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/clinical/cckm-tools/content/order-sets/inpatient/cardiologyct-surgery/name-98405-en.cckm

201606179

page

100

UWHC,UWMF,

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

IP - Esophagectomy-Benign Foregut - Adult - Discharge [3424]

IP - Esophagectomy-Benign Foregut - Adult - Discharge [3424] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Cardiology/CT Surgery


IP - Esophagectomy/Benign Foregut - Adult - Discharge [3424]
Do NOT use Esophagectomy Discharge Instructions if placing orders using this order set.
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:
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):
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

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
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 6/21/16, No Print
acetaMINOPHEN (TYLENOL) suppository [34153] 650 mg, 1 suppository, 1, starting 6/21/16, No Print
Blood Glucose Management [111710]
glucagon 1 mg injection kit [107799] 1 mg, 1 each, 1, starting 6/21/16, No Print
Glucose 40 % oral gel [118089] 10 g, 1 Tube, 1, starting 6/21/16, 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:24400}.
- If your patient's blood glucoses are uncontrolled contact
provider.
- "Uncontrolled" blood glucoses mean:
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

* 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 6/21/16, No Print
Senna-Docusate Sodium 8.6-50 MG per tab [70181] 1-2 tab, 1 tab, 1, starting 6/21/16, No Print
magnesium hydroxide (MILK OF MAGNESIA) susp
[65443]
30 mL, 1 Bottle, 1, starting 6/21/16, No Print
polyethylene glycol (MIRALAX) oral powder [61353] 17 g, 1 Bottle, 1, starting 6/21/16, No Print
Non-categorized Medications [111711]
guaifenesin-dextroMETHORPHAN (ROBITUSSIN DM)
syrup [51568]
10 mL, 1 Bottle, 1, starting 6/21/16, No Print
carbamide peroxide (DEBROX) 6.5% otic soln [35545] 3 drop, 1 Bottle, 1, starting 6/21/16 until 6/26/16, No Print
alum-mag-simeth (MYLANTA ES) susp [44073] 30 mL, 1 Bottle, 1, starting 6/21/16, No Print
Discharge Orders
Reason for Hospitalization [131464]
Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This order
will appear on the patient's After Hospital Care Plan., Routine
Surgical Procedures (Single Response) [206669]
Esophagectomy [206620]
Head of Bed Greater Than 30 Degrees At All Times
[NURACT0011]
Routine
Esophagectomy Full Liquid Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid:
Esophagectomy: Full Liquids
Fat Controlled:
Fiber:
Fluid Restriction: Fluid Restriction (mLs/24 Hr)
Fluid Restriction Amount:
Heart Healthy:
Metabolic:
Renal:
Sodium Controlled:
NPO:
Clear Liquid Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid: Clear Liquid
Esophagectomy:
Fat Controlled:
Fiber:
Fluid Restriction: Fluid Restriction (mLs/24 Hr)
Fluid Restriction Amount:
Heart Healthy:
Metabolic:
Renal:
Sodium Controlled:
NPO:
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

Record Daily Food Intake [NURDIE0013] Routine, Bring food record to follow up appointment.
Flush J-Tube - Between Tube Feedings
[NURWND0018]
Routine, Flush Jejunostomy tube (J-Tube) between tube
feedings with 10 mL, 6 times a day.
Flush J-Tube - Hydration [NURWND0018] Routine, Flush Jejunostomy tube (J-Tube) for hydration
with *** mL, *** times a day.
Flush J-Tube - After Every Tube Feed [NURWND0018] Routine
Nissen Fundoplication [206626]
Nissen Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid: Clear Liquid
Esophagectomy:
Fat Controlled:
Fiber:
Fluid Restriction:
Heart Healthy:
Metabolic:
Renal:
Sodium Controlled:
NPO:
Clear Liquid Diet for 3 days, then a Full Liquid Diet for 3
days, then a Soft Mechanical Diet until follow up
appointment.
Record Daily Food Intake [NURDIE0013] Routine, Bring food record to follow up appointment.
Other Procedure [206668]
Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Record Daily Food Intake [NURDIE0013] Routine, Bring food record to follow up appointment.
Weight Monitoring [101991]
Measure Weight - Daily [NURMON0015] Routine
Frequency: Daily
Activity [101989]
Up as Tolerated [NURACT0011] Routine, Walk at least 4 times per day
Driving Restriction [NURACT0011] Routine, No driving for 2 weeks or while taking narcotics
Lifting Restriction [NURACT0011] Routine, Do not lift greater than 10 pounds until follow up
appointment
Wound Care [101993]
Wound Care [NURWND0018] Routine, Patient may shower. Do not immerse incisions until
fully healed (4-6 weeks). No tub baths until follow up
appointment. Monitor wound(s) for signs and symptoms of
infection (redness, swelling, drainage, odor). If you notice
these symptoms, call your surgeon's office (or the thoracic
resident on-call if after hours). Daily dressing changes as
needed to keep site clean and dry.
Drain Care [NURWND0018] Routine, Measure and record drain output daily. Bring record
to follow up appointment. Follow drain care instructions as
directed by nursing staff.
Respiratory [101995]
Incentive Spirometry [NURTRT0048] Routine, Perform at least 5 times per day
DME - Home Oxygen [142943]
Both of the following orders MUST be completed in order for this DME to be delivered to the patient.
New reimbursement requirements in 2013 require that a physician, PA, NP, or CNS has a face-to-face encounter with a
patient prior to ordering certain durable medical equipment (DME). It also requires that the DME supplier be provided with
the documentation of the face-to-face encounter and a signed order prior to delivery of the DME.
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

National Coverage Determination for Home Use of
Oxygen (See section D for qualifying diagnoses)
URL: http://www.cms.gov/medicare-coverage-
database/details/ncd-details.aspx?
NCDId=169&ncdver=1&bc=AgAAQAAAAAAAAA%3d%
3d&
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 - Home Oxygen Justification [1009463] Details
Bowel Care [123370]
Bowel Care [NURELM0068] Routine, Opioid pain medications can cause constipation
and/or straining with bowel movements. Try to limit opioids to
management of severe pain. Stop using opioid medications
as soon as severe pain subsides.
If you are able to take fluids by mouth and are not on any fluid
volume restrictions, be sure to drink plenty of fluids and take
Senokot while on opioids to avoid constipation:
Senokot 2 tablets by mouth once daily at bedtime while on
opioids. Stop or do not take if you have loose stools.
Senokot is available over the counter without a prescription.
If you experience constipation and/or straining with bowel
movements and you are able to take pills by mouth, you
make take:
Miralax 17 grams (1 capful) by mouth daily as needed for
constipation or straining with bowel movements. Stop or do
not take if you have loose stools. Miralax is available over the
counter without a prescription. Follow the instructions on the
label to mix with a beverage.
If you are unable to swallow pills or have been directed not to,
you may have been prescribed stool softeners/laxatives
(Senna, Colace, and Miralax) in a liquid form. You may
administer these liquid medications through your J tube or
take the solution form orally as directed.
Bladder Care [123369]
Bladder Care [NURELM0067] Routine
Other Patient Care Instructions [123386]
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
When to Call Your Doctor [131466]
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.
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

You should include actual provider names (i.e. not 'PCP').
You should NOT include the discharging unit as a contact.,
Routine, Call the Thoracic Surgery clinic at 608-263-7502 (or
thoracic surgery resident on call after hours at 608-263-6400)
if you have any symptoms: increased pain, not relieved by
medication; increased pain and redness around your incision;
fever over 100.5 degrees for 24 hours; increased shortness of
breath; weight gain as directed; increased output from the
drain; if the drain output becomes thick or cloudy; or of you
have nausea or vomiting.
Heart Failure Recommended Care
These order groups are showing because either your patient has an EF < 40% documented or has Heart Failure on their
problem list.
UW Health HF guideline 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
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)
Discharge Medications
Medications - Opioid - Discharge Prescriptions [206391]
oxycodone soln - 5-10 mg q4h prn 500 mL [45975] 500 mL, 0, starting 6/21/16, Normal
Medications - Non-opioid - Discharge Prescriptions [206392]
acetaMINOPHEN alcohol free (TYLENOL) 160 MG/5ML
susp - 650 mg q4h prn [43991]
650 mg, 100 mL, 0, starting 6/21/16, Normal
docusate sodium (COLACE) 100 mg soln - 2x/d [74449] 100 mg, 100 mL, 0, starting 6/21/16, Normal
sennosides (SENNA) 8.8 MG/5ML syrup [50880] 10 mL, starting 6/21/16, Normal
polyethylene glycol (MIRALAX) oral powder [61353] starting 6/21/16, Normal
ondansetron (ZOFRAN ODT) 4 MG disintegrating tab
[64224]
4 mg, starting 6/21/16, Normal
Follow Up Care
Follow Up Appointments [101998]
Schedule Follow Up Appointment [NURCOM0026] Reason for Appointment:
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
Schedule Follow Up Appointment [NURCOM0026] Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
Schedule Follow Up Appointment [NURCOM0026] Reason for Appointment: Postop follow-up
When do you want appointment: In 2 weeks
Which Clinic or Specialty:
Which Provider (Optional):
Esophagectomy patients should be seen in the Cancer Clinic
for post-op visit.
Schedule Follow Up Appointment [NURCOM0026] Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
Patient to Schedule Appointment [NURCOM0026] Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
Patient to Schedule Appointment [NURCOM0026] Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
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
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

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 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.
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
Page 8 of 10
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

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.
Follow Up Diagnostic Tests and Imaging [101996]
X-RAY CHEST PA & LAT VIEWS [R71020] Status: Future, Expires: 8/5/16, Normal, Routine, PERFORM
BEFORE FOLLOW-UP VISIT.
Discharge Labs [134929]
Please use the table below to determine what type of order to use to place discharge lab orders.
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
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

responsible for the RESULTS of any ordered labs.
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
Follow Up Labs [101997]
These lab orders should only be used if the current Attending Provider or Consulting Provider will be responsible for the
result of the lab.
CBC WITHOUT DIFFERENTIAL [HEMO] Status: Future, Expires: 8/5/16, Normal, Routine, To be drawn
at follow up clinic visit
ELECTROLYTES [LYTE] Status: Future, Expires: 8/5/16, Normal, Routine, To be drawn
at follow up clinic visit
BUN [BUN] Status: Future, Expires: 8/5/16, Normal, Routine, To be drawn
at follow up clinic visit
CREATININE [CRET] Status: Future, Expires: 8/5/16, Normal, Routine, To be drawn
at follow up clinic visit
GLUCOSE [GLU] Status: Future, Expires: 8/5/16, Normal, Routine, To be drawn
at follow up clinic visit
CALCIUM [CA] Status: Future, Expires: 8/5/16, Normal, Routine, To be drawn
at follow up clinic visit
Page 10 of 10
Printed by LIND, JANNA S [JSL237] at 6/21/2016 12:31:04 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org