/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/gynecology/,

/clinical/cckm-tools/content/order-sets/inpatient/gynecology/name-98281-en.cckm

20180129

page

100

UWHC,UWMF,

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

IP - Gynecology Oncology - Adult - Admission [4081]

IP - Gynecology Oncology - Adult - Admission [4081] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Gynecology


IP - Gynecology Oncology - Adult - Admission [4081]
for Adult Patients OnlyIntended
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) [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:
Page 1 of 19
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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) [109874]
Admit To Inpatient Status [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 Status [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Discharge When Medically Ready Criteria [244367]
Discharge When Medically Ready - Gyn Onc
[244362]
appropriate discharge criteria below:Select
Ambulating [ADT0107] Or cleared by PT/OT
Pain Controlled With Oral Medication [ADT0108] Details
Tolerating PO [ADT0100] Details
Vital Signs Stable [ADT0106] Vital signs not within Notify parameters
Discharge Criteria: Flatus [ADT0102] Details
Anticoagulation Injection Teaching Complete
[ADT0128]
Teaching to Complete: Anticoagulation Injection
Teaching Complete, if indicated
Neurogenic Voiding Trial [ADT0129] Details
Voiding Trial [ADT0113] Details
Lab Value [ADT0112] Specify Lab and Value:
Lab Value [ADT0112] Specify Lab and Value:
Lab Value [ADT0112] Specify Lab and Value:
Other [ADT0105] Other Criteria:
Other [ADT0105] Other Criteria:
Other [ADT0105] Other Criteria:
Isolation Status
If patient requires Isolation, please search for isolation in the additional orders section below.
Isolation Status [111283]
Enhanced Contact Isolation - CDIFF [ISO0348] What is the reason for isolation? CDIFF
Page 2 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 1/24/2018 2:27:41 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Contact Isolation - MDRO (MRSA) [ISO0334] CONTINUOUS
What is the Reason for Isolation? MRSA
Contact Isolation - MDRO (VRE) [ISO0334] CONTINUOUS
What is the Reason for Isolation? VRE
Isolation - Protective Precautions [3000922]
Protective Precautions [ISO0349] What is the Reason for Isolation?
Isolation Cart [EQP0016] CONTINUOUS, Routine
Protective - Positive Pressure Room
[NURCOM0109]
CONTINUOUS
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [130119]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [244132]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [244133]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [244134]
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 [244135]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis (Single Response) [150156]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [244140]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [244141]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [244142]
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
Page 3 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 1/24/2018 2:27:41 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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 [244143]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs [109875]
Vital Signs [NURMON0013] EVERY 8 HOURS, Starting today, Routine
Temperature Measurement Method: Oral
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital Signs [NURMON0013] SEE COMMENTS, Starting today with First
Occurrence As Scheduled, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 4 hours for 12 hours, then every 8 hours.
Activity [109876]
Ambulate Ad Lib [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: ad lib
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Ambulate Three Times Daily [NURACT0008] CONTINUOUS, Starting today, 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:
Page 4 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 1/24/2018 2:27:41 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Chair Ad Lib [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR: ad lib
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Chair Three Times Daily [NURACT0008] CONTINUOUS, Starting today, 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:
Nutrition [109877]
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Diabetes Meal Plan [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Diabetes
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:
Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Respiratory [7485]
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 92
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Page 5 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 1/24/2018 2:27:41 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Aspiration Precautions [PRECAU0007] CONTINUOUS, Starting today, Routine
Solid Consistency:
Liquid Consistency:
Medication Administration:
Supervision:
Positioning Strategies:
Patient Location:
Incentive Spirometry [NURTRT0018] EVERY 2 HOURS, Starting today, Routine, While
awake.
Cough And Deep Breathe [NURTRT0019] EVERY 2 HOURS, Starting today, Routine, While
awake.
Intake and Output [109878]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Routine
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With? Portable Scale
Weigh when?
Standing preferred.
Maintain Urinary Catheter [NURELM0013] CONTINUOUS, 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:
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today, 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?
Non-Categorized Patient Care Orders [111284]
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
ONCE, Starting today, Routine
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
NG Tube Placement - Adult [120994]
Page 6 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 1/24/2018 2:27:41 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Starting today For Until specified,
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 SINGLE VIEW [R74018] 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
Contingency Parameters [109879]
Page 7 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 1/24/2018 2:27:41 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg): 80
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): 110
If heart rate < (bpm): 60
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 150
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 90
If urine output < (mL): 30 for 4 hours
Other: Central venous pressure less than 3 or greater
than 15 mmHg,If patient on heparin and platelets
decrease by half from baseline or are below normal
range,If persistent back pain, lower extremity
numbness or weakness and on heparin and epidural
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 [109687]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
sodium chloride 0.9 % infusion [64367] Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS
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
sodium chloride 0.9% BOLUS [730003] Intravenous
lactated ringers infusion [38890] Intravenous, CONTINUOUS
Medications - General
Page 8 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 1/24/2018 2:27:41 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Analgesics - Opioids - Intravenous (Single Response) [109688]
HYDROmorphone PF (DILAUDID) injection
RANGE [750050]
Intravenous, EVERY 3 HOURS PRN For 4 Doses
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
for 3 Minutes
MORPHine PF injection RANGE [750057] 1-2 mg, Intravenous, EVERY 3 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
for 4 Minutes
Analgesics - Opioids - Oral (Single Response) [198915]
oxycodone tab RANGE [750032] 5-10 mg, Oral
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
Analgesics - Acetaminophen [198922]
acetaMINOPHEN (TYLENOL) tab - NOTE: Do
NOT order for patients admitted with fever
[34149]
650 mg, Oral, EVERY 6 HOURS PRN, pain
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.
Anti-emetics [109960]
ondansetron (ZOFRAN) tab [45939] 4 mg, Oral, EVERY 12 HOURS PRN, nausea/vomiting
First Line
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 12 HOURS PRN,
nausea/vomiting, First line when unable to take orally.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting, Second line when unresponsive to
first line therapy after 30 minutes
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting, Second line when unable to take
orally and unresponsive to first line therapy after 30
minutes
lorazepam (ATIVAN) tab RANGE [750026] 0.5-1 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting, Third line when unresponsive to
previous therapies after 30 minutes
lorazepam (ATIVAN) injection RANGE [750075] 0.5-1 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting, Third line when unable to take orally
and unresponsive to previous therapies after 30
minutes
Bowel Management [111020]
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
2 tab, Oral, 2 X DAILY
Hold for loose stools
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY PRN, constipation, First line
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Oral, 1 X DAILY PRN, constipation, Second
line if no response to first line therapy within 12 hours
Hypnotics (Single Response) [228331]
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
melatonin tab [119466] 3 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Trazodone - Melatonin [227992] "And" Linked Panel
Page 9 of 19
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use first line.
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
melatonin tab [119466] 3 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use second line if failure to respond to trazodone
within 60 minutes
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Hypnotics (Single Response) [228334]
traZODONE (DESYREL) tab [720150] 25 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
If needed, give prior to midnight if possible. May
contribute to sedation the following day.
melatonin tab [119466] 1 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Medications - Anti-infectives for Fever
Broad Spectrum Coverage (Single Response) [106258]
Pharmacokinetic/ Pharmacodynamic Dose
Optimization of Antibiotics for the Treatment of
Gram Negative Infection
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/?path=/content/cpg/infection-and-
isolation/name-97543-en.cckm
Treatment of Patients with Reported Allergies to
Beta-Lactam Antibiotics – Adult – Inpatient clinical
practice guideline
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/?path=/content/cpg/infection-and-
isolation/name-97535-en.cckm
Cefepime [186245] "And" Linked Panel
cefepime (MAXIPIME) 2 g vial + minibag [52163] 2 g, Intravenous, ONCE For 1 Doses, for 30 Minutes
cefepime (MAXIPIME) 2 g vial + minibag [52163] 2 g, Intravenous
Start 6 hours after initial one-time order
for 4 Hours
Note: Run cefepime (MAXIPIME) over 4 hours
[950056]
Details
meropenem (MERREM) intraVENOUS - NOTE:
Choose meropenem when patient has received
both cefepime and piperacillin/ tazobactam in the
past 90 days [800055]
500 mg, Intravenous, EVERY 6 HOURS For 96 Hours
Administer every 6 hours per Pharmacokinetic/
Pharmacodynamic Dose Optimization of Antibiotics for
the Treatment of Gram Negative Infection for first
fever spike
aztreonam (AZACTAM) intraVENOUS - NOTE:
Choose when patient has severe or immediate
IgE mediated allergy to beta-lactam antibiotics.
Must order concurrent IV vancomycin [800013]
2 g, Intravenous, EVERY 8 HOURS For 96 Hours
See Treatment of Patients with Reported Allergies to
Beta-Lactam Antibiotics – Adult – Inpatient clinical
practice guideline
Gram Positive Coverage [105209]
vancomycin (VANCOCIN) intraVENOUS - NOTE:
Choose when there is conern for cellulitis, line
infection, or when patient has severe or
immediate IgE mediated allergy to beta-lactam
antibiotics [800084]
1 g, Intravenous, DOSE PER PHARMACY
Anaerobic Coverage (Single Response) [22500]
metRONIDazole (FLAGYL) intraVENOUS- NOTE:
Choose when there is concern for intra-abdominal
infection [800062]
500 mg, Intravenous, EVERY 8 HOURS
Page 10 of 19
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

metRONIDazole (FLAGYL) tab - NOTE: Choose
when there is concern for intra-abdominal
infection [39639]
500 mg, Oral, 3 X DAILY
Laboratory
Draw Now (If Not Completed in ED) [110193]
TYPE AND SCREEN [HCTS] NEXT DRAW, Starting today For 1 Occurrences,
Routine, As good clinical practice and for patient
safety, the Transfusion Service will automatically
crossmatch 2 packed RBCs on all patients with
antibodies to ensure blood would be available in the
event it is needed. If you would like to opt out of this
automatic order for this patient please contact the
UWHC Blood Bank at (608) 263-8367 or The
American Center Lab at (608) 234-6600 as
appropriate.
CBC WITH DIFFERENTIAL [CBC] 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?
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?
ABSOLUTE NEUTROPHIL COUNT [HCANC] 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?
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?
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?
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?
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 11 of 19
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

BILIRUBIN, TOTAL [TBIL] 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?
PROTEIN, TOTAL [TP] 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?
ALKALINE PHOSPHATASE [ALKP] 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?
AST/SGOT [AST] 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?
ALT/SGPT [ALT] 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?
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?
TSH [TSH] 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 AND
CULTURE IF >5 WBC/HPF [HCUACULT]
ONCE, Starting today 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?
HCG, QUANTITATIVE [BHCG] NEXT DRAW, Starting today For 1 Occurrences,
Routine, This test is not intended for aiding in the
diagnosis of cancer or for monitoring the treatment of
cancer patients.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 12 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 1/24/2018 2:27:41 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

TROPONIN [GM2447] EVERY 6 HOURS, Starting today For 3 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?
CA 125 [XCA125] 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?
PREALBUMIN [XPRALB] 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?
Draw Now - Blood Cultures [197980]
Only order blood cultures if antibiotics are also ordered.
CULTURE, BLOOD, BACTERIA/YEAST (2
SITES) [116728]
.Practices for Blood Culturing Best This order equals 2 sites (4 bottles). See link below for
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
NEXT DRAW, 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, BLOOD, BACTERIA AND YEAST
[GM4045]
NEXT DRAW, 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?
Draw in AM [110194]
CBC WITHOUT DIFFERENTIAL [HEMO] 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 19
Printed by WILLIAMS, HEATHER R [HRS0] at 1/24/2018 2:27:41 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

ABSOLUTE NEUTROPHIL COUNT [HCANC] 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?
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?
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?
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?
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?
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?
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?
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?
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?
URINALYSIS WITH MICROSCOPY AND
CULTURE IF >5 WBC/HPF [HCUACULT]
NEXT AM 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?
Page 14 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 1/24/2018 2:27:41 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [110213]
X-RAY CHEST 2 VIEWS [R71046] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area:
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
X-RAY ABDOMEN 2 VIEWS [R74019] 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?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
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.
CT CHEST WO & CT ABD/PELVIS W [216109] "And" Linked Panel
CT CHEST W/ O IV CONTRAST [R71250] ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered
by this exam?
Relevant recent/past history?
Is patient pregnant?
Allergies to IV contrast or iodine?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
CT Chest W/O & CT Abd/Pelvis W to be scheduled
together
Page 15 of 19
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CT ABDOMEN PELVIS W IV CONTRAST
[R07416]
ONCE-RAD NEXT AVAILABLE, Routine
Can pt be given oral contrast?
Current signs and symptoms?
What specific question(s) would you like answered
by this exam?
Relevant recent/past history?
Is patient pregnant?
Allergies to IV contrast or iodine?
Has the patient ever taken chemotherapy drug
Interleuken-2 (IL-2)?
Creatinine level must be obtained within the last
month for patients matching the following (select all
applicable or None):
Last creatinine value? (will auto pull in date and
value in comment):
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Last patient weight? (will auto pull in value and date
in comment):
Transport Method:
CT Chest W/O & CT Abd/Pelvis W to be scheduled
together
CT ABDOMEN PELVIS W & W/ O IV CONTRAST
[R07033]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Can pt be given oral contrast?
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history.
Last creatinine value? (will auto pull in date and value
in comment):
Last patient weight? (will auto pull in value and date in
comment):
Transport Method:
CT ANGIO CHEST PE PROTOCOL [R71275A] 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? Please include relevant recent/past
history.
Last creatinine value? (will auto pull in date and value
in comment):
Last patient weight? (will auto pull in value and date in
comment):
Transport Method:
Consults
Consults [110214]
Consult Palliative Care - Adult (Inpatient)
[CON0055]
ONCE, Starting today For 1 Occurrences, Routine
Reason For Consult:
Can this consult be done via video?
Consult Wound and Skin Care Service (Inpatient)
[CON0086]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Can this consult be done via video?
Page 16 of 19
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult:
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult:
Consult Ace/Geriatric [CON0001] ONCE, Starting today For 1 Occurrences, Routine
Purpose of Consult: EVALUATE AND RECOMMEND
Reason for Consult:
Consult Spiritual Care (Inpatient) [CON0056] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Can this consult be done via video?
Consult Ostomy Care Service (Inpatient)
[CON0052]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Can this consult be done via video?
Diabetes Consult Order Panel (Adult) [188497]
Diabetes Management Service : Will provide management or treatment recommendations for
patients with hyperglycemia and/or those who report outpatient use of insulin or other diabetes
medications. Patients should be expected to remain inpatient > 24 hrs from time of consult.
Consult is required for patients with insulin pumps or who use U-500 insulin. Consult Endocrine
for any non-diabetes-related endocrine questions.
Learning Center - Diabetes Education (Adult): Diabetes Education (Adult): Diabetes education
(meter/insulin skills/other diabetes survival skills) for patients/families with knowledge deficits
and/or need for diabetes knowledge assessment. Recommended for all new diagnoses or
patients with A1C > 9.
Diabetes Education – Nutrition : Diabetes nutrition therapy including nutrition assessment,
carbohydrate education (consistent carbohydrate meals, use of insulin-to-carbohydrate ratio),
and/or individualized, nutritious meal planning for carbohydrates, portions, or considering other
comorbidities. Recommended for all new diagnoses or patients with A1C > 9
Consult Diabetes Management Service (DMS)
(Inpatient) [CON0022]
ONCE
Can this consult be done via video?
Call back number:
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Consult Learning Center - Diabetes Education
(Adult) [CON0021]
ONCE, Routine, - If patient is newly diagnosed or is
new to insulin, provide 24 hours notice to allow
adequate time for education,
- Indicate diabetes medication/treatment plan if
known.
- Consults requested after 1600 on Fridays may not
be seen until following Monday. Learning Center
available Mon-Sat 0800-1630 (only 1 RN available
on Saturday for CSC and AFCH).
- Staff may be contacted by Pager 7927 on
weekdays and Pager 3276 on weekends.
- Learning Center staff are not available on holidays.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Page 17 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 1/24/2018 2:27:41 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Consult Diabetes Education - Nutrition (Inpatient)
[CON0126]
ONCE, Routine, · If your patient is newly diagnosed
and/or is new to insulin therapy, provide 24 hours
notice to allow adequate time for nutrition education.
· Indicate diabetes medication/treatment plan if
known.
· Consults requested after 1300 on Friday may not
be completed until the following Monday.
· If you are placing a consult on a weekend day for a
patient who will be discharging that weekend, please
have the Paging Center contact the on-call dietitian
to help you facilitate the diabetes nutrition education
session prior to the patient's discharge.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
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)
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
Page 18 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 1/24/2018 2:27:41 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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 19 of 19
Printed by WILLIAMS, HEATHER R [HRS0] at 1/24/2018 2:27:41 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org