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IP - Otological Surgery - Adult - Discharge [4936]

IP - Otological Surgery - Adult - Discharge [4936] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, ENT


IP - Otological Surgery - Adult - Discharge [4936]
Skilled Nursing Facility Orders
This Patient is going to a skilled nursing facilty, directly below is a group of orders commonly
associated with this patient population. Please review the orders below and select the appropriate
ones for this patient. If this patient is not going to a SNF, contact Case Management to update the
discharge plan. Updating the discharge plan will remove this set of SNF orders from the order set.
Skilled Nursing Facility Certification Statement [114940]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Certification Statement [118260]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Admit Order [114941]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Admit Order [118261]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Patient Care Orders [111713]
For dyspnea, Oxygen at 2 L/minute per nasal
canula; If this is an acute change for the patient
call PCP with assessment ASAP after oxygen is
started. Suction PRN to clear airways.
[NURCOM0022]
Routine
DME - Home Oxygen [1009468] Patient's O2 Requirements Assessed and Meets
Criteria for Home O2:
Delivery Device:
Equipment Needed:
Continuous (liters/min):
Continuous (FiO2):
With Activity (liters/min):
With Activity (FiO2):
With Sleep (liters/min):
With Sleep (FiO2):
Length of Need:
Vendor:
DME - CPAP [1009443] Formal Sleep Study Completed:
Diagnosis:
CPAP Pressure (cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Page 1 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 7/31/2017 1:47:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

DME - BiPAP (S) [1009441] Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S):
Diagnosis:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
DME - BiPAP (S/T) [1009442] Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S/T):
Diagnosis:
Respiratory Rate:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Patient may self administer medication per RN
assessment [NURCOM0022]
Routine
Patient medications (per Skilled Nursing Facility
policy) may be left at bedside [NURCOM0022]
Routine
Facility Therapy Needs [113391]
Physical Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Occupational Therapy to Evaluate and Treat at
Next Facility [NURCOM0022]
Routine
Speech Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Communicable Diseases [111717]
State Law requires at least one of the following statements be checked for your patient. May check both if
applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have any
other clinically apparent communicable diseases.
[NURCOM0022]
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Page 2 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 7/31/2017 1:47:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Communicable Diseases [118262]
State Law requires at least one of the following statements be checked for your patient. May check both if
applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have any
other clinically apparent communicable diseases.
[NURCOM0022]
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Analgesics [111708]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, 1 tab, 1, starting 7/31/17, No Print
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, 1 suppository, 1, starting 7/31/17, No Print
Blood Glucose Management [111710]
glucagon 1 mg injection kit [107799] 1 mg, 1 each, 1, starting 7/31/17, No Print
Glucose 40 % oral gel [118089] 10 g, 1 Tube, 1, starting 7/31/17, 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 7/31/17, No Print
Senna-Docusate Sodium 8.6-50 MG per tab
[70181]
1-2 tab, 1 tab, 1, starting 7/31/17, No Print
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, 1 Bottle, 1, starting 7/31/17, No Print
polyethylene glycol (MIRALAX) oral powder
[61353]
17 g, 1 Bottle, 1, starting 7/31/17, No Print
Non-categorized Medications [111711]
guaifenesin-dextroMETHORPHAN (ROBITUSSIN
DM) syrup [51568]
10 mL, 1 Bottle, 1, starting 7/31/17, No Print
carbamide peroxide (DEBROX) 6.5% otic soln
[35545]
3 drop, 1 Bottle, 1, starting 7/31/17 until 8/5/17, No
Print
alum-mag-simeth (MYLANTA ES) susp [44073] 30 mL, 1 Bottle, 1, starting 7/31/17, No Print
Patient Care Orders
Confirmed Discharge Date/Time [151653]
Page 3 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 7/31/2017 1:47:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Confirmed Discharge Date/Time [ADT0013] Confirmed Discharge Date:
Confirmed Discharge Time:
Conditions for Discharge:
Provider to be Present at Discharge?
Reason For Hospitalization [132036]
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 Procedure (Single Response) [132056]
Atresiaplasty [132023]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Sinus precautions: No nose blowing, no ear popping,
pressurization, sneeze with open mouth. Keep water
out of ear canal. Use a Vaseline-coated cotton ball in
the ear canal/bowl during showering to keep water
out. No strenuous activity, lifting > 10 lb for 2 weeks.
No driving, operating heavy machinery while taking
narcotics. No plane flights, scuba diving for one
month.
Wound Care [NURWND0015] Routine, Remove mastoid dressing and canal cotton
ball after 24 hours. Mastoid dressing may be worn at
night for comfort. Patient can shower after 48 hours.
Do not submerge incision (tub/pool). Apply bacitracin
to incision twice a day for one week. Start ear drops
twice a day once ear canal packing removed.
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, Follow up in Otolaryngology
(ENT) Clinic in 7-9 days for packing removal and in
four weeks, no audiogram needed.
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start to use twice a day after
packing removed at one week
BAHA [132057]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
No strenuous activity, lifting > 10 lb for 2 weeks.
Wound Care [NURWND0015] Routine, Remove the ear dressing after 24 hours.
There will be a yellow gauze dressing underneath a
white cap at the operative site. You can shower
after 48 hours but should keep the operative site dry
until the follow-up appointment. Do not submerge
incision (tub/pool) or scrub for 14 days.
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, You have been fitted with a
bone anchored hearing aid. No driving, operating
heavy machinery while taking narcotics. You will be
given a prescription for an antibiotic for 7 days. You
will also get pain meds and a stool softener to be
used for constipation, or while you are taking pain
medications. Follow up in 7-9 days in Otolaryngology
(ENT) Clinic for healing cap removal and
postoperative check up.
Page 4 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 7/31/2017 1:47:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

BAHA [132059]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
No lifting greater than 25 pounds for one week.
Wound Care [NURWND0015] Routine, Mastoid dressing may be removed
tomorrow morning. Mastoid dressing may be worn at
night for comfort. Keep wound clean. Keep wound
dry for 48 hours. You may shower tomorrow, keep
ear dry while doing so. Monitor wound(s) for signs
and symptoms of infection (redness, swelling,
drainage, odor).
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 while on narcotics.
OK to use aspirin or ibuprofen. Take all medication
as directed. Follow up with Otolaryngology (ENT)
Clinic in 5-10 days. Keep all follow up appointments.
If BAHA white healing cap falls off, then call the
numbers listed below, if it falls off anytime before 4
days after surgery it will need replacement.
Canal Wall DOWN
Mastoidectomy/Tympanomastoidectomy
[132060]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Sinus precautions: No nose blowing, no ear
popping/pressurization, sneeze with open mouth. No
strenuous activity, lifting > 10 lb for 2 weeks. No
plane flights, scuba diving for one month.
Wound Care [NURWND0015] Routine, Remove mastoid dressing after 24 hours.
Patient can shower after 48 hours. Do not submerge
incision (tub/pool). Apply bacitracin to incision twice
a day for one week. Start ear drops twice a day once
ear canal packing removed. Keep water out of ear
canal. Use a Vaseline-coated cotton ball in the ear
canal/bowl during showering to keep water out.
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. Follow up with
Otolaryngology (ENT) Clinic at one week for packing
removal and with Otolaryngology (ENT) Clinic in four
weeks. No audiogram needed.
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops tomorrow
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops 1 week before
your follow up appointment
Canal Wall UP
Mastoidectomy/Tympanomastoidectomy
[132061]
Page 5 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 7/31/2017 1:47:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Sinus precautions: No nose blowing, no ear
popping/pressurization, sneeze with open mouth. No
strenuous activity, lifting > 10 lb for 2 weeks. No
plane flights, scuba diving for one month.
Wound Care [NURWND0015] Routine, Remove mastoid dressing and canal cotton
ball after 24 hours. Mastoid dressing may be worn at
night for comfort. Patient can shower after 48 hours.
Do not submerge incision (tub/pool). Gently wash,
dry area of incision in shower. Apply bacitracin to
incision twice a day for one week. Start ear drops
once mastoid dressing off. Keep water out of ear
canal. Use a Vaseline-coated cotton ball in the ear
canal/bowl during showering to keep water out.
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. Follow up with
Otolaryngology (ENT) Clinic in four weeks. No need
for audiogram.
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops tomorrow
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops 1 week before
your follow up appointment
Canal Wall Reconstruction
Tympanomastoidectomy [132067]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Sinus precautions: No nose blowing, no ear popping,
pressurization, sneeze with open mouth. No
strenuous activity, lifting > 10 lb for 2 weeks. No
plane flights, scuba diving for one month.
Wound Care [NURWND0015] Routine, Remove mastoid/craniotomy dressing after
5 days then patient can shower. Do not submerge
incision (tub/pool). Gently wash, dry area of incision
in shower. Apply bacitracin to incision twice a day for
one week
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. Follow up with
Otolaryngology (ENT) Clinic in one week for packing
and/or suture removal and again in four weeks - no
audiogram necessary.
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops tomorrow
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops 1 week before
your follow up appointment
Cochlear Implant [132069]
Page 6 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 7/31/2017 1:47:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Sinus precautions: No nose blowing, no ear
popping/pressurization, sneeze with open mouth. No
strenuous activity, lifting > 10 lb for 2 weeks.
Wound Care [NURWND0015] Routine, Remove mastoid dressing after 24 hours.
Mastoid dressing may be worn at night for comfort.
Patient can shower after 48 hours. Do not submerge
incision (tub/pool). Gently wash, dry area of incision
in shower. Apply bacitracin to incision twice a day for
one week.
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. Follow up in one
month with Otolaryngology (ENT) Clinic coordinated
with audiology for activation.
Ear Surgery [228181]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
No lifting greater than 10 pounds for 2 weeks. Sinus
precautions: no nose blowing, sneeze with mouth
open. No plane flights, scuba diving for one month.
Wound Care [NURWND0015] Routine, Do not soak or scrub wound for 2 weeks.
Patient may shower in 48 hours. Monitor wound(s)
for signs and symptoms of infection (redness,
swelling, drainage, odor). Keep water out of ear
canal. Use a Vaseline-coated cotton ball in the ear
canal/bowl during showering to keep water out.
Remove mastoid dressing and/or canal cotton ball
after ***. Mastoid dressing may be worn at night for
comfort. Patient can shower after 48 hours. Do not
submerge incision (tub/pool). Gently wash, dry area
of incision in shower. Apply bacitracin to incision
twice a day for one week. Start ear drops once
mastoid dressing off. See pharmacy list for
administration instructions.
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. Avoid blood
thinning agents: NSAIDs (ibuprofen, naproxen, etc),
aspirin, fish oil for 7 days. Take all medication as
directed. Follow up in Otolaryngology (ENT) Clinic in
***
Endaural Tympanoplasty/Ossiculoplast [132073]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Sinus precautions: No nose blowing, no ear
popping/pressurization, sneeze with open mouth. No
strenuous activity, lifting > 10 lb for 2 weeks. No
plane flights, scuba diving for one month.
Page 7 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 7/31/2017 1:47:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Wound Care [NURWND0015] Routine, Remove mastoid dressing after 24 hours.
Mastoid dressing may be worn at night for comfort.
Patient can shower after 48 hours. Do not submerge
incision (tub/pool). Apply bacitracin to incision twice
a day for one week. Start ear drops twice a day once
ear canal packing removed. Keep water out of ear
canal. Use a Vaseline-coated cotton ball in the ear
canal/bowl during showering to keep water out.
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. Follow up with
Otolaryngology (ENT) Clinic in one week for packing
removal and again in six weeks with an audiogram.
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops tomorrow
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops 1 week before
your follow up appointment
Endolymphatic Sac Decompression/Shunt
[132075]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Sinus precautions: No nose blowing, no ear
popping/pressurization, sneeze with open mouth. No
strenuous activity, lifting > 10 lb for 2 weeks.
Wound Care [NURWND0015] Routine, Remove mastoid dressing after 24 hours.
Mastoid dressing may be worn at night for comfort.
Patient can shower after 48 hours. Do not submerge
incision (tub/pool). Gently wash, dry area of incision
in shower. Apply bacitracin to incision twice a day for
one week.
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. Follow up in one
month in Otolaryngology (ENT) Clinic.
Middle Fossa Craniotomy for acoustic neuroma,
vestibular nerve section, facial nerve
decompression [132076]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Sinus precautions: No nose blowing, no ear
popping/pressurization, sneeze with open mouth. No
strenuous activity, lifting > 10 lb for 2 weeks. Avoid
straining with bowel movements - use rectal
suppository PRN (Dulcolax). No driving for at least
two weeks. Fall risk - avoid heights, ladders for > 1
month or when significant balance compensation
has occurred.
Wound Care [NURWND0015] Routine, Remove mastoid/craniotomy dressing after
5 days then patient can shower. Do not submerge
incision (tub/pool). Gently wash, dry area of incision
in shower. Apply bacitracin to incision twice a day for
one week
Page 8 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 7/31/2017 1:47:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

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. Follow up on your
postoperative day ten in Otolaryngology (ENT) Clinic
for suture removal and again in one month in
Otolaryngology (ENT) Clinic with audiogram.
Stapedotomy [132079]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Sinus precautions: No nose blowing, no ear
popping/pressurization, sneeze with open mouth. No
strenuous activity, lifting > 10 lb for 2 weeks. No
plane flights, scuba diving for one month.
Wound Care [NURWND0015] Routine, Remove cotton ball and start ear drops on
postoperative day one. Keep water out of ear canal.
Use a Vaseline-coated cotton ball in the ear
canal/bowl during showering to keep water out.
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. Follow up with
Otolaryngology (ENT) Clinic in 6 weeks with an
audiogram.
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops tomorrow
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops 1 week before
your follow up appointment
Translabyrinthine/Transcochlear/Transotic
Resection of CPA mass or Glomus Tumor
Removal (Infratemporal Fossa Approach) or
Temporal Bone Resection (Carcinoma) [132080]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Sinus precautions: No nose blowing, no ear popping,
pressurization, sneeze with open mouth. No
strenuous activity, lifting > 10 lb for 2 weeks. Avoid
straining with bowel movements - use rectal
suppository PRN (Dulcolax). No driving for at least
two weeks. Fall risk - avoid heights, ladders for > 1
month or when significant balance compensation
has occurred.
Wound Care [NURWND0015] Routine, Remove mastoid dressing after 5 days then
patient can shower. Mastoid dressing may be worn
at night for comfort. Do not submerge incision
(tub/pool). Gently wash, dry area of incision in
shower. Keep water out of ear canal. Use a
Vaseline-coated cotton ball in the ear canal/bowl
during showering to keep water out. Apply bacitracin
to incision twice a day for one week.
Page 9 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 7/31/2017 1:47:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

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.Follow up in clinic
in 10-14 days for suture removal. Follow up on one
month with Otolaryngology (ENT) Clinic.
Tympanoplasty POST-
AURICULAR /Ossiculoplasty/Exploratory
Tympanotomy [132081]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Sinus precautions: No nose blowing, no ear
popping/pressurization, sneeze with open mouth. No
strenuous activity, lifting > 10 lb for 2 weeks. No
plane flights, scuba diving for one month.
Wound Care [NURWND0015] Routine, Remove mastoid dressing and canal cotton
ball after 24 hours. Mastoid dressing may be worn at
night for comfort. Patient can shower after 48 hours.
Do not submerge incision (tub/pool). Gently wash,
dry area of incision in shower. Apply bacitracin to
incision twice a day for one week. Start ear drops
once mastoid dressing off. Keep water out of ear
canal. Use a Vaseline-coated cotton ball in the ear
canal/bowl during showering to keep water out.
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. Follow up with
Otolaryngology (ENT) Clinic in six weeks with an
audiogram.
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops tomorrow
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops 1 week before
your follow up appointment
Tympanoplasty
TRANSCANAL/Ossiculoplasty/Exploratory
Tympanotomy [132083]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Sinus precautions: No nose blowing, no ear
popping/pressurization, sneeze with open mouth. No
strenuous activity, lifting > 10 lb for 2 weeks. No
plane flights, scuba diving for one month.
Wound Care [NURWND0015] Routine, Remove cotton ball and start ear drops on
postoperative day one. Patient can shower after 48
hours. Do not submerge incision (tub/pool). Gently
wash, dry area of incision in shower. Apply bacitracin
to incision twice a day for one week. Start ear drops
once mastoid dressing off. Keep water out of ear
canal. Use a Vaseline-coated cotton ball in the ear
canal/bowl during showering to keep water out.
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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. Follow up with
Otolaryngology (ENT) Clinic in six weeks with an
audiogram.
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops tomorrow
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops 1 week before
your follow up appointment
Tympanoplasty [132084]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
Sinus precautions, cough and sneeze with your
mouth open, avoid nose blowing. No strenuous
activity, lifting > 10 lb for 2 weeks. No plane flights,
scuba diving for one month.
Wound Care [NURWND0015] Routine, Keep water out of ear canal. Use a
Vaseline-coated cotton ball in the ear canal/bowl
during showering to keep water out. If you have a
mastoid dressing over the ear, then do not shower
until it is removed or until 48 hours has elapsed from
the time of your surgery, whichever happens last.
Change cotton ball as needed.
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. Follow up with
Otolaryngology (ENT) Clinic in approximately 1-2
months with a hearing test.
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops tomorrow
Ear Drops [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Start ear drops 1 week before
your follow up appointment
Nutrition [132038]
Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Respiratory [132039]
Home Oxygen [DC0006] This order should NOT be used for Home Oxygen,
CPAP, BiPAP, Nebulizers, or Cough Assist Machines.
There are separate orders available for these items.,
Routine
Type (Each Agency Requires a Separate Order):
Oxygen
Diagnosis:
Supplies:
Vendor:
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Schedule Appointment With Sleep Lab
[NURCOM0026]
Reason for Hospital Follow Up Appointment: To
determine if patient has sleep apnea which needs to
be treated with night CPAP
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Sleep Lab
Bowel Care [132042]
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 Patient Care Instructions [132043]
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 [132044]
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
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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 Referrals
Follow-Up Appointments - Cardiac Rehab (Single Response) [132045]
Outpatient Cardiac Rehab is recommended. Please select one of the following.
Referral Cardiac Rehab (Outpatient) [CON0174] All patients being discharged from UWHC IP CVM
with the following diagnoses should receive a referral
to cardiac rehab: Acute Myocardial Infarction (i.e. all
STEMI or NSTEMI patients), Stable Angina, Coronary
Artery Bypass Surgery, Valve Surgery (repair or
replacement), Percutaneous Coronary Angioplasty or
Stenting, or Heart Transplant, or Stable Congestive
Heart Failure.
Typically, outpatient cardiac rehab follow-up
appointments occur 3-4 weeks post-hospitalization.
Inpatient Preventive Cardiology staff clinicians will
refer and make arrangements for the patient. If you
have further questions, you may call them at 263-
6630.
Routine
Has this patient been seen by inpatient Cardiac
Rehab/Preventive Cardiology during this encounter?
Reason Cardiac Rehab Not Ordered [COR0027] Routine
Reason Not Ordered:
Follow-Up Appointments - Cardiac Rehab [132046]
Page 13 of 19
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Referral Cardiac Rehab (Outpatient) [CON0174] All patients being discharged from UWHC IP CVM
with the following diagnoses should receive a referral
to cardiac rehab: Acute Myocardial Infarction (i.e. all
STEMI or NSTEMI patients), Stable Angina, Coronary
Artery Bypass Surgery, Valve Surgery (repair or
replacement), Percutaneous Coronary Angioplasty or
Stenting, or Heart Transplant, or Stable Congestive
Heart Failure.
Typically, outpatient cardiac rehab follow-up
appointments occur 3-4 weeks post-hospitalization.
Inpatient Preventive Cardiology staff clinicians will
refer and make arrangements for the patient. If you
have further questions, you may call them at 263-
6630.
Routine
Has this patient been seen by inpatient Cardiac
Rehab/Preventive Cardiology during this encounter?
Follow-Up Care
Follow-Up Apoointments [132047]
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]
*** 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
Page 14 of 19
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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.
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.
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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 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.
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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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 [132048]
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 17 of 19
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@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.
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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Labs [132049]
Consulting Provider will lab orders should only be used if the current Attending Provider or These
lab.be responsible for the result of the
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:11/30/17 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:9/1/18 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:11/30/17 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:11/30/17 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:9/1/18 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:11/30/17 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:11/30/17 MANUAL,Count:1,
Normal, Routine
BILIRUBIN, TOTAL [TBIL] Status: Standing, Expires:11/30/17 MANUAL,Count:1,
Normal, Routine
PROTEIN, TOTAL [TP] Status: Standing, Expires:11/30/17 MANUAL,Count:1,
Normal, Routine
ALBUMIN [ALB] Status: Standing, Expires:11/30/17 MANUAL,Count:1,
Normal, Routine
ALKALINE PHOSPHATASE [ALKP] Status: Standing, Expires:11/30/17 MANUAL,Count:1,
Normal, Routine
AST/SGOT [AST] Status: Standing, Expires:9/1/18 MANUAL,Count:1,
Normal, Routine
ALT/SGPT [ALT] Status: Standing, Expires:9/1/18 MANUAL,Count:1,
Normal, Routine
Imaging [132050]
X-RAY CHEST AP VIEW [R71010] Status: Future, Expires: 9/30/2018, Normal, Routine
CT HEAD W & W/ O IV CONTRAST [R70470] Status: Future, Expires: 9/30/2018, Normal, Routine
Page 19 of 19
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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