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201706156

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IP - Otolaryngologic Surgery - Head/Neck/General - Adult - Discharge [4923]

IP - Otolaryngologic Surgery - Head/Neck/General - Adult - Discharge [4923] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, ENT


IP - Otolaryngologic Surgery - Head/Neck/General - Adult - Discharge [4923]
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 Non-Categorized 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 Assessed and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Page 1 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@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 Assessed 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 Assessed 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
Page 2 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 6/1/17, No Print
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, 1 suppository, 1, starting 6/1/17, No Print
Blood Glucose Management [111710]
glucagon 1 mg injection kit [107799] 1 mg, 1 each, 1, starting 6/1/17, No Print
Glucose 40 % oral gel [118089] 10 g, 1 Tube, 1, starting 6/1/17, 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 6/1/17, No Print
Senna-Docusate Sodium 8.6-50 MG per tab
[70181]
1-2 tab, 1 tab, 1, starting 6/1/17, No Print
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, 1 Bottle, 1, starting 6/1/17, No Print
polyethylene glycol (MIRALAX) oral powder
[61353]
17 g, 1 Bottle, 1, starting 6/1/17, No Print
ZZNon-categorized Medications [111711]
guaifenesin-dextroMETHORPHAN
(ROBITUSSIN DM) syrup [51568]
10 mL, 1 Bottle, 1, starting 6/1/17, No Print
carbamide peroxide (DEBROX) 6.5% otic soln
[35545]
3 drop, 1 Bottle, 1, starting 6/1/17 until 6/6/17, No
Print
Page 3 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

alum-mag-simeth (MYLANTA ES) susp [44073] 30 mL, 1 Bottle, 1, starting 6/1/17, No Print
Patient Care Orders
Confirmed Discharge Date/Time [151653]
Confirmed Discharge Date/Time [ADT0013] Confirmed Discharge Date:
Confirmed Discharge Time:
Conditions for Discharge:
Provider to be Present at Discharge?
Reason For Hospitalization [131692]
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 [131693]
Head and Neck Reconstructions [131705]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
No strenuous activity or lifting greater than 10
pounds for 2 weeks
Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Adhere to prescribed diet for ***
{DAYS/WEEKS:16512}.
Wound Care [NURWND0015] Routine, Monitor wound(s) for signs and symptoms
of infection (redness, swelling, drainage, odor).
Clean incisions gently with soap and water 1x
daily. Do not soak or scrub. Do not submerge
incisions for one month. Apply thin layer of
petroleum jelly (Vaseline) to incision twice each day
for one week. Patient may shower in ***
{DAYS/HRS:10998}.
Split Thickness Skin Graft Donor Site Care
[NURWND0015]
Routine, Split Thickness Skin Graft Donor Site
Care:
Keep tegaderm in place until follow-up. If it leaks at
the edge, please reinforce with additional
tegaderm.
Radial Forearm Flap donor site care
[NURWND0015]
Routine, Radial Forearm Flap donor site care:
Place xeroform dressing over wound and wrap
lightly with a kerlex gauze wrap. Change once
daily. It is okay to shower with the dressing off and
gently pat dry.
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, No aspirin or NSAIDs
(such as ibuprofen) for *** {DAYS/WEEKS:16512}.
Take all medication as directed. Do not drive or
operate heavy machinery while on narcotic pain
medications. Follow-up Instructions: Follow up with
Dr. @ATTPROV@ in *** {DAYS/WEEKS:16512}.
Keep all follow up appointments.
Nasal Septoplasty [132077]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
No nose blowing. Cough and sneeze with your
mouth open. No lifting greater than 10 pounds for 2
weeks. Avoid constipation. Stay hydrated and use
stool softener if you become constipated.
Page 4 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Wound Care [NURWND0015] Routine, Start nasal saline sprays to both sides of
the nose 10 sprays to each side of the nose 2 times
daily, starting today. Some blood-tinged drainage
from the nose is expected. Call if you develop
significant bleeding from the nose or mouth. No
bathing restrictions
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, No driving, operating
heavy machinery while taking narcotics. No ASA or
NSAIDs for 10 days. Take all medication as
directed. Follow up with your nose surgeon as
scheduled (an appointment is usually scheduled
within 1 week). If packing is in place, then your
follow up is usually within one week. Keep all
follow up appointments.
Phonosurgery/Laryngoscopy [131706]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Light activity for 5 days. Strict voice rest for 3 days;
followed by soft voice use for 4 days.
Wound Care [NURWND0015] Routine, Monitor wound(s) for signs and symptoms
of infection (redness, swelling, drainage, odor).
Report any bleeding from the mouth immediately to
MD or Emergency Medical Services.
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, Do not take blood
thinning agents: NSAIDs (ibuprofen, naproxen, etc),
aspirin, fish oil for 5 days. Take all medication as
directed. Call right away if you develop noisy
breathing or difficulty breathing. Difficulty
breathing can be an emergency. If you are unable
to contact your doctor, call 911 or go to the nearest
emergency department. Follow-up Instructions:
Follow up with Voice Therapy in 1 week and again
1 month post operatively. Follow up with your MD
in 1 month, simultaneously with your second voice
therapy appointment. Keep all follow up
appointments.
Sinus Surgery [132078]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
No nose blowing. Cough and sneeze with your
mouth open. No lifting greater than 10 pounds for 2
weeks. Avoid constipation. Stay hydrated and use
stool softener if you become constipated.
Page 5 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Wound Care (Non dissolvable packing)
[NURWND0015]
Routine, You have packing in place in your nose.
Use saline nasal sprays every four hours while
awake to prevent this packing from drying out. It is
very important to follow up as scheduled and to
have packing removed within less than one week.
If, for some reason you do not have follow up in
one week or less, call your surgeon's office at the
number below to ensure that there has been no
scheduling mistake or missed appointment. Some
blood-tinged drainage from the nose is expected.
Call if you develop significant bleeding from the
nose or mouth. No bathing restrictions.
Wound Care (Dissolvable packing)
[NURWND0015]
Routine, You have dissolvable packing in place in
your nose. You should begin to use saline nasal
sprays 2-3 times per day on the third day after
surgery. Some blood-tinged drainage from the nose
is expected. Call if you develop significant bleeding
from the nose or mouth. No bathing restrictions.
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, No driving, operating
heavy machinery while taking narcotics. No ASA or
NSAIDs for 10 days. Take all medication as
directed. Follow up with your sinus surgeon as
scheduled. Keep all follow up appointments.
Tracheotomy [131707]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
No lifting greater than 10 pounds for 2 weeks. Light
activity for one week; no heavy lifting for two
weeks.
Wound Care [NURWND0015] Routine, Monitor wound(s) for signs and symptoms
of infection (redness, swelling, drainage, odor).
Report any bleeding from the mouth or trach site
immediately to MD or Emergency Medical Services.
Patient may shower.
Discharge - Respiratory Equipment [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):
Diagnosis:
Supplies:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Trach Care with a Trach Tube in Place
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After
Hospital Care Plan., Routine, Irrigate trach tube
with 5 ml of saline at least three times a day, or
more often if needed. Suction as needed if you feel
your airway is partly blocked or full of mucous. You
must remove the inner cannula before irrigating.
Suction Airway [NURTAD0017] Normal, Routine, Qty-1
Page 6 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Wound Care - Tracheotomy/Tracheostomy
[NURWND0015]
Routine, Perform site care every time you clean
your trach or stoma. Clean around the area with
cotton-tipped swabs using mild soap and water or
saline. You can also use a washcloth. Make sure it
is clean and you are able to reach under the
faceplate of the trach tube, if you have one in place.
If your nurse told you to use a gauze dressing
around your trach tube, change it when you do site
care or when it is soiled.
Monitor wound(s) for signs and symptoms of
infection (redness, swelling, increased drainage,
odor). Report any bleeding from the mouth or trach
site immediately to your doctor or Emergency
Medical Services. Patient may shower.
Health Facts For You [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After
Hospital Care Plan., Routine, < LIST HERE>
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, Have the trach
obturator available at all times for easy replacement
in the event of inadvertent removal of trach tube.
Use humidified air or humidifier nearby as much as
possible to keep secretions moist and avoid
crusting.
At times we send patients home with a
tracheostomy plugging trial. If you have any
problems breathing or have significant coughing
and secretions, please remove trach plug. If you do
not gain satisfactory relief, you should pull out the
inner cannula of the tracheostomy. If you are still in
respiratory distress, have someone call 911.
Avoid blood thinning agents: NSAIDs (ibuprofen,
naproxen, etc), aspirin, fish oil for 7 days. Take all
medication as directed. No driving while on
narcotics. Follow-up Instructions: Our clinic will
phone follow up. Keep all follow up appointments.
Tonsillectomy/UPP [132123]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Light activity for one week.
Page 7 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Diet [NUT8888] Routine
General:
Diet Modifications: Surgical Soft
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid:
Esophagectomy:
Fat Controlled:
Fiber:
Fluid Restriction:
Heart Healthy:
Metabolic:
Renal:
Sodium Controlled:
NPO:
Tube Feeding:
Adhere to soft food diet for one week
Wound Care [NURWND0015] Routine, Monitor wound(s) for signs and symptoms
of infection (redness, swelling, drainage, odor).
Report any bleeding from the mouth immediately to
MD or Emergency Medical Services.
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, Avoid blood thinning
agents: NSAIDs (ibuprofen, naproxen, etc), aspirin,
fish oil for 7-10 days. Take all medication as
directed. Follow-up Instructions: Our clinic will
phone follow up. Keep all follow up appointments.
General [131708]
Activity [NURACT0008] Routine
Discharge Activity:
Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Wound Care [NURWND0015] Routine
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
Nutrition [196184]
Diet- General: No Restrictions [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
Diet- Soft Food Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Adhere to soft food diet for one week.
Other Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Adhere to diet for *** days/weeks
Page 8 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Adult/Adolescent/Pediatric Tube Feeding,
Continuous - Discharge [NUT0010]
Routine
General:
Products (Adult):
Products (Adol/Ped):
J-Tube and Nasojejunal tube require a pump. Give ***
mL per hour. Equivalent Formula okay. Flush with ***
mL water.
Adult/Adolescent/Pediatric Tube Feeding, Cyclic
- Discharge [NUT0011]
Routine
Tube Type:
Products (Adult):
Products (Adol/Ped):
J-Tube and Nasojejunal tube require a pump. Give ***
mL per hour. Equivalent Formula okay. Flush with ***
mL water.
Adult/Adolescent/Pediatric Tube Feeding, Bolus -
Discharge [NUT0012]
Routine
Tube Type:
Products (Adult):
Products (Adol/Ped):
J-Tube and Nasojejunal tube require a pump. Give ***
mL per hour. Equivalent Formula okay. Flush with ***
mL water.
Feeding Tube Care [196185]
G-Tube Site Care [NURWND0015] Routine, Cleanse the skin around the tube and the
tube with warm water once daily, more often if there is
drainage around the tube.
J-Tube Site Care [NURWND0015] Routine, Cleanse the skin with normal saline and
cotton-tipped swabs. Place sterile split 4x4 gauze
dressing on the skin under the tube and tape in place.
Secure the tube by taping it to your stomach.
Respiratory [131694]
DME - Home Oxygen [142943]
Both of the following orders MUST be completed in order for this DME to be delivered to the
patient.
-CNS has a facereimbursement requirements in 2013 require that a physician, PA, NP, or New
durable medical equipment (DME). It face encounter with a patient prior to ordering certain -to
face -to-provided with the documentation of the facealso requires that the DME supplier be
order prior to delivery of the DME.encounter and a signed
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
Page 9 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Schedule Appointment With Sleep Lab
[NURCOM0026]
Reason for Hospital Follow Up Appointment: To
determine if patient has sleep apnea that needs to be
treated with night CPAP
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Sleep Lab
Bowel Care [131696]
Bowel Care [NURELM0068] Routine, Take stool softeners as directed while using
opioid pain medications. Hold stool softeners for
loose stools. You can also help the constipation
caused by opioid pain medications by increasing your
activity as tolerated. Eat a diet high in fiber, fruits and
vegetables. Drinking warm fluids and staying well
hydrated also helps.
Other Discharge Patient Care Instructions [196186]
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 [131697]
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, If you have any of these symptoms:
increased pain; not relieved by medication, fever over
100.5 degrees for 24 hours, or increased shortness of
breath or any other questions/problems, contact the
Adult Otolaryngology Clinic at 608-263-6190 or
Pediatric Otolaryngology Clinic at 608-265-7760
during business hours. For urgent questions or
concerns after hours or on weekends, call 608-263-
6400 and ask for the Otolaryngology resident on call.
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
Page 10 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@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 [131698]
Schedule Appointment With Physical Therapy
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Other Provider or Specialist
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: Other Provider or Specialist
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: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Speech Therapy
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Patient to Schedule Appointment
[NURCOM0056]
Routine
Purpose:
With whom:
For when:
Follow Up Appointments - Diabetes (Single Response) [148552]
Page 11 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

*** 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 12 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@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 13 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@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 [131699]
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 14 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@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 15 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Labs [131700]
Consulting Provider lab orders should only be used if the current Attending Provider or These
lab.will be responsible for the result of the
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:10/1/17 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:7/3/18 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:10/1/17 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:10/1/17 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:7/3/18 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:10/1/17 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:10/1/17 MANUAL,Count:1,
Normal, Routine
BILIRUBIN, TOTAL [TBIL] Status: Standing, Expires:10/1/17 MANUAL,Count:1,
Normal, Routine
PROTEIN, TOTAL [TP] Status: Standing, Expires:10/1/17 MANUAL,Count:1,
Normal, Routine
ALBUMIN [ALB] Status: Standing, Expires:10/1/17 MANUAL,Count:1,
Normal, Routine
ALKALINE PHOSPHATASE [ALKP] Status: Standing, Expires:10/1/17 MANUAL,Count:1,
Normal, Routine
AST/SGOT [AST] Status: Standing, Expires:7/3/18 MANUAL,Count:1,
Normal, Routine
ALT/SGPT [ALT] Status: Standing, Expires:7/3/18 MANUAL,Count:1,
Normal, Routine
PTH [HCPTHIN] Status: Standing, Expires:10/1/17 MANUAL,Count:1,
Normal, Routine
Imaging [131701]
X-RAY CHEST AP VIEW [R71010] Status: Future, Expires: 8/1/18, Normal, Routine
CT HEAD W & W/ O IV CONTRAST [R70470] Status: Future, Expires: 8/1/18, Normal, Routine
Page 16 of 16
Printed by WILLIAMS, HEATHER R S [HRS0] at 6/1/2017 1:15:30 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org