/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/general-surgery/,

/clinical/cckm-tools/content/order-sets/inpatient/general-surgery/name-104337-en.cckm

201612362

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,General Surgery

IP - Congenital Diaphragmatic Hernia - Neonatal - Admission [5726]

IP - Congenital Diaphragmatic Hernia - Neonatal - Admission [5726] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, General Surgery


IP - Congenital Diaphragmatic Hernia - Neonatal - Admission [5726]
and Treatment of Congenital Diaphragmatic HerniaManagement Refer to Guideline:
Management and Treatment of Congenital
Diaphragmatic Hernia
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/?
path=/content/cpg/neonatology/name-101114-
en.cckm
Admission Status
Level of Care (Single Response) [186484]
*An admit patient order has already been written, but the level of care at which the patient
should be placed still needs to be identified.
Place Patient on General Care [ADT0018] General Care, has already been signed. This order
will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intermediate Care (IMC)
[ADT0018]
Intermediate Care, has already been signed. This
order will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intensive Care (ICU) [ADT0018] Intensive Care, has already been signed. This order
will ensure that the patient is placed at the
appropriate level of care.
Admit to Inpatient (Single Response) [188296]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically
necessary because of either an anticipated LOS >2
midnights, complexity and/or severity of illness, an
inpatient-only surgery, or a previously-authorized
inpatient stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [151587]
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Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS: Critical Care
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [82665]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Patient Care Orders
Vital Signs [209527]
Vital Signs [NURMON0013] EVERY 1 HOUR, Starting today, Routine
Temperature Measurement Method: Other
(Comment) (Skin Servo)
Temperature Measurement Restrictions: No Rectal
Temps
BP Source: Invasive
BP Location: Arterial
BP Position:
BP Restrictions:
Page 2 of 34
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Vital Signs [NURMON0013] 2X DAILY, Routine
Temperature Measurement Method: Axillary
Temperature Measurement Restrictions: No Rectal
Temps
BP Source: Automated (Monitor more frequently if
poorly correlated with invasive.)
BP Location:
BP Position:
BP Restrictions:
Patient Monitoring [209524]
Assess Physiologic Systems [NURCOM0022] SEE COMMENTS, Every 4-6 Hours with focused
assessments as needed.
Pulse Oximetry [NURMON0009] CONTINUOUS, Routine, Measure oxygen saturation
pre- and post-ductal.
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [139419]
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [NURMON0014]
CONTINUOUS, Routine, Most pediatric patients do
NOT require rhythm analysis. Please complete the
Notify Provider order below, including specification
for apnea > *** seconds. If indicated, order pulse
oximetry separately.
Device Present:
Device Mode:
Device Low Rate Limit (BPM):
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Notify [NURCOM0001] Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds
Measure Cerebral Oximetry (NIRS)
[NURMON0097]
CONTINUOUS, Routine
Measure Somatic Oximetry (NIRS)
[NURMON0098]
CONTINUOUS, Routine
Use Radiant Warmer [NURTRT0026] CONTINUOUS, Routine, Maintain axillary
temperature of 36.5 to 37.5 degrees Celsius. Hourly
bed set temperatures and skin temperatures.
Avoid Routine Pupil Checks. Complete Only On
Admission Or With Acute Changes
[NURCOM0022]
CONTINUOUS
Measure Weight [NURMON0015] SEE COMMENTS, Routine
Weigh With?
Weigh when?
Measure on admission. No daily weights.
Nutrition [209529]
Diet - Custom [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Neonatal
NPO: STRICT NPO
Infant Nutrition Primary:
Infant Nutrition Secondary:
Fortification:
Calories per Ounce:
Route:
Route (Comments):
Frequency:
Frequency (Comments):
Total Volume per Feeding (mL):
Page 3 of 34
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Use Human Milk for Oral Cares [NURCOM0022] CONTINUOUS, Use human milk for oral care, even
for patients who are NPO, unless otherwise specified
or patient does not tolerate.
Respiratory [209523]
Mechanical Ventilation - Pediatric [209560]
Chlorhexidine.patients 6 years and older SELECT the order for For
chlorhexidine (PERIDEX) 0.12 % soln
MULTIDOSE - NOTE: For Patients 6 years of
age or older [792004]
15 mL, Mouth/Throat, 2 X DAILY
Use to swab oral cavity. D/C when patient no
longer on ventilation.
Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Routine
Mechanical Ventilation - Peds [RT0090] CONTINUOUS, Routine, For ADULT patients order
chlorihexidene gluconate (PERIDEX) 0.12% soln
15 mL to swab oral cavity 2x daily while on
ventilation.
Ventilator Management: Per MD
Wean Peds: Per MD
Mode: SIMV+PC
Set Rate/Min:
Tidal Volume Multiplier: (no target tidal volume for
CDH patients)
PEEP (cmH2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Pressure Support:
Pressure Control:
P High (cmH20):
P Low (PEEP) (cmH20):
T High (sec):
T Low (T PEEP) (sec):
PS above P High (cmH2O):
PS above PEEP (cmH2O):
NAVA Level (µV):
Suggested Initial Settings:
PIP 15-25 cm H20
PEEP 3-5 cm H20
RR 40 – 60 breaths/minute
iT 0.3 – 0.5
FiO2 – titrate to keep pre-ductal saturation > 95%
artificial tears PF ophthalmic ointment [157764] Eyes (Each), PRN, Irritation
Adminster to each eye every 2-4 hours as needed.
For use while patient is mechanically ventilated and
sedated. Please refer to ocular care algorithm.
Ventilator Associated Pneumonia (VAP
Precautions) [NURCOM0022]
SEE COMMENTS, Ventilator Associated
Pneumonia Precautions
Suction Airway [NURTAD0017] PRN, Routine
Location: Tracheal
Avoid routine suctioning unless agreed upon by the
medical team.
ETCO2 Monitoring [RT0006] CONTINUOUS, Routine
Non-Categorized Patient Care Orders [208818]
Minimize Stimulation [NURCOM0022] CONTINUOUS, Dimly lit room. Noise Reduction.
Consider phototherapy mask and earmuffs.
Cluster All Cares [NURCOM0022] CONTINUOUS, Coordinate all care whenever
possible including respiratory therapy, nursing, and
MD.
No Baths [NURCOM0022] CONTINUOUS
Page 4 of 34
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No Routine Bedding Changes [NURCOM0022] CONTINUOUS
Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Routine
Options: Low, Intermittent Suction
Flush with: Normal saline
Flush Frequency: EVERY 4-6 HOURS
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed? Yes
Device Status:
Replogle tube 10 french
Intravenous Therapy
IV Fluids [209530]
dextrose 10 %, amino acids (TROPHAMINE) 3.5
%, heparin 0.5 Units/mL in water (sterile)
[700637]
Intravenous, CONTINUOUS
dextrose 10 % infusion [36626] Intravenous, CONTINUOUS
heparin in sodium chloride 0.9 % 50 mL patency
line - intravenous [700923]
Intravenous, CONTINUOUS
heparin in sodium chloride 0.9 % 50 mL patency
line - intrarterial [700923]
Intraarterial, CONTINUOUS
Note: Total Fluid Goal of 80 mL/kg/day [950018] 4 X DAILY (NOTE ACKNOWLEDGE)
Premedication for Needle Insertion [209531]
Lidocaine [152737]
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, prior to needle
sticks to reduce pain. See "LMX Use Instructions"
order in Active Orders report or the Admin
Instructions for application details
FOR PATIENTS 5 Kg OR LESS: Do NOT apply to
area greater than 100 square centimeters.
(maximum 1 g/site; maximum 1 site per hour, 6
times per day).
FOR PATIENTS 5.1-10 Kg: Do NOT apply to area
greater than 100 square centimeters. (maximum 1
g/site; maximum 2 sites per hour, 6 times per day).
FOR PATIENTS GREATER THAN 10 Kg: Do NOT
apply to area greater than 200 square centimeters.
(maximum 2.5 g/site; maximum 4 sites per hour, 6
times per day).
For patients less than 1 year old do NOT leave on
longer than 1 hour. For patients 1 year or older do
NOT leave on longer than 2 hours
LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Details
Medications
Opioids (Single Response) [209525]
Morphine [209561]
MORPHine infusion PEDS [800156] 0.01-0.05 mg/kg/hr, Intravenous, CONTINUOUS
Titrate per Peds ICU Analgesia/Sedation protocol.
Initiate per protocol or current rate and titrate to
sedation goal.
MORPHine PF injection [800122] 0.1 mg/kg, Intravenous, EVERY 2 HOURS PRN,
pain, agitation
Page 5 of 34
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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Fentanyl [209562]
FENTanyl infusion PEDS [800143] 1-2 mcg/kg/hr, Intravenous, CONTINUOUS
Titrate per Peds ICU Analgesia/Sedation protocol.
Initiate per protocol or current rate and titrate to
sedation goal.
FENTanyl PF injection [800187] 1 mcg/kg, Intravenous, EVERY 2 HOURS PRN,
pain, agitation
Sedatives (Single Response) [209532]
midazolam (VERSED) injection [800197] 0.1 mg/kg, Intravenous, EVERY 2 HOURS PRN,
sedation
lorazepam (ATIVAN) injection [800053] 0.1 mg/kg, Intravenous, EVERY 6 HOURS PRN,
agitation
dexmedetomidine (PRECEDEX) infusion PEDS
[800135]
0.5-1.5 mcg/kg/hr, Intravenous, CONTINUOUS
Titrate per Peds ICU Analgesia/Sedation protocol.
Initiate per protocol or current rate and titrate to
sedation goal.
Vasoactive Agents [208828]
DOPamine (INTROPIN) infusion PEDS [800137] 3-25 mcg/kg/min, Intravenous, CONTINUOUS
Titrate per provider direction. Initiate at ***
mcg/kg/min or current rate. Adjust by *** mcg/kg/min
every *** minutes to maintain MAP between *** to ***
mmHg.
Central line preferred, however,
peripheral/intraosseous access may be used when
benefit outweighs risks
If MAP below goal at 25 mcg/kg/min, Notify MD
milrinone (PRIMACOR) infusion PEDS [800155] 0.5 mcg/kg/min, Intravenous, CONTINUOUS
Do NOT titrate
Central line preferred, however,
peripheral/intraosseous access may be used when
benefit outweighs risks
Typical dose range 0.25-0.75 mcg/kg/min
epiNEPHrine infusion PEDS [800138] 0.02-0.2 mcg/kg/min, Intravenous, CONTINUOUS
Titrate per provider direction. Initiate at ***
mcg/kg/min or current rate. Adjust by *** mcg/kg/min
every *** minutes to maintain MAP between *** to ***
mmHg.
Central line preferred, however,
peripheral/intraosseous access may be used when
benefit outweighs risks
(PEDS-SHOCK) vasopressin (PITRESSIN)
infusion [800170]
0.3-2 milli-units/kg/min, Intravenous, CONTINUOUS
Titrate per provider direction. Initiate at 0.5
mcg/kg/min or current rate. Adjust by *** mcg/kg/min
every *** minutes to maintain MAP between *** to ***
mmHg
alprostadil (PROSTIN VR) infusion PEDS
[800127]
Intravenous, CONTINUOUS
Change syringe every day at 1800 with other line
changes
Resuscitation [209544]
atropine injection - Minimum dose of 0.1 mg
[760347]
0.02 mg/kg, Intravenous, ONCE PRN For 1 Doses,
bradycardia
Minimum dose of 0.1 mg
for 1 Minutes
Page 6 of 34
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calcium CHLOride injection 20 mg/kg -
(Maximum Dose = 1 gram) [800104]
20 mg/kg, Intravenous, ONCE PRN For 1 Doses,
emergency resuscitation. To be given only with
physician confirmation that PRN criteria have been
met
epINEPHrine (CARDIAC 1:10,000) PEDS 0.1
mg/mL injection CUSTOM [760293]
10 mcg/kg, Intravenous, ONCE PRN For 1 Doses,
emergency resuscitation. To be given only with
physician confirmation that PRN criteria have been
met
sodium bicarbonate injection [800214] 0.5 mEq/kg, Intravenous, ONCE PRN For 1 Doses,
emergency resuscitation. To be given only with
physician confirmation that PRN criteria have been
met
Birth Medications [148434]
erythromycin (ROMYCIN) ophthalmic ointment
[37228]
Eyes (Each)
phytonadione (VITAMIN K1) injection - For
infants < 1.5 kg [800219]
0.3 mg/kg, Intramuscular, ONCE For 1 Doses
phytonadione (VITAMIN K1) injection - For
infants 1.5 kg or more [800219]
1 mg, Intramuscular, ONCE For 1 Doses
Non-categorized [208837]
calcium CHLOride intraVENOUS [800104] 10 mg/kg, Intravenous, ONCE For 1 Doses
calcium GLUConate intraVENOUS [800105] 100 mg/kg, Intravenous, ONCE For 1 Doses
rocuronium (ZEMURON) injection [800213] 1 mg/kg, Intravenous, EVERY 1 HOUR PRN,
movement
Laboratory
Whole Blood Testing on Unit [209545]
Glucose, POC [IPGLUCOSE] SEE COMMENTS, Routine, Glucose, POC should
always be ordered in conjunction with orders for
hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Obtain with every lab draw and signs/symptoms of
hypo/hyperglycemia. May result on Nova meter or
ABL90 Blood Gas Analyzer.
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL - RN COLLECT For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
With every Whole Blood lab draw
BLOOD GASES AND O2 SATURATION
[HCBGASOS]
STAT - RN COLLECT For 1 Occurrences, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES, WHOLE BLOOD
[HCWBLYTS]
STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM, IONIZED, WHOLE BLOOD
[HCWBICA]
STAT - RN COLLECT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 7 of 34
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HEMOGLOBIN, WHOLE BLOOD [HCWBHGB] STAT - RN COLLECT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LACTATE [GM2255] STAT - RN COLLECT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL, WHOLE BLOOD
[HCWBTBIL]
STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Must send tube to core lab
Labs [209546]
BUN [BUN] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALBUMIN [ALB] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTEIN, TOTAL [HCGTSP] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] SPECIFIC TIME - RN COLLECT For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, DIRECT [DBIL] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
AST/SGOT [AST] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 8 of 34
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
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ALKALINE PHOSPHATASE [ALKP] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
C REACTIVE PROTEIN [CRPN] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
NEONATAL SCREEN [NEOSCR] SPECIFIC TIME - RN COLLECT For 1 Occurrences,
Routine, This test is to be used for a complete
Wisconsin State Newborn Screen. Do not use to
order other testing to be collected using dried blood
spots.
Last patient weight? (will auto pull in value and date in
comment):
Has pt EVER been transfused? (If YES enter date of
last transfusion below):
Date of Last Transfusion:
Date of last newborn screen:
Timing of Collection (See WSLH Collection Info
reference link below):
CBC WITHOUT DIFFERENTIAL [HEMO] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITH DIFFERENTIAL [CBC] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
URINALYSIS WITH MICROSCOPY [UA] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Cultures [148227]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
STAT - RN COLLECT For 1 Occurrences, Routine,
For optimum diagnosis of sepsis, sample 3-4 sites
only on the first day of a septic episode. Cultures on
subsequent days are of minimal diagnostic value.
Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture,
Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
ONCE For 1 Occurrences, Routine, For patients with
an ET tube or tracheostomy, quantitative mini-BAL by
RT or bronchoscopic BAL are the preferred methods
of specimen collection.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 9 of 34
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CULTURE, URINE WITH GRAM STAIN
[HCURNCS]
ONCE For 1 Occurrences, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MRSA BY PCR [HCMRSA] CONDITIONAL - RN COLLECT For 7 Days, Routine,
There is no need to obtain repeated surveillance tests
to clear patients from MRSA isolation. Once a patient
is flagged as MRSA positive it will remain in the
HealthLink header indefinitely.
For NICU patients: left and right nares only.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Perform on all patients. Patient must be 48 hours of
age for initial screen.
NICU Nutrition Lab Panel [144336]
NICU Nutrition Lab Panel [144324]
BUN [BUN] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
CALCIUM [CA] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
AST/SGOT [AST] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
GLUCOSE [GLU] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
BILIRUBIN, DIRECT [DBIL] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
Page 10 of 34
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ALBUMIN [ALB] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
ALKALINE PHOSPHATASE [ALKP] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
TRIGLYCERIDE [TRIG] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
GGT [GGT] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
C REACTIVE PROTEIN [CRPN] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
Coagulation [144339]
PROTHROMBIN TIME/INR [PT] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PTT [PTT] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FIBRINOGEN [GM1320] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
D-DIMER, QUANT [GM1332] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FIBRIN MONOMER [HCFIBMON] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Blood Bank
Tests [144387]
TYPE AND SCREEN, NEONATAL [HCNTS] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Red Blood Cells (Single Response) [214405]
Page 11 of 34
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

indication below.Select
PR1-(Patient younger than 4 months) Acute
blood loss or anticipated surgical blood loss
[214406]
Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PR1 (Patient younger than 4
months) Acute blood loss or anticipated surgical
blood loss
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently
urgent to require release of blood before
completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any
injuries resulting from release of blood before such
testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
PR2-(Patient younger than 4 months) Target
Hemoglobin > 7 g/dL or Hematocrit > 21% in
stable patient with signs of anemia (RA or nasal
cannula with FiO2 < 25%, and reticulocyte count
< 4%) [214407]
Page 12 of 34
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PR2 (Patient younger than 4
months) Target Hemoglobin > 7 g/dL or Hematocrit
> 21% in stable patient with signs of anemia (RA or
nasal cannula with FiO2 < 25%, and reticulocyte
count < 4%)
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently
urgent to require release of blood before
completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any
injuries resulting from release of blood before such
testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
PR3-(Patient younger than 4 months) Target
Hemoglobin > 8 g/dL or Hematocrit > 24% with
mild lung disease, NC/CPAP/NIPPV with FiO2 <
40%, and signs of poor oxygenation [214408]
Page 13 of 34
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PR3 (Patient younger than 4
months) Target Hemoglobin > 8 g/dL or Hematocrit
> 24% with mild lung disease, NC/CPAP/NIPPV
with FiO2 < 40%, and signs of poor oxygenation
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently
urgent to require release of blood before
completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any
injuries resulting from release of blood before such
testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
PR4-(Patient younger than 4 months) Target
Hemoglobin > 10 g/dL or Hematocrit > 30% with
severe lung disease, intubated or on
nasopharyngeal synchronized intermittent
mandatory ventilation with FiO2 > 40%,
congenital heart disease, and/or prematurity
[214421]
Page 14 of 34
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PR4 (Patient younger than 4
months) Target Hemoglobin > 10 g/dL or
Hematocrit > 30% with severe lung disease,
intubated or on nasopharyngeal synchronized
intermittent mandatory ventilation with FiO2 > 40%,
congenital heart disease, and/or prematurity
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently
urgent to require release of blood before
completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any
injuries resulting from release of blood before such
testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
PR5-Acute blood loss or anticipated surgical
blood loss [214425]
Page 15 of 34
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PR5 Acute blood loss or
anticipated surgical blood loss
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently
urgent to require release of blood before
completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any
injuries resulting from release of blood before such
testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
PR6-Target Hemoglobin > 7 g/dL or Hematocrit >
21% [214426]
Page 16 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PR6 Target Hemoglobin > 7
g/dL or Hematocrit > 21%
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently
urgent to require release of blood before
completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any
injuries resulting from release of blood before such
testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
PR7-Signs of poor oxygen delivery or target
Hemoglobin > 10 g/dL or Hematocrit > 30% in
patients with severe pulmonary disease requiring
assisted ventilation or congenital heart disease
[214427]
Page 17 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PR7 Signs of poor oxygen
delivery or target Hemoglobin > 10 g/dL or
Hematocrit > 30% in patients with severe
pulmonary disease requiring assisted ventilation or
congenital heart disease
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently
urgent to require release of blood before
completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any
injuries resulting from release of blood before such
testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
PR8-Chronic transfusions in selected patients
with Sickle Cell or thalassemia syndromes OR
partial exchange or exchange transfusion
[214428]
Page 18 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PR8 Chronic transfusions in
selected patients with Sickle Cell or thalassemia
syndromes OR partial exchange or exchange
transfusion
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently
urgent to require release of blood before
completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any
injuries resulting from release of blood before such
testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
PR9-Massive Transfusion Procedure [214429]
Page 19 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PR9 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently
urgent to require release of blood before
completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any
injuries resulting from release of blood before such
testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
PR10-Other [214430]
Page 20 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PR10 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently
urgent to require release of blood before
completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any
injuries resulting from release of blood before such
testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
Plasma (Single Response) [214461]
indication below.Select
PF1-Elevated INR with active bleeding or
anticipated major surgery/invasive procedure
[214434]
Plasma (Neonatal) [BLB0024] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PF1 Elevated INR with active
bleeding or anticipated major surgery/invasive
procedure
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Page 21 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Plasma (Neonatal) [NURTRT0071] TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PF2-Pump prime in pediatric open heart surgery
as appropriate for neonates and lower weight
pediatric patients [214437]
Plasma (Neonatal) [BLB0024] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PF2 Pump prime in pediatric
open heart surgery as appropriate for neonates and
lower weight pediatric patients
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Transfuse Plasma (Neonatal) [NURTRT0071] TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PF3-Replacement therapy for hemostatic factor
deficiencies if concentrate not available [214441]
Plasma (Neonatal) [BLB0024] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PF3 Replacement therapy for
hemostatic factor deficiencies if concentrate not
available
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Transfuse Plasma (Neonatal) [NURTRT0071] TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PF4-Disseminated intravascular coagulation with
active bleeding [214442]
Page 22 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Plasma (Neonatal) [BLB0024] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PF4 Disseminated intravascular
coagulation with active bleeding
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Transfuse Plasma (Neonatal) [NURTRT0071] TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PF5-Immediate reversal of warfarin effect for
emergency surgery or active bleeding (in
combination with vitamin K) [214443]
Plasma (Neonatal) [BLB0024] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PF5 Immediate reversal of
warfarin effect for emergency surgery or active
bleeding (in combination with vitamin K)
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Transfuse Plasma (Neonatal) [NURTRT0071] TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PF6-Massive Transfusion Procedure [214444]
Plasma (Neonatal) [BLB0024] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PF6 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Page 23 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Plasma (Neonatal) [NURTRT0071] TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PF7-Other [214445]
Plasma (Neonatal) [BLB0024] < 1 UNIT For 1 Occurrences, Routine
Reason for Order: PF7 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Transfuse Plasma (Neonatal) [NURTRT0071] TRANSFUSE < 1 UNIT For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
Platelets (Single Response) [214462]
indication below.Select
PP1-Target Platelets > 20 K/µL in a stable
premature infant (GA < 37 weeks) [214446]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
Reason for Order: PP1 Target Platelets > 20 K/µL
in a stable premature infant (GA < 37 weeks)
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Page 24 of 34
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Platelets (Neonatal) [NURTRT0072] TRANSFUSE < 1 SINGLE DONOR UNIT For 1
Occurrences, Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP2-Target Platelets > 30 K/µL in a sick
premature infant (GA < 37 weeks) or minor signs
of bleeding [214447]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
Reason for Order: PP2 Target Platelets > 30 K/µL
in a sick premature infant (GA < 37 weeks) or minor
signs of bleeding
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] TRANSFUSE < 1 SINGLE DONOR UNIT For 1
Occurrences, Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP3-Target Platelets > 50 K/µL and extreme
prematurity (GA < 37 weeks) at high risk for IVH
or neonatal encephalopathy [214448]
Page 25 of 34
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
Reason for Order: PP3 Target Platelets > 50 K/µL
and extreme prematurity (GA < 37 weeks) at high
risk for IVH or neonatal encephalopathy
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] TRANSFUSE < 1 SINGLE DONOR UNIT For 1
Occurrences, Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP4-Target Platelets > 10 K/µL in a non-bleeding
patient with failure of platelet production [214449]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
Reason for Order: PP4 Target Platelets > 10 K/µL
in a non-bleeding patient with failure of platelet
production
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Page 26 of 34
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Platelets (Neonatal) [NURTRT0072] TRANSFUSE < 1 SINGLE DONOR UNIT For 1
Occurrences, Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP5-Target Platelets > 20 K/µL in a non-bleeding
patient with failure of platelet production and risk
factors (sepsis, fever, coagulopathy, etc.)
[214450]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
Reason for Order: PP5 Target Platelets > 20 K/µL
in a non-bleeding patient with failure of platelet
production and risk factors (sepsis, fever,
coagulopathy, etc.)
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] TRANSFUSE < 1 SINGLE DONOR UNIT For 1
Occurrences, Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP6-Target Platelets > 50 K/µL with failure of
platelet production AND active bleeding OR need
for an invasive procedure [214451]
Page 27 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
Reason for Order: PP6 Target Platelets > 50 K/µL
with failure of platelet production AND active
bleeding OR need for an invasive procedure
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] TRANSFUSE < 1 SINGLE DONOR UNIT For 1
Occurrences, Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP7-Significant bleeding in a patient with a
qualitative platelet defect, regardless of platelet
count [214452]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
Reason for Order: PP7 Significant bleeding in a
patient with a qualitative platelet defect, regardless
of platelet count
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Page 28 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Platelets (Neonatal) [NURTRT0072] TRANSFUSE < 1 SINGLE DONOR UNIT For 1
Occurrences, Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP8-Target Platelets > 75 K/µL in a non-bleeding
patient on ECMO [214453]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
Reason for Order: PP8 Target Platelets > 75 K/µL
in a non-bleeding patient on ECMO
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] TRANSFUSE < 1 SINGLE DONOR UNIT For 1
Occurrences, Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP9-Target Platelets > 100 K/µL with major
CNS/eye/cardiac surgery (for up to 48 hrs. post-
operatively) [214454]
Page 29 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
Reason for Order: PP9 Target Platelets > 100 K/µL
with major CNS/eye/cardiac surgery (for up to 48
hrs. post-operatively)
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] TRANSFUSE < 1 SINGLE DONOR UNIT For 1
Occurrences, Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP10-Massive Transfusion Procedure [214455]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
Reason for Order: PP10 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Page 30 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transfuse Platelets (Neonatal) [NURTRT0072] TRANSFUSE < 1 SINGLE DONOR UNIT For 1
Occurrences, Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP11-Other [214456]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
Reason for Order: PP11 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during
the first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] TRANSFUSE < 1 SINGLE DONOR UNIT For 1
Occurrences, Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
Cryoprecipitate (Single Response) [214463]
indication below.Select
PC1-Active bleeding OR anticipated major
surgery/invasive procedure (e.g., ECMO) with
fibrinogen < 100 mg/dL or dysfibrinogenemia
[214457]
Page 31 of 34
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Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Cryoprecipitate (Neonatal) [BLB0026] 1 UNIT For 1 Occurrences, Routine
Reason for Order: PC1 Active bleeding OR
anticipated major surgery/invasive procedure (e.g.,
ECMO) with fibrinogen < 100 mg/dL or
dysfibrinogenemia
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Transfuse Cryoprecipitate (Neonatal)
[NURTRT0073]
Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PC2-Factor XIII deficiency [214458]
Cryoprecipitate (Neonatal) [BLB0026] 1 UNIT For 1 Occurrences, Routine
Reason for Order: PC2 Factor XIII deficiency
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Transfuse Cryoprecipitate (Neonatal)
[NURTRT0073]
Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PC3-Massive Transfusion Procedure [214459]
Cryoprecipitate (Neonatal) [BLB0026] 1 UNIT For 1 Occurrences, Routine
Reason for Order: PC3 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Transfuse Cryoprecipitate (Neonatal)
[NURTRT0073]
Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PC4-Other [214460]
Page 32 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Cryoprecipitate (Neonatal) [BLB0026] 1 UNIT For 1 Occurrences, Routine
Reason for Order: PC4 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
Consent Status:
Total Volume to be transfused (mL):
Transfuse Cryoprecipitate (Neonatal)
[NURTRT0073]
Routine, Patient Weight
No data found for Wt
REMINDER: Call Blood Bank at 263-8367 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [209533]
X-RAY BABYGRAM (PEDS CHEST/ABD
COMBINED-LESS THAN 2 YEARS) [R07709]
ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
STAT
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Congenital
Diaphragmatic Hernia.
What specific question(s) would you like answered by
this exam? Evaluate tube placement, line placement,
lung volume.
Relevant recent/past history? Congenital
Diaphragmatic Hernia.
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
X-RAY CHEST AP VIEW [R71010] CONDITIONAL, STAT
Current signs and symptoms? Evaluate tube
placement, lung volumes
What specific question(s) would you like answered by
this exam? desaturation, tube dislodgment
Relevant recent/past history? Congenital
Diaphragmatic Hernia
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Page 33 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org

Transthoracic Resting Echocardiogram (PEDS)
[ECH0012]
Urgency:
Current signs and symptoms?
Relevant recent/past history?
What condition is suspected?
Is this the comprehensive post operation dishcharge
evaluation?
Do you want Agitated Bubble Study? No
|
aEEG [EEG0014] ONCE, Routine
Reason for Monitoring: Background and Seizures
Video EEG [EEG0008] ONCE, Routine
Reason for Monitoring:
Sleep deprived?
Duration:
Has a Neurology Consult been obtained? (If no,
obtain a Neurology Consult prior to ordering the
procedure):
BestPractice
No Hospital Problems Have Yet Been Identified. [209534]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
Page 34 of 34
Printed by LIND, JANNA S [JSL237] at 12/22/2016 11:06:34 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 12/2016CCKM@uwhealth.org