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UWHC,UWMF,

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

IP - Otolaryngologic Surgery - Pediatrics - Discharge [4920]

IP - Otolaryngologic Surgery - Pediatrics - Discharge [4920] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, ENT


IP - Otolaryngologic Surgery - Pediatrics - Discharge [4920]
Patient Care Orders
Reason For Hospitalization [131644]
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) [131666]
Adenoids [131645]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Light activity for 5 days.
Diet - General: No Restrictions [NUT0006] Routine
General: General: No restrictions: See Health Facts for
You #276,General: No restrictions: See Health Facts for
You #276,General: No restrictions: See Health Facts for
You #276,General: No restrictions: See Health Facts for
You #276,General: No restrictions: See Health Facts for
You #276,General: No restrictions: See Health Facts for
You #276,General: No restrictions: See Health Facts for
You #276,General: No restrictions: See Health Facts for
You #276
Liquids and Modified Consistency:
Fluid Restriction:
Sodium:
Dysphagia:
Fat:
Renal:
Potassium:
Micronutrients:
Infant Formula Product:
Infant Formula Concentration:
Diet - General (No Modifications) [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
Wound Care [NURWND0015] Routine, Monitor wound(s) for signs and symptoms of
infection (redness, swelling, drainage, odor). Keep soapy
water out of ears. Dry ear precautions until otherwise
notified.
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 unless otherwise prescribed
for 5 days. Take all medication as directed. Follow-up
Instructions: Follow up one to three months with audiology
and with your surgeon as scheduled.
Ear Tubes [131646]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Dry ear precautions as discussed pre-operatively.
Diet - General: No Restrictions [NUT0006] Routine
General: General: No restrictions: See Health Facts for
You #276,General: No restrictions: See Health Facts for
You #276
Liquids and Modified Consistency:
Fluid Restriction:
Sodium:
Dysphagia:
Fat:
Renal:
Potassium:
Micronutrients:
Infant Formula Product:
Page 1 of 8
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

Infant Formula Concentration:
Diet - General (No Modifications) [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Wound Care [NURWND0015] Routine, Keep soapy water out of ears.
Other Discharge Patient Care Instructions
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care Plan.,
Routine, Take all medication as directed. Follow-up
Instructions: Follow up with your surgeon and with
audiometry on the scheduled day in 1-3 months.
Tonsillectomy [131648]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Light activity for one week.
Diet [NUT0006] Routine
General: Other
Liquids and Modified Consistency:
Fluid Restriction:
Sodium:
Dysphagia:
Fat:
Renal:
Potassium:
Micronutrients:
Infant Formula Product:
Infant Formula Concentration:
Adhere to soft food diet for one week
Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid:
Esophagectomy:
Fat Controlled:
Fiber:
Fluid Restriction:
Heart Healthy:
Metabolic:
Renal:
Sodium Controlled:
NPO:
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 unless otherwise prescribed
for 7-10 days. Take all medication as directed. Follow-up
Instructions: Our clinic will phone follow up. Keep all
follow up appointments.
General [131664]
Activity [NURACT0008] Routine
Discharge Activity:
Diet [NUT0006] Routine
Diet:
General:
Liquids and Modified Consistency:
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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Fluid Restriction:
Sodium:
Dysphagia:
Fat:
Renal:
Potassium:
Micronutrients:
Infant Formula Product:
Infant Formula Concentration:
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
Respiratory [131647]
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.
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
Schedule Appointment With Sleep Lab [NURCOM0026] Reason for Appointment: To determine if patient has sleep
apnea that needs to be treated with night CPAP
When do you want appointment:
Which Clinic or Specialty: Sleep Lab
Which Provider (Optional):
Bladder Care [131649]
Bladder Care [NURELM0067] Routine
Bowel Care [131650]
Bowel Care [NURELM0068] Routine
When to Call Your Doctor [131652]
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
Page 3 of 8
Printed by LIND, JANNA S [JSL237] at 5/27/2016 2:20:21 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

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.
Follow-Up Care
Follow-Up Apoointments [131655]
Schedule Appointment With Physical Therapy
[NURCOM0026]
Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty: Physical Therapy
Which Provider (Optional):
Schedule Appointment With Occupational Therapy
[NURCOM0026]
Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty: Occupational Therapy
Which Provider (Optional):
Schedule Appointment With Speech Therapy
[NURCOM0026]
Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty: Speech Therapy
Which Provider (Optional):
Schedule Appointment with Audiology [NURCOM0026] Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty: Audiology
Which Provider (Optional):
Otolaryngology Clinic to Phone Patient for Follow-Up
[NURCOM0026]
Reason for Appointment: Post-op evaluation
When do you want appointment: Per Clinic
Which Clinic or Specialty: Clinic to Call Patient
Which Provider (Optional):
Schedule Appointment [NURCOM0026] Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
Schedule Appointment [NURCOM0026] Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
Schedule Appointment [NURCOM0026] Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
Patient to Schedule Appointment [NURCOM0056] Routine
Purpose:
With whom:
For when:
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
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Printed by LIND, JANNA S [JSL237] at 5/27/2016 2:20:21 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@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.
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.
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
Page 5 of 8
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

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
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 [131656]
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]
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
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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.
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
Labs [131657]
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 WITH DIFFERENTIAL [CBC] Status: Standing, Expires:9/26/16 MANUAL,Count:1, Normal,
Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:6/28/17 MANUAL,Count:1, Normal,
Routine
BILIRUBIN, TOTAL [TBIL] Status: Standing, Expires:9/26/16 MANUAL,Count:1, Normal,
Routine
PROTEIN, TOTAL [TP] Status: Standing, Expires:9/26/16 MANUAL,Count:1, Normal,
Routine
ALBUMIN [ALB] Status: Standing, Expires:9/26/16 MANUAL,Count:1, Normal,
Routine
ALKALINE PHOSPHATASE [ALKP] Status: Standing, Expires:9/26/16 MANUAL,Count:1, Normal,
Routine
AST/SGOT [AST] Status: Standing, Expires:6/28/17 MANUAL,Count:1, Normal,
Routine
ALT/SGPT [ALT] Status: Standing, Expires:6/28/17 MANUAL,Count:1, Normal,
Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:9/26/16 Manual,Count:1, Normal,
Routine
GLUCOSE [GLU] Status: Standing, Expires:9/26/16 Manual,Count:1, Normal,
Routine
BUN [BUN] Status: Standing, Expires:9/26/16 Manual,Count:1, Normal,
Routine
CREATININE [CRET] Status: Standing, Expires:6/28/17 Manual,Count:1, Normal,
Page 7 of 8
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

Routine
CALCIUM [CA] Status: Standing, Expires:9/26/16 Manual,Count:1, Normal,
Routine
PTH [HCPTHIN] Status: Standing, Expires:9/26/16 Manual,Count:1, Normal,
Routine
Imaging [131658]
X-RAY CHEST AP VIEW [R71010] Status: Future, Expires: 7/27/17, Normal, Routine
CT HEAD W & W/ O IV CONTRAST [R70470] Status: Future, Expires: 7/27/17, Normal, Routine
CT ABDOMEN PELVIS W & W/ O IV CONTRAST
[R07033]
Status: Future, Expires: 7/27/17, Normal, Routine
Page 8 of 8
Printed by LIND, JANNA S [JSL237] at 5/27/2016 2:20:21 PM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org