/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-98333-en.cckm

201712341

page

100

UWHC,UWMF,

Tools,

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

IP - General Trauma - General Care - Adult - Observation - Admission [4061]

IP - General Trauma - General Care - Adult - Observation - Admission [4061] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, General Surgery


IP - General Trauma - General Care - Adult - Observation - Admission [4061]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [187515]
*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 [109279]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service: TRAUMA SURGERY-ADULT
Admission Status [140854]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service: TRAUMA SURGERY-ADULT
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [136416]
Page 1 of 17
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:13:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Moderate VTE Risk with Low Bleed Risk
[209996]
enoxaparin (LOVENOX) injection [800040] 30 mg, Subcutaneous, EVERY 12 HOURS
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
Sequential Compression Device (SCD)
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
High VTE Risk with Low Bleed Risk [241260]
enoxaparin (LOVENOX) injection [800040] 30 mg, Subcutaneous, EVERY 12 HOURS
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
High Bleed Risk [237204]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis (Single Response) [150230]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Moderate VTE Risk with Low Bleed Risk
[209996]
enoxaparin (LOVENOX) injection [800040] 30 mg, Subcutaneous, EVERY 12 HOURS
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
Page 2 of 17
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:13:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Sequential Compression Device (SCD)
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
High VTE Risk with Low Bleed Risk [241263]
enoxaparin (LOVENOX) injection [800040] 30 mg, Subcutaneous, EVERY 12 HOURS
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
High Bleed Risk [237206]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs [109280]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every hour times 4, then every 4 hours times 2, then
every 8 hours.
Patient Monitoring [109282]
Assess Neurologic Status [NURMON0006] SEE COMMENTS, Starting today For Until specified,
Routine, Every hour times 4, then every 4 hours times
2, then every 8 hours.
Page 3 of 17
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Neurovascular Checks [NURMON0045] SEE COMMENTS, Starting today For Until specified,
Routine
Location:
Every hour times 4, then every 4 hours times 2, then
every 8 hours.
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
CONTINUOUS For 24 Hours, Routine
Indication: Other (Comment Required)
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Measure Weight [NURMON0015] ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
Immediately on admission
Measure Height [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine, On
admission
Maintain Chest Tube [NURTAD0001] CONTINUOUS, Starting today For Until specified,
Routine
Location:
Position: N/A - Single Location
Drainage Options:
Site Assessment Frequency:
Care Frequency:
Wash With:
Primary Dressing:
Secondary Dressing:
Location:
Activity [16324]
Bedrest [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: other (comment)
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Cervical Spine Precautions [PRECAU0005] CONTINUOUS, Starting today For Until specified,
Routine, Cervical Spine Precautions:
Cervical collar at all times.
No pillow behind head.
No lifting anything greater than 10 pounds.
No lifting of arms over head.
C-Spine Cleared [NURTRT0060] CONTINUOUS, Starting today, Routine
Thoracic/Lumbar Spine Precautions
[PRECAU0009]
CONTINUOUS, Starting today For Until specified,
Routine, Thoracic/Lumbar Spine Precautions:
Head of bed less than 30 degrees unless otherwise
stated.
Head of bed flat for log rolling side to side.
T/L-Spine Cleared [NURTRT0061] CONTINUOUS, Starting today, Routine
Page 4 of 17
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:13:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Bedrest Logroll [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: strict logroll
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Apply Brace, Spine [NURTRT0014] CONTINUOUS, Starting today, Routine
Type: Cervical Collar - soft
Wearing schedule:
No pillow under head if wearing cervical collar.
Chair 3 Times Daily [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR: 3x daily
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Ambulate 3 Times Daily [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE: 3x daily
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Ad Lib [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Page 5 of 17
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:13:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Weight Bearing Status [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Activity - Head of Bed (Single Response) [29990]
Order Head of Bed Flat for Patients with a Known Spine Fracture and the Spine Service has Deemed
Unstable.
Elevate Head Of Bed [NURACT0002] Equal to (degrees): 30
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today
Head of Bed Flat [NURACT0002] Equal to (degrees): 0
Greater than (degrees):
Less than (degrees):
Other options: At all times
Routine, CONTINUOUS, Starting today, Order head of
bed flat for patients with a known stable spine fracture
and the spine service has deemed unstable.
Nutrition [16350]
managementto "Tube Feeding Supplemental" order set for tube feeding Refer
NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Wired Jaw - Clear Liquids [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Clear Liquid
No Red or Purple Dye:
Liquid Thickness: Thin
Bedside Meal Instructions:
Room Service Class:
Mechanical Soft (Dental) Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Consistency
Solid Consistency: Mechanical Soft
Liquid Thickness:
Bedside Meal Instructions:
Room Service Class:
Nourishments & Supplements [NUT0005] EFFECTIVE NOW, Starting today, Routine
Medical Food / Oral Supplement(s):
Nourishment / Snack Item(s):
Schedule:
Page 6 of 17
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12/2017CCKM@uwhealth.org

General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Respiratory [109283]
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Respiratory Therapy per Spinal Cord Injury
Protocol [RT0035]
Routine
Protocol Type:
Oxygen Therapy [RT0032] CONTINUOUS, Starting today For Until specified,
Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device:
Attempt to Wean Off Oxygen? Yes
Pulse Oximetry [NURMON0009] SEE COMMENTS, Starting today For Until specified,
Routine, Every hour times 4, then every 4 hours times
2, then every 8 hours.
Incentive Spirometry [NURTRT0018] EVERY 1 HOUR, Routine
Cough And Deep Breathe [NURTRT0019] EVERY 1 HOUR, Routine
Wound Care [16327]
Nursing Communication [NURCOM0022] SEE COMMENTS, Starting today with First
Occurrence As Scheduled For Until specified, Vacuum
glass from hair then wash hair with shampoo and
water or 3-in-1 foam shampoo/skin immediately on
admission and as needed.
Wound Care [NURWND0015] CONTINUOUS, Starting today For Until specified,
Routine
Wound Type: Abrasion
Wound Site:
Wound Location:
Assess Frequency:
Care Frequency: 1X DAILY
Wash With: Soap and Water
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing:
Secondary Dressing:
Wash abrasions and lacerations with antibacterial
soap and water daily.
Intake and Output [109284]
Measure Intake And Output [NURMON0005] SEE COMMENTS, Starting today For Until specified,
Routine, Every hour times 4, then every 4 hours times
2, then every 8 hours.
Measure Caloric Intake [NURDIE0011] 1X DAILY, Starting today For Until specified, Routine
Non-Categorized Patient Care Orders [109285]
Glucose, POC [IPGLUCOSE] EVERY 6 HOURS, Starting today For 4 Occurrences,
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?
Page 7 of 17
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Oral Care [NURCOM0022] SEE COMMENTS, Starting today with First
Occurrence As Scheduled For Until specified, Every 8
hours.
NG Tube Placement - Adult [120994]
Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Routine
Options: Low, Intermittent Suction
Flush with:
Flush Frequency: EVERY 8 HOURS
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed?
Device Status:
Refer to Policy 2.20 Enteral Tubes Used for
Instillation of Fluids, Medications, or Feeding
Recommendations for flush quantity:
For adult patients, 30 mLs of fluid should be
sufficient.
lidocaine-oxymetazoline 4%-0.05% (ADULT)
nasal spray [785081]
2 spray, Nasal, ONCE For 1 Doses
For numbing prior to feeding tube insertion.
Slowly spray the chosen nostril once, if required may
repeat x1 in opposite nostril. Angle toward back of
throat spraying the anterior nostril and wait 30-60
seconds before introducing more local
anesthetic into the nostril. Caution: Entire bottle
should not be used for insertion of tube. Discard
excess solution when procedure completed.
X-RAY ABDOMEN AP VIEW (KUB) [R74000] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered
by this exam? Evaluate nasogastric tube placement
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date
in comment):
Transport Method: Floor Determined/Entered
If Conditional, What Condition? Evaluate nasogastric
tube placement. The location of nasogastric tube
should be confirmed prior to the instillation of fluids,
medications, or feedings. Refer to Policy 2.20
Enteral Tubes Used for Instillation of Fluids,
Medications, or Feeding
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today For Until specified,
Routine, To discontinue this order, enter a new order
for "Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes in
the new order.
Type: Indwelling Single Lumen
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Initiate Bladder Management Protocol
[NURELM0014]
CONTINUOUS, Routine
Page 8 of 17
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Feeding Tube Bedside Placement - Adult
[121915]
Feeding Tube Placement Request
[NURDIE0015]
ONCE, Routine
Feeding Tube Placement Reason:
Feeding Tube Placement:
Insertion Point:
Allow removal of existing orogastric or nasograstric
tube?
lidocaine-oxymetazoline 4%-0.05% (ADULT)
nasal spray [785081]
2 spray, Nasal, ONCE PRN For 36 Hours, feeding
tube placement
For numbing prior to feeding tube insertion.
Slowly spray the chosen nostril once, if required may
repeat x1 in opposite nostril. Angle toward back of
throat spraying the anterior nostril and wait 30-60
seconds before introducing more local
anesthetic into the nostril. Caution: Entire bottle
should not be used for insertion of tube. Discard
excess solution when procedure completed.
metoclopramide (REGLAN) injection [800059] 10 mg, Intravenous, ONCE PRN For 36 Hours,
peristalsis during feeding tube insertion
Maintain Enteral (Naso-) Tube [NURTAD0040] CONTINUOUS, Routine
Status:
Flush With: Water
Flush Volume (mL): 30 mL
Flush Frequency: EVERY 4 HOURS
Feedings may not be initiated in a newly placed
small bore feeding tube until physician radiograph
confirmation of placement is obtained via a written or
verbal report.
Flush with 30 mL of water per feeding tube every 4
hours and as needed to flush feeding tube after each
medication administration or alimentation. Refer to
policy 2.20 Enteral Feeding Tube.
Notify Feeding Tube Team [NURCOM0001] Provider to Notify: Other (Comment)
Notify based on: Other
Other: Feeding tube needs repositioning,Bridle
umbilical tape or clip needs to be changed,Viokase
unclogging kit is ineffective
X-RAY ABDOMEN AP VIEW (KUB) [R74000] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered
by this exam? Evaluate feeding tube placement
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date
in comment):
Transport Method: Floor Determined/Entered
If Conditional, What Condition? Evaluate feeding
tube placement
Consult Feeding Tube Team (Inpatient)
[CON0113]
ONCE For 1 Occurrences, Routine
Reason for Consult:
Contingency Parameters [109286]
Page 9 of 17
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12/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 150
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 100
If diastolic blood pressure < (mmHg): 40
If temperature > (C): 38
If temperature < (C): 36
If heart rate > (bpm): 120
If heart rate < (bpm): 50
If respiratory rate >: 30
If respiratory rate <: 8
If blood glucose > (mg/dL): 180
If blood glucose < (mg/dL): 50
If pain score >: 8
Pulse Oximetry < (%): 88
If urine output < (mL): 30 milliliter/hour or greater than
100 milliliter/hour
Other: Pain not controlled with ordered analgesics or
ordered interventions
Intravenous Therapy
Premedications for Needle Insertion [106310]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is immediate.
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, peripheral line
insertion - see Admin Instructions
Do NOT apply to area greater than 200 square
centimeters (maximum 2.5 g/site; maximum 4 sites
per hour, 6 times per day). Do NOT leave on longer
than 2 hours. Use for stable patient, no allergies to
lidocaine, with at least 30 minutes time prior to IV use
sodium chloride (bacteriostatic) 0.9 % injection
[50585]
0.05-0.1 mL, Intradermal, PRN, peripheral line
insertion - see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
IV Fluids [16791]
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion [44910]
Intravenous, CONTINUOUS
sodium chloride 0.9% with KCl 20 mEq/L infusion
[46261]
Intravenous, CONTINUOUS
lactated ringers infusion [38890] Intravenous, CONTINUOUS
sodium chloride 0.9 % infusion [64367] Intravenous, CONTINUOUS
General Medications
Analgesics - Acetaminophen - PRN (Single Response) [219008]
acetaMINOPHEN (TYLENOL) tab [34150] 1,000 mg, Oral, 3 X DAILY PRN, pain/fever
See Pain Management Algorithm for the Selection of
As-needed Analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg.
Analgesics - Opioid - Intravenous - PRN [16869]
Page 10 of 17
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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MORPHine PF injection [750057] 1-4 mg, Intravenous, EVERY 1 HOUR PRN, pain
See Pain Management Algorithm for the Selection of
As-needed Analgesics
for 4 Minutes
Anti-emetics [16795]
Adult - Standard - Anti-emetics [240445]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line if unable to take medications by mouth
or enteral tube OR if immediate effect is needed.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line if there is inadequate response to
first line anti-emetic within 30 minutes. If there is no
response to second line therapy within 30 minutes,
notify provider
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line. Use if there is inadequate
response to first line anti-emetic within 30 minutes
and if unable to take medications by mouth or
enteral tube OR if immediate effect is needed. If
there is no response to second line therapy within 30
minutes, notify provider
Bowel Management [16800]
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 2 X DAILY (AT MEALTIME)
Dissolve in 8 ounces of water
.
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Oral, 1 X DAILY PRN, constipation
First Line Therapy
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation
Second Line Therapy, if no response to first line
therapy after 6 hours OR if patient unable to take
medications by mouth or enteral tube OR if needed
immediate laxation.
Non-Categorized General Medications [16801]
bacitracin ointment [49271] Topical, 2 X DAILY
Apply to abrasions/lacerations
naloxone (NARCAN) injection [800199] 0.1 mg, Intravenous, PRN, opioid overdose
Administer every 3 minutes times 4 doses as needed
for respiratory rate less than 8 breaths/minute. Notify
MD if naloxone administered
Laboratory
Labs - Next Draw [140596]
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT DRAW, Starting today 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 11 of 17
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12/2017CCKM@uwhealth.org

PROTHROMBIN TIME/INR [PT] NEXT DRAW, Starting today 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] NEXT DRAW, Starting today 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 DRAW, Starting today 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 DRAW, Starting today 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] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LACTATE [GM2255] NEXT DRAW, Starting today 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 DRAW, Starting today 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 DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] NEXT DRAW, Starting today 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 DRAW, Starting today 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 DRAW, Starting today 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 12 of 17
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:13:39 PM
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12/2017CCKM@uwhealth.org

BLOOD GASES AND O2 SATURATION
[HCBGASOS]
NEXT DRAW, Starting today 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?
FIBRINOGEN [GM1320] NEXT DRAW, Starting today 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] CONDITIONAL, Starting today For 24 Hours, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
AMYLASE [AMYL] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LIPASE [LIPS] NEXT DRAW 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 DRAW 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 DRAW 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 DRAW 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 DRAW 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 DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Labs - Next AM [140684]
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?
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?
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?
Page 13 of 17
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:13:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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?
AMYLASE [AMYL] 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?
LIPASE [LIPS] 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?
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?
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?
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?
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?
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?
PROTHROMBIN TIME/INR [PT] 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?
Draw Every 4 Hours Times 6 [110168]
PLATELET COUNT [PLT] EVERY 4 HOURS, Starting today For 24 Hours,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 14 of 17
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:13:39 PM
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

PROTHROMBIN TIME/INR [PT] EVERY 4 HOURS, Starting today For 24 Hours,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Troponin [109290]
TROPONIN [GM2447] EVERY 2 HOURS For 4 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Hematocrit (Single Response) [140853]
HEMATOCRIT - Every 4 hours for 24 hours [HCT] EVERY 4 HOURS, Starting today For 24 Hours,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEMATOCRIT - Every 6 hours for 24 hours
[HCT]
EVERY 6 HOURS, Starting today For 24 Hours,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Diagnostic Tests and Imaging
Studies [16332]
ECG - 12 Lead Without Rhythm [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
ECG - 12 Lead With Rhythm Strip [EKG0009] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
X-RAY CHEST AP VIEW AM BEDSIDE [R71010] ONCE-RAD NEXT AVAILABLE, Starting tomorrow For
1 Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
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 15 of 17
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:13:39 PM
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12/2017CCKM@uwhealth.org

X-RAY ABDOMEN AP VIEW (KUB) [R74000] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
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
Post-Op/Phase II
X-RAY CHEST PA & LAT VIEWS [R71020] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Consults
Consults [110174]
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: DISCHARGE PLANNING
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Can this consult be done via video?
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult: ADL
Training
Consult Speech Therapy (Inpatient) Eval and
Treat [CON0077]
ONCE, Starting today For 1 Occurrences, Routine
Patient Type:
Behavioral Health Consults (select below)
[132899]
amp, transplant), - adjustment, protocol (eg. burn, trauma, rehab, pre-Psychology Health
noncompliance, grief, pain
Addictive Disorders - alcohol or drug related problems (eg. treatment recommendations,
withdrawal mgmt)
Psychiatry - safety, agitation, capacity, med mgmt, psychotropic SE
ACE - 60 and older - delirium, dementia, depression, decisional capacity, sleep (also for non-
behavioral geriatric syndromes; overall geriatric evaluation, mobility/falls, functional decline,
social/caregiver issues, disposition, medication management)
Page 16 of 17
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:13:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Consult Health Psychology (Inpatient)
[CON0033]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-Friday)
or if special assessment needs.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Addictive Disorders (Inpatient)
[CON0003]
ONCE, Routine, This order is for ADULT patients.
Please use the Consult Adolescent/Pediatric AODA
Counselor order for adolescent/pediatric patients
instead.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Psychiatry (Inpatient) [CON0064] ONCE
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Consult Ace/Geriatric (Inpatient) [CON0001] ONCE, Routine
Reason for Consult:
Can this consult be done via video?
BestPractice
No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
Page 17 of 17
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:13:39 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org