Neurovascular Assessment [NURMON0045] EVERY 15 MINUTES, Routine, Postprocedure: Every
15 minutes x 4, every 30 minutes x 4, every 1 hour x 4
and then every 2 hours while in ICU. Every 8 hours
while in general care., Post-Op/Phase II
Patient Monitoring [119050]
Maintain Arterial Line [NURVAD0001] CONTINUOUS, Starting today, Routine
Device Status:
Flush Solution:
Site:
Post-Op/Phase II
Activity - Manual [193469]
Page 4 of 13
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Prior to Sheath Removal - Bedrest/Logroll
[NURACT0011]
CONTINUOUS, Starting today For Until specified,
Prior to Sheath Removal - Bedrest/Logroll. Patient
may roll to affected side for comfort, keeping the
affected leg extended, Post-Op/Phase II
Prior to Sheath Removal - Elevate Head Of Bed
Less Than 30 Degrees [NURACT0002]
Equal to (degrees):
Greater than (degrees):
Less than (degrees): 30
Other options:
Routine, CONTINUOUS, Starting today, Prior to
Sheath Removal - elevate head of bed less than 30
degrees, Post-Op/Phase II
Post Sheath Removal - Activity Progression
[NURACT0011]
CONTINUOUS, Starting today For Until specified,
Post Sheath Removal - bedrest during femoral
compression device application. Roll to affected side
for comfort with affected leg extended, starting 1 hour
post sheath removal. Ambulate with assistance,
starting *** hours post-sheath removal., Post-
Op/Phase II
Post Sheath Removal - Elevate Head Of Bed
Equal to 45 Degrees [NURACT0002]
Equal to (degrees): 45
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today, Post Sheath
Removal - elevate head of bed equal to 45 degrees
starting *** hours post sheath removal, Post-Op/Phase
II
Activity - Closure Device [193470]
Activity - Chair [NURACT0008] CONTINUOUS, Routine
AD LIB:
AMBULATE:
CHAIR: other (comment)
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Once bedrest is over and groin sites stable, out of bed
to chair 1 time on day of procedure. Starting post
procedure day 1, out of bed to chair 3 times daily with
meals., Post-Op/Phase II
Activity - Ambulate [NURACT0008] CONTINUOUS, Routine
AD LIB:
AMBULATE: other (comment)
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Once bedrest over and groin sites stable, ambulate 1
time on day of procedure. Starting post procedure day
1, ambulate 4 times daily., Post-Op/Phase II
Page 5 of 13
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Post Sheath Removal - Activity Progression
[NURACT0011]
CONTINUOUS, Starting today For Until specified,
Post Sheath Removal - bedrest during femoral
compression device application. Roll to affected side
for comfort with affected leg extended, starting 1 hour
post sheath removal. Ambulate with assistance,
starting *** hours post-sheath removal if there is no
hematoma., Post-Op/Phase II
Post Sheath Removal - Elevate Head Of Bed
Equal to 45 Degrees [NURACT0002]
Equal to (degrees): 45
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today, Post Sheath
Removal - elevate head of bed equal to 45 degrees
starting *** hours post sheath removal, Post-Op/Phase
II
Respiratory [213559]
Incentive Spirometry [NURTRT0018] EVERY 2 HOURS, Routine, Every 2 hours while
awake., Post-Op/Phase II
Pulse Oximetry [NURMON0009] ONCE For 1 Occurrences, Routine, Post-Op/Phase II
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 90
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Post-Op/Phase II
Respiratory Therapy per Protocol [RT0035] CONTINUOUS, Starting today, Routine
Protocol Type:
Post-Op/Phase II
Mechanical Ventilation - Adult [117146]
Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Routine
Mechanical Ventilation [RT0028] CONTINUOUS, Routine, For ADULT patients order
chlorihexidene gluconate (PERIDEX) 0.12% soln 15
mL to swab oral cavity 2x daily while on ventilation.
Is this a modification to a current vent order?
Ventilator Management:
Wean:
Set Rate/Min:
PEEP (cmH2O):
Mode:
Tidal Volume Multiplier: 6
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Pressure Support:
Pressure Control:
P High (cmH20):
P Low (PEEP) (cmH20):
T High (sec):
T Low (T PEEP) (sec):
PS above P High (cmH2O):
PS above PEEP (cmH2O):
NAVA Level (µV):
chlorhexidine (PERIDEX) 0.12 % soln
MULTIDOSE [792004]
15 mL, Mouth/Throat, 2 X DAILY Starting today
Use to swab oral cavity. Discontinue when patient no
longer on ventilation.
Nutrition [212638]
Page 6 of 13
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Diet - NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Diet - Adult - Renal [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Renal
Sodium:
Potassium:
Phosphorus:
Fluid Restriction Total mLs/24H (IV/PO):
Protein:
Bedside Meal Instructions:
Room Service Class:
Diet - Adult - Diabetes [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Diabetes
Bedside Meal Instructions:
Room Service Class:
Wound Care [212642]
Wound Care [NURWND0015] CONTINUOUS, Starting today, Routine
Wound Type:
Wound Site:
Wound Location:
Assess Frequency: SEE COMMENTS
Care Frequency: 1X DAILY
Wash With: Soap and Water
Irrigate/Rinse With: Other (Comment) (Water)
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing: Gauze
Secondary Dressing:
Assess frequency every 15 minutes x 4, then every 30
minutes x 4, then every 1 hour x 4, then every 4
hours., Post-Op/Phase II
Intake and Output [219058]
Measure Intake And Output [NURMON0005] SEE COMMENTS, Starting today, Routine, Measure
every 2 hours while in ICU and every 8 hours while in
general care., Post-Op/Phase II
Non-Categorized [119092]
Measure Weight [NURMON0015] 1X DAILY For Until specified, Routine
Weigh With?
Weigh when?
Post-Op/Phase II
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
CONTINUOUS, Starting today For Until specified,
Routine
Indication: Other (Comment Required)
Notify Provider:
Functional Cardiac Defibrillator Present:
Post-Op/Phase II
Contingency Parameters [124451]
Page 7 of 13
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on:
Other:Chest pain/rhythm change, failure to sense,
hematoma or bleeding at procedure site. Change in
neurovascular exam, or affected extremity including
pain, cool/cold to touch, numbness or tingling.
Temporary Transvenous Pacemaker
Pacemaker Care [119097]
Refer to Policy 1.37A - Temporary Pacing:
Transvenous, Transcutaneous, Epicardial, and
Semi-Permanent (Adult) [NURTRT0048]
CONTINUOUS, Starting today For Until specified,
Post-Op/Phase II
Introducer/cordis dressing change per policy 1.56
Central Venous Access Device Use, Maintenance
and Removal (Adult & Pediatric) [NURTRT0048]
CONTINUOUS, Starting today For Until specified,
Post-Op/Phase II
Record the Number of Centimeters Pacemaker
Wire is in at Entrance to the Skin [NURTRT0048]
EVERY 4 HOURS, Starting today For Until specified,
Post-Op/Phase II
Temporary Transvenous Pacemaker Settings [119101]
Temporary Transvenous Pacemaker Settings
[NURTRT0079]
CONTINUOUS, Starting today For Until specified,
Routine
Mode: VVI
Ventricular Voltage (Milliamperes):
Ventricular Sensitivity (Millivolts):
Ventricular Rate (Beats/Min):
Battery Change:
Post-Op/Phase II
Temporary Transvenous Pacemaker Status (Single Response) [119103]
Pacemaker On [NURTRT0080] CONTINUOUS, Starting today For Until specified,
Routine, Post-Op/Phase II
Pacemaker Off and Connected [NURTRT0081] CONTINUOUS, Starting today For Until specified,
Routine, Post-Op/Phase II
Intravenous Therapy
IV Fluids [119169]
dextrose 5 % infusion [36633] at 75 mL/hr, Intravenous, CONTINUOUS Starting
today, Post-Op/Phase II
dextrose 5%-NaCl 0.45% infusion [51613] at 75 mL/hr, Intravenous, CONTINUOUS Starting
today, Post-Op/Phase II
dextrose 5 %-NaCl 0.9% infusion [51641] at 75 mL/hr, Intravenous, CONTINUOUS Starting
today, Post-Op/Phase II
sodium chloride 0.45 % infusion [42187] at 75 mL/hr, Intravenous, CONTINUOUS Starting
today, Post-Op/Phase II
sodium chloride 0.9 % infusion [64367] at 75 mL/hr, Intravenous, CONTINUOUS Starting
today, Post-Op/Phase II
Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today For Until specified,
Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
Medications - Anti-infectives
First Line (Single Response) [152826]
Patients who are 40-120 kg [226983]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS -
Maximum 2000 mg [800084]
15 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Patients who are greater than 120 kg [226986]
Page 8 of 13
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

cefuroxime (ZINACEF) intraVENOUS [800030] 3 g, Intravenous, EVERY 8 HOURS For 2 Doses,
Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Vancomycin should be dosed with a total body
weight if equal to or greater than 120 kg
(Maximum Dose 2 grams) [800084]
15 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies [120303]
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, EVERY 12 HOURS For 1
Doses, Post-Op/Phase II
Medications
If patient not on Coumadin pre-procedure: will be on Aspirin and Plavix daily for at least 3 months.
If patient on Coumadin pre-procedure: may restart that evening. Patient will not be on Aspirin
post-op, but will be on Plavix for 3 months. Coumadin as per it's indication (goal INR 2.0-2.5
while on Plavix as well).
Analgesics (Single Response) [119173]
FENTanyl PF injection RANGE [750047] 12.5-25 mcg, Intravenous, EVERY 1 HOUR PRN
Starting today, Severe pain, for 1 Minutes, Post-
Op/Phase II
HYDROmorphone PF (DILAUDID) injection
RANGE [750050]
0.2-0.5 mg, Intravenous, EVERY 1 HOUR PRN
Starting today, Severe pain, for 3 Minutes, Post-
Op/Phase II
Platelet Inhibitors-Asprin [212525]
aspirin chew tab [720014] 81 mg, Oral, 1 X DAILY Starting today with First Dose
Include Now
Take aspirin daily for 6 months in addition to any
previously existing warfarin.
Post-Op/Phase II
Aspirin Reason Not Ordered [COR0003] ONCE, Starting today For 1 Occurrences, Routine
Reason Not Ordered:
Post-Op/Phase II
clopidogrel (PLAVIX) tab [720168] 75 mg, Oral, 1 X DAILY Starting tomorrow, Post-
Op/Phase II
Ancillary Medications [119177]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain/fever,
Post-Op/Phase II
hydrALAZINE (APRESOLINE) injection [800109] 10-20 mg, Intravenous, EVERY 2 HOURS PRN,
hypertension
Administer for systolic blood pressure greater than
180 mmHg
Post-Op/Phase II
Anti-emetics [119178]
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting
Give IV if unable to take orally.
Post-Op/Phase II
ondansetron (ZOFRAN) tab [45939] 4 mg, Oral, EVERY 24 HOURS PRN,
nausea/vomiting, Post-Op/Phase II
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
IV push slowly, max rate 5 mg/minute. For second line
therapy.
Post-Op/Phase II
Bowel Management [119179]
senna-docusate (SENOKOT S) 8.6-50 MG per
tab [60530]
1 tab, Oral, 2 X DAILY
Hold for loose stools
Post-Op/Phase II
Page 9 of 13
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Oral, 1 X DAILY PRN, constipation, Post-
Op/Phase II
Laboratory
Laboratory - On Arrival To Unit [212645]
CBC WITHOUT DIFFERENTIAL [HEMO] COLLECT UPON ADMISSION, 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?
Post-Op/Phase II
ELECTROLYTES [LYTE] COLLECT UPON ADMISSION, 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?
Post-Op/Phase II
BUN [BUN] COLLECT UPON ADMISSION, 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?
Post-Op/Phase II
CREATININE [CRET] COLLECT UPON ADMISSION, 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?
Post-Op/Phase II
GLUCOSE [GLU] COLLECT UPON ADMISSION, 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?
Post-Op/Phase II
CALCIUM [CA] COLLECT UPON ADMISSION, 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?
Post-Op/Phase II
MAGNESIUM [MAG] COLLECT UPON ADMISSION, 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?
Post-Op/Phase II
PROTHROMBIN TIME/INR [PT] COLLECT UPON ADMISSION, 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?
Post-Op/Phase II
Laboratory [212646]
Page 10 of 13
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

CBC WITHOUT DIFFERENTIAL [HEMO] NEXT AM, 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?
Post-Op/Phase II
ELECTROLYTES [LYTE] NEXT AM, Starting today at 5:00 AM For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
BUN [BUN] NEXT AM, Starting today at 5:00 AM For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
CREATININE [CRET] NEXT AM, Starting today at 5:00 AM For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
BLOOD GASES [HCBGAS] NEXT AM, Starting today For 1 Occurrences, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Post-Op/Phase II
PROTHROMBIN TIME/INR [PT] NEXT AM, 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?
Post-Op/Phase II
Diagnostic Tests and Imaging
Cardiology [216098]
12 Lead Without Rhythm [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: OTHER (COMMENT)
Obtain unless patient is paced, Post-Op/Phase II
12 Lead Without Rhythm [EKG0008] 1X DAILY, Starting today, Routine
Reason for exam: CHEST PAIN
Post-Op/Phase II
Transthoracic Resting Echocardiogram
[ECH0003]
ONCE, Starting tomorrow For 1 Occurrences, Routine
Reason for exam: MITRACLIP
Do you want Agitated Bubble Study?
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Post-operative, Post-Op/Phase II
Day of Discharge [212648]
12 Lead Without Rhythm [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: OTHER (COMMENT)
Obtain unless patient is paced., Post-Op/Phase II
Consults
Consults [212649]
Diabetes Consult Order Panel (Adult) [188497]
Page 11 of 13
Printed by LIND, JANNA S [JSL237] at 7/3/2017 11:37:27 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Diabetes Management Service : Will provide management or treatment recommendations for
patients with hyperglycemia and/or those who report outpatient use of insulin or other diabetes
medications. Patients should be expected to remain inpatient > 24 hrs from time of consult.
Consult is required for patients with insulin pumps or who use U-500 insulin. Consult Endocrine
for any non-diabetes-related endocrine questions.
Learning Center - Diabetes Education (Adult): Diabetes Education (Adult): Diabetes education
(meter/insulin skills/other diabetes survival skills) for patients/families with knowledge deficits
and/or need for diabetes knowledge assessment. Recommended for all new diagnoses or
patients with A1C > 9.
Diabetes Education – Nutrition: Diabetes nutrition therapy including nutrition assessment,
carbohydrate education (consistent carbohydrate meals, use of insulin-to-carbohydrate ratio),
and/or individualized, nutritious meal planning for carbohydrates, portions, or considering other
comorbidities. Recommended for all new diagnoses or patients with A1C > 9
Consult Diabetes Management Service (DMS)
(Inpatient) [CON0022]
ONCE
Can this consult be done via video?
Call back number:
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Post-Op/Phase II
Consult Learning Center - Diabetes Education
(Adult) [CON0021]
ONCE, Routine, - If patient is newly diagnosed or is
new to insulin, provide 24 hours notice to allow
adequate time for education,
- Indicate diabetes medication/treatment plan if
known.
- Consults requested after 1600 on Fridays may not
be seen until following Monday. Learning Center
available Mon-Sat 0800-1630 (only 1 RN available
on Saturday for CSC and AFCH).
- Staff may be contacted by Pager 7927 on
weekdays and Pager 3276 on weekends.
- Learning Center staff are not available on holidays.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Post-Op/Phase II
Page 12 of 13
Printed by LIND, JANNA S [JSL237] at 7/3/2017 11:37:27 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Consult Diabetes Education - Nutrition (Inpatient)
[CON0126]
ONCE, Routine, · If your patient is newly diagnosed
and/or is new to insulin therapy, provide 24 hours
notice to allow adequate time for nutrition education.
· Indicate diabetes medication/treatment plan if
known.
· Consults requested after 1300 on Friday may not
be completed until the following Monday.
· If you are placing a consult on a weekend day for a
patient who will be discharging that weekend, please
have the Paging Center contact the on-call dietitian
to help you facilitate the diabetes nutrition education
session prior to the patient's discharge.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Post-Op/Phase II
Consult Cardiac Rehab/Preventive Cardiology
(Inpatient) [CON0010]
ONCE, Routine
Reason for consult:
Can this consult be done via video?
Post-Op/Phase II
Page 13 of 13
Printed by LIND, JANNA S [JSL237] at 7/3/2017 11:37:27 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org