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IP – Trauma Surgery – Adult – Discharge [4840]

IP – Trauma Surgery – Adult – Discharge [4840] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, General Surgery


IP - Trauma Surgery - Adult - Discharge [4840]
Patient Care Orders
Reason For Hospitalization [129976]
Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This order
will appear on the patient's After Hospital Care Plan., Routine,
You were hospitalized for evaluation and treatment after your
trauma. Your treatments included consultation from
appropriate specialists, therapies, and pain management.
Activity [129996]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
{Restrictions:4022111}
{Additional Restrictions:4022112}
Wear Brace [NURACT0011] Routine, Type of brace: {TRAUMA BRACES:4002112}
Wearing schedule: {BRACE SCHEDULE:4002115}
{Additional Instructions:4022115}
PMT Brace - Additional Instructions [NURACT0011] Routine, Remember, someone must help you with your brace
for activities of daily living. Shower with your PMT brace on.
After showering, lay flat without moving while someone
removes brace, dries you off, changes pads and reapplies
your brace.
Lifting Restrictions [NURACT0011] Routine, {LIFTING RESTRICTIONS:4022113}
Driving Instructions [NURACT0011] Routine, No driving while on opioid pain medication. If
wearing spine or leg brace, do not drive. Do not remove
brace to drive.
Nutrition [129978]
Diet [NUT0006] Routine
Diet:
General:
Liquids and Modified Consistency:
Fluid Restriction:
Sodium:
Dysphagia:
Fat:
Renal:
Potassium:
Micronutrients:
Infant Formula Product:
Infant Formula Concentration:
Respiratory [129979]
DME - Home Oxygen [142943]
Both of the following orders MUST be completed in order for this DME to be delivered to the patient.
New reimbursement requirements in 2013 require that a physician, PA, NP, or CNS has a face-to-face encounter with a
patient prior to ordering certain durable medical equipment (DME). It also requires that the DME supplier be provided with
the documentation of the face-to-face encounter and a signed order prior to delivery of the DME.
National Coverage Determination for Home Use of
Oxygen (See section D for qualifying diagnoses)
URL: http://www.cms.gov/medicare-coverage-
database/details/ncd-details.aspx?
NCDId=169&ncdver=1&bc=AgAAQAAAAAAAAA%3d%
3d&
DME - Home Oxygen [1009468] Patient's O2 Requirements Assessed and Meets Criteria
for Home O2:
Delivery Device:
Continuous (liters/min):
Continuous (FiO2):
With Activity (liters/min):
With Activity (FiO2):
With Sleep Only (liters/min):
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With Sleep Only (FiO2):
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Length of Need:
DME - Home Oxygen Justification [1009463] Details
Wound Care [129980]
Wound Care - Standard [NURWND0015] Routine, Monitor any wounds for signs and symptoms of
infection, including redness, swelling, drainage, or odor.
Wash abrasions daily with soap and water, apply bacitracin to
wound, cover with non-stick (cuticerin) gauze and wrap with
gauze. Please change dressing twice daily.
Wound Care - Ortho [NURWND0015] Routine, Keep clean dressing over incision until dry; change
every other day or earlier as needed. May shower 5 days
from date of surgery, avoid tub for 3 weeks. No hot tubs,
pools, ponds or jacuzzi. Leave steri-strips in place for 10 days
from date of surgery. If steri-strips are still on you may
carefully remove the steri-strips after 10 days.
Wound Care - Other [NURWND0015] Routine
Bathing Instructions [NURWND0018] Routine, {bathe:4022114}
Line Care [NURWND0018] Routine, Your dressing needs to be changed every *** days.
Your line should be removed ***.
Drain Care [NURWND0018] Routine, Record drain output as instructed by nursing. Bring
record of drain output to first clinic appointment.
Chest Tube Site Care [NURWND0018] Routine, Change chest tube site dressing in 48 hours. Cover
with dry gauze and tape. If no drainage is present, you may
leave open to air. May shower after first dressing change.
Bladder Care [129981]
Bladder Care [NURELM0067] Routine
Bowel Care [129982]
Bowel Care [NURELM0068] Routine, Ensure regular bowel movements. You may be at
risk for constipation due to opioid use and decreased mobility.
Other Patient Care Instructions [129983]
Other Discharge Patient Care Instructions
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This order
will appear on the patient's After Hospital Care Plan., Routine,
- Continue to use your Incentive Spirometer, cough and deep
breath as instructed.
- Please refer to your education materials for further
information: Trauma Patient Guidebook or Your Stay on the
Trauma Unit Pamphlet
- Take all medication as directed.
- Most opioid pain medications cannot be called in to your
pharmacy, so please be sure to bring your pain medication
bottles with you to every clinic appointment and discuss any
refill needs at your clinic visit.
Cast Care [NURCOM0071] Please complete in PATIENT FRIENDLY terms. This order
will appear on the patient's After Hospital Care Plan., Routine,
1. Keep splint or cast clean and dry. Moisture can irritate the
skin and cause the splint or cast to weaken or break.
2. Do not do anything to change the shape of your
cast/splint, or try to modify it yourself.
3. Wiggle your fingers and/or toes to reduce swelling and
increase circulation.
4. Elevate your injured extremity above the level of your
heart to decrease swelling.
5. Call with concerns or if you notice:
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-Increased pain or pain not relieved with medication
-Swelling or tightness in the cast/splint not reduced with
elevation
-Numbness or tingling that does not change with position
-Blue or very pale color to fingers or toes
-Loss of movement
-An unusual odor or drainage coming out from beneath the
cast/splint
-Broken or damaged cast/splint
6. To relieve itching in the cast, blow cool air into it with a hair
dryer. Do not stick anything into the cast to scratch the skin,
or shake powder into the cast.
7. Call with questions during the day at (608)-263-7540
(Orthopedic Clinic) or afterhours at (608)-263-6400 and ask
for the orthopedic resident on-call.
When to Call Your Doctor [129984]
When to Call Your Doctor [NURCOM0079] Please complete in PATIENT FRIENDLY terms. This order
will appear on the patient's After Hospital Care Plan.
You should include specific instructions on when and who to
call.
You should include actual provider names (i.e. not 'PCP').
You should NOT include the discharging unit as a contact.,
Routine, Call your doctor if you have any of these symptoms:
-increased pain not relieved by medication
-fever over 100.5 degrees for 24 hours
-signs of infection listed above
-increased shortness of breath, persistent nausea, vomiting,
or constipation
-weight gain as directed.
Call your doctor if you have any of the following signs and
symptoms of blood clots:
-swelling, redness, warmth, or discoloration of the affected
area
-pain or tenderness may be present in the area where a clot
has formed
-chest pain, shortness of breath, a rapid pulse and/or rapid
breathing.
Contact Numbers:
If you have questions Monday through Friday 8am - 5pm
please call the nurse triage line at: 608-263-7502
If you have questions after hours or on weekends, please call:
608-263-6400 and ask for the trauma resident on call.
Follow-Up Care
Follow-Up Apoointments [129987]
Schedule Appointment [NURCOM0026] Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
Schedule Appointment [NURCOM0026] Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
Schedule Appointment [NURCOM0026] Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
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Patient to Schedule Appointment [NURCOM0056] Routine
Purpose:
With whom:
For when:
Recommended Labs [134929]
Please use the table below to determine what type of order to use to place discharge lab orders.
Who is Responsible for the Result? Where Will Labs be Completed? What Order Should You Use?
Current Attending Provider UW Health Lab Specific lab orders
Current Attending Provider Non-UW Health Lab Outside Lab Order
Current Consulting Provider UW Health Lab Specific lab orders with authorizing provider changed to consultant
Current Consulting Provider Non-UW Health Lab Outside Lab Order with authorizing provider changed to consultant
Another Provider UW Health Lab Recommended Discharge Labs
Another Provider Non-UW Health Lab Recommended Discharge Labs
RECOMMENDED DISCHARGE LABS:
This order should be used to recommend to another provider labs that a patient should have completed after discharge.
The provider designated in the 'Send Recommendations To' field is responsible for PLACING the lab orders AND will be
responsible for the RESULTS of any ordered labs.
OUTSIDE LAB ORDER:
This order should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER will be responsible for the result
of the lab AND the patient will have labs completed at a NON-UW HEALTH LAB. The patient will receive a paper order to
take with them to the lab.
SPECIFIC LAB ORDERS:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER will be responsible for the
result of the lab AND the patient will have the labs completed at a UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient's care will be responsible for the result, you must change
the AUTHORIZING PROVIDER on the order to the CONSULTING PROVIDER before signing the order.
Recommended Discharge Labs [NURCOM0075] Details
Outside Discharge Lab Order [LABDCOUT] Expires: 2/5/15, Normal, Routine, Qty-1
Laboratory [131000]
These lab orders should only be used if the current Attending Provider or Consulting Provider will be responsible for the
result of the lab.
CBC WITH DIFFERENTIAL [CBC] Expires:2/5/15 MANUAL,Count:1, Normal, Routine
BASIC METABOLIC PANEL [BMET] Expires:2/5/15 MANUAL,Count:1, Normal, Routine
COMPREHENSIVE METABOLIC PANEL [METB] Expires:2/5/15 MANUAL,Count:1, Normal, Routine
MAGNESIUM [MAG] Expires:2/5/15 MANUAL,Count:1, Normal, Routine
PHOSPHATE [PHOS] Expires:2/5/15 MANUAL,Count:1, Normal, Routine
URINALYSIS WITH MICROSCOPY AND CULTURE IF
>5 WBC/HPF [HCUACULT]
Expires:2/5/15 MANUAL,Count:1, Normal, Routine
Diagnostic Tests and Imaging [131001]
X-RAY CHEST AP VIEW [R71010] Expires: 12/6/15, Normal, Routine
X-RAY CHEST PA & LAT VIEWS [R71020] Expires: 12/6/15, Normal, Routine
CT HEAD W/ O IV CONTRAST [R70450] Expires: 12/6/15, Normal, Routine
X-RAY CERVICAL SPINE 2-3 VIEWS [R72040] Expires: 12/6/15, Normal, Routine
X-RAY THORACIC SPINE 2 VIEWS [R72070] Expires: 12/6/15, Normal, Routine
X-RAY LUMBAR SPINE 2-3 VIEWS [R72100] Expires: 12/6/15, Normal, Routine
Facility Therapy Needs [129988]
Continue Physical Therapy at Next Facility
[NURCOM0022]
Routine
Continue Occupational Therapy at Next Facility
[NURCOM0022]
Routine
Continue Speech Therapy at Next Facility
[NURCOM0022]
Routine
Discharge - Home Care [137330]
Both of the following orders MUST be completed in order for this patient to receive home care.
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Discharge - Home Care [DC0001] Routine
Type (Each Agency Requires a Separate Order):
Agency:
Agency City:
Agency Phone:
Agency Fax:
Discharge - Home Care Justification [DC0032] Details
Discharge - Outpatient Therapy [DC0002] Routine
Type(Each Agency Requires a Separate Order):
Diagnosis:
Facility:
Facility City:
Facility Phone:
Facility Fax:
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority