/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-98282-en.cckm

20180112

page

100

UWHC,UWMF,

Tools,

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

IP - Gynecology Oncology - Adult - Discharge [3597]

IP - Gynecology Oncology - Adult - Discharge [3597] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Gynecology


IP - Gynecology Oncology - Adult - Discharge [3597]
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [142353]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
Normal, Routine, Qty-1
enoxaparin (LOVENOX) 40 mg injection [142049] 40 mg, 28 Syringe, 0, starting 1/10/18, Normal
enoxaparin (LOVENOX) 30 mg injection - For
patients weighing less than 50 kg or with
creatinine clearance less than 30 [142048]
30 mg, 28 Syringe, 0, starting 1/10/18, Normal
enoxaparin (LOVENOX) 40 mg injection - For
patients equal to or greater than BMI = 40
[142049]
40 mg, 56 Syringe, 0, starting 1/10/18, Normal
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, 84 Syringe, 0, starting 1/10/18, Normal
dalteparin (FRAGMIN) injection 5000 units/0.2 mL
[144844]
5,000 units, 56 Syringe, , starting 1/10/18, Normal
Skilled Nursing Facility Orders
This Patient is going to a skilled nursing facilty, directly below is a group of orders commonly
associated with this patient population. Please review the orders below and select the appropriate
ones for this patient. If this patient is not going to a SNF, contact Case Management to update the
discharge plan. Updating the discharge plan will remove this set of SNF orders from the order set.
Skilled Nursing Facility Certification Statement [114940]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Certification Statement [118260]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Admit Order [114941]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Admit Order [118261]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Patient Care Orders [111713]
For dyspnea, Oxygen at 2 L/minute per nasal
canula; If this is an acute change for the patient
call PCP with assessment ASAP after oxygen is
started. Suction PRN to clear airways.
[NURCOM0022]
Routine
DME - Home Oxygen [1009468] Length of Need:
Patient's O2 Requirements Assessed and Meets
Criteria for Home O2:
Delivery Device:
Equipment Needed:
Continuous (liters/min):
Continuous (FiO2):
With Activity (liters/min):
With Activity (FiO2):
With Sleep (liters/min):
With Sleep (FiO2):
Length of Need:
Vendor:
Page 1 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 12:44:05 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

DME - CPAP [1009443] Length of Need:
Formal Sleep Study Completed:
Diagnosis:
CPAP Pressure (cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
DME - BiPAP (S) [1009441] Length of Need:
Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S):
Diagnosis:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
DME - BiPAP (S/T) [1009442] Length of Need:
Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S/T):
Diagnosis:
Respiratory Rate:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Patient may self administer medication per RN
assessment [NURCOM0022]
Routine
Patient medications (per Skilled Nursing Facility
policy) may be left at bedside [NURCOM0022]
Routine
Facility Therapy Needs [113391]
Physical Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Occupational Therapy to Evaluate and Treat at
Next Facility [NURCOM0022]
Routine
Page 2 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 12:44:05 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Speech Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Communicable Diseases [111717]
State Law requires at least one of the following statements be checked for your patient. May check both if
applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have any
other clinically apparent communicable diseases.
[NURCOM0022]
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Communicable Diseases [118262]
State Law requires at least one of the following statements be checked for your patient. May check both if
applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have any
other clinically apparent communicable diseases.
[NURCOM0022]
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Analgesics [111708]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, 1 tab, 1, starting 1/10/18, No Print
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, 1 suppository, 1, starting 1/10/18, No Print
Blood Glucose Management [111710]
glucagon 1 mg injection kit [107799] 1 mg, 1 each, 1, starting 1/10/18, No Print
Glucose 40 % oral gel [118089] 10 g, 1 Tube, 1, starting 1/10/18, No Print
Nursing Communication [NURCOM0022] Routine, Notify {Notify for Blood Glucose:3004146} if
blood glucose is greater than 400 mg/dL or less than
40 mg/dL
Diabetes Care Instructions [NURCOM0112] Routine, - Patient's blood glucose goal range before
meals is *** mg/dL.
- Monitor patient's blood glucose {Glucose Monitoring
Frequency:25242}.
- If your patient's blood glucoses are uncontrolled
contact provider.
- "Uncontrolled" blood glucoses mean:
* Blood glucose above 150 mg/dL more than half the
time during a week.
* Blood glucose over *** mg/dL.
* Blood glucose less than 70 mg/dL two or more times
per week (or if having signs/symptoms of low blood
glucose such as shaking, sweating, or light-
headedness).
Bowel Management [111709]
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, 1 suppository, 1, starting 1/10/18, No Print
Page 3 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 12:44:05 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Senna-Docusate Sodium 8.6-50 MG per tab
[70181]
1-2 tab, 1 tab, 1, starting 1/10/18, No Print
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, 1 Bottle, 1, starting 1/10/18, No Print
polyethylene glycol (MIRALAX) oral powder
[61353]
17 g, 1 Bottle, 1, starting 1/10/18, No Print
Non-categorized Medications [111711]
guaifenesin-dextroMETHORPHAN (ROBITUSSIN
DM) syrup [51568]
10 mL, 1 Bottle, 1, starting 1/10/18, No Print
carbamide peroxide (DEBROX) 6.5% otic soln
[35545]
3 drop, 1 Bottle, 1, starting 1/10/18 until 1/15/18, No
Print
alum-mag-simeth (MYLANTA ES) susp [44073] 30 mL, 1 Bottle, 1, starting 1/10/18, No Print
Patient Care Orders
Confirmed Discharge Date/Time [151653]
Confirmed Discharge Date/Time [ADT0013] Confirmed Discharge Date:
Confirmed Discharge Time:
Conditions for Discharge:
Provider to be Present at Discharge?
Reason for Hospitalization [130355]
Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Activity [243869]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
If your surgery included small incision sites
(laparoscopic surgery). Do not lift more than 10 lbs. for
2 weeks.
If your surgery included one large incision
(open/laparotomy). Do not lift more than 10 lbs. for
6 weeks.
It is ok to walk up and down stairs and ok to walk for
exercise. Do not do strenuous exercise that uses your
belly muscles (i.e. pilates, biking)
Do not drive for two weeks or while taking narcotics.
Do not have sex, douche, use tampons or put
anything into the vagina for 6 weeks. This is called
pelvic rest.
No Activity Restrictions [NURACT0011] Routine, Activity as tolerated.
Activity - Sitting Restrictions [105402]
Activity - Sitting Restrictions [NURACT0008] Routine
Discharge Activity: Other (Comment)
Nutrition [243876]
General Diet (No Modifications) [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
Diabetes Diet [NUT8888] Routine
General:
Diet Modifications: Diabetes
Other Diet Modifications:
Page 4 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 12:44:05 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Low Fiber Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid:
Esophagectomy:
Fat Controlled:
Fiber: Low Fiber
Fluid Restriction:
Heart Healthy:
Metabolic:
Renal:
Sodium Controlled:
NPO:
Tube Feeding:
Respiratory [105166]
DME - Home Oxygen [142943]
Both of the following orders MUST be completed in order for this DME to be delivered to the
patient.
-to-CNS has a facereimbursement requirements in 2013 require that a physician, PA, NP, or New
durable medical equipment (DME). It also face encounter with a patient prior to ordering certain
face encounter -to-provided with the documentation of the facerequires that the DME supplier be
order prior to delivery of the DME.and a signed
DME - Home Oxygen [1009468] Length of Need:
Patient's O2 Requirements Assessed and Meets
Criteria for Home O2:
Delivery Device:
Equipment Needed:
Continuous (liters/min):
Continuous (FiO2):
With Activity (liters/min):
With Activity (FiO2):
With Sleep (liters/min):
With Sleep (FiO2):
Length of Need:
Vendor:
DME - Home Oxygen Justification [1009463] Details
Wound Care [243875]
Wound Care [NURWND0015] Routine, You can take off any dressing or Tegaderm
that is in place 24 hours after discharge. Steri-strips
should stay on until they begin to peel off on their own.
Keep the incision open to air. It is ok to shower. Pat
gently to dry.
Do not swim or soak in hot tubs.
Wound Care - Vulvar Care [NURWND0015] Routine, Each time you urinate or have a bowel
movement, rinse the area very well with warm water.
Use the squirt bottle you were given or take a sitz
bath. Pat gently with a soft towel to dry. This prevents
any skin break down. After patting dry, you can use a
blow dryer to fully dry the area. If you use a blow
dryer, use it on "cool" setting on low for 5-10 minutes.
Wound Care - Additional Orders [NURWND0015] Routine
Page 5 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 12:44:05 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Drain Management [105168]
Maintain Urinary Catheter [NURELM0013] Routine, Indwelling single lumen catheter with
dependent drainage. Secure to leg as instructed.
Overnight bag is okay.
Drain Care [NURELM0013] Routine
Bowel Care [243898]
Bowel Care [NURELM0068] Routine
Constipation Prevention and Treatment
[NURELM0068]
Routine, Gyn Onc Constipation Prevention and
Treatment Strategies:
If you are constipated and you are having nausea and
vomiting call the Gyn/Onc RN triage line/After Hours
line at 608-263-1548.
Prevention of Constipation:
You may have a hard time with bowel movements if
you recently had surgery, are receiving chemotherapy
or are taking narcotics. Keep yourself well hydrated
with non-caffeinated beverages. Being up and about is
helpful as well. Narcotic pain pills will cause
constipation. While on narcotics take a stool softener
(Docusate Sodium/Colace) 100mg twice daily and
Miralax 17 gm once daily. You can buy this without a
doctor's order at the drugstore.
Treatment of Constipation:
If you have no bowel movement within 48 hours after
leaving the hospital follow these instructions:
Have you had surgery on your bowels in the last
month?
I don't know- Please contact the Gyn/Onc RN triage
line/After Hours line at 608-263-1548 to review your
records
Yes- Increase Miralax to twice daily dosing OR take
Milk of Magnesia 2-4 tablespoonsful
No- Use a Dulcolax suppository rectally. You should
have a bowel movement within 4-6 hours.
If no bowel movement within 4-6 hours of taking the
suppository or milk of magnesia OR within 12 hours
of increasing miralax please call Gyn/Onc RN triage
line/After Hours line at 608-263-1548.
Bladder Care [123374]
Bladder Care [NURELM0067] Routine
Other Patient Care Instructions [243910]
Other Discharge Patient Care Instructions
[NURCOM0022]
Routine
Pain Expectations and Instructions
[NURCOM0022]
Routine, Pain is common after abdominal surgery. The
pain is rarely equal on both sides of the abdomen.
This surgical pain is from irritation of the abdominal
muscles. The care team encourages patients to start
with scheduled ibuprofen and acetaminophen
(Tylenol), and adding narcotics only as needed for
breakthrough pain.
When to Call Your Doctor [130354]
Page 6 of 14
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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

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:
pain that is not helped with medicine,
fever over 100.4 degrees for two readings taken 4
hours apart,
increased shortness of breath,
redness/drainage at incision site,
not able to tolerate food/liquid by mouth,
vaginal bleeding that soaks more than one pad per
hour.
- Call 911 for emergencies.
- Call your doctor at the Gynecology Oncology clinic
Monday-Friday 8:00am to 5:00pm at 608-263-1548.
- To reach a doctor after hours or on weekends, call
608-263-1548 and ask for the gynecology oncology
doctor on call.
- For clinic appointments call 608-265-1700. Toll free
phone number is 800-323-8942. Clinic fax number is
608-263-2201.
Heart Failure Recommended Care
These order groups are showing because either your patient has an EF < 40% documented or
has Heart Failure on their problem list.
UW Health HF guideline URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/cardiovascular/name-97485-
en.cckm
Heart Failure Discharge Instructions [190359]
Weigh yourself daily or as directed
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Page 7 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 12:44:05 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

When to Call Your Doctor [NURCOM0079] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Call your doctor if you have any of
these symptoms as they may indicate worsening
Heart Failure:
- Increased shortness of breath
- Cough or chest congestion
- Swelling in your abdomen or legs
- Any increase or decrease in weight of more than 3
pounds in a day or 5 pounds total
If you do not have a scheduled return
appointment, please schedule an appointment
with your primary physician [NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Core Measure Documentation - ACE Inhibitor/ARB (Single Response) [150651]
Core Measures - This Does NOT Generate A Medication Order (Use Med Reconciliation To
Prescribe Medications)
ACE Inhibitor/ARB Reason Not Ordered
[COR0001]
ONCE, Starting today For 1 Occurrences, Routine
Reason Not Ordered:
ACE Inhibitor/ARB Already Ordered [COR0001] ONCE, Starting today For 1 Occurrences, Routine
Reason Not Ordered: Other (Comments required for
not ordering BOTH an ACEI and an ARB)
Follow-Up Care
Follow-Up Appointments [105170]
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Postoperative Follow Up
Which Provider: Other Provider or Specialist
When do you want appointment: Other (Enter
comments)
Which Clinic or Specialty: Gynecology Oncology
Schedule Appointment with Primary Care
Provider [NURCOM0026]
Reason for Hospital Follow Up Appointment: Follow
up after hospitalization regarding ***
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty:
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Patient to Schedule Appointment [NURCOM0056] Routine
Purpose:
With whom:
For when:
For Clinic Appointments call 608-265-1700
Follow Up Appointments - Diabetes (Single Response) [148552]
*** RESPONSE REQUIRED *** This order facilitates documentation (only) about follow-up
appointments for patients with diabetes. Scheduling an appointment before discharge with a
provider who will manage a patient’s diabetes care (e.g., primary care physician, endocrinologist,
etc.) is a Joint Commission requirement. Exclusions are allowed based upon patient situation
(e.g., discharge to a skilled nursing facility, patient refusal, etc.). Only select “Appointment
Scheduled” if an appointment has already been scheduled, and use the Schedule Appointment
order as needed to request assistance in scheduling
Page 8 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 12:44:05 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

No appointment: Patient does not have diabetes
[COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
does not have diabetes
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Appointment scheduled (with provider who can
manage diabetes) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment scheduled
(with provider who can manage diabetes)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Appointment scheduled per patient report
(ENTER DATE IN COMMENTS) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment scheduled per
patient report (ENTER DATE IN COMMENTS)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 9 of 14
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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

Appointment pending: patient discharged on
weekend; follow-up information provided
[COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment pending:
patient discharged on weekend; follow-up information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Free clinic information provided [COR0064] ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Free clinic information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
No appointment: Patient discharging to a facility
(e.g., skilled nursing facility, correctional facility,
etc.) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
discharging to a facility (e.g., skilled nursing facility,
correctional facility, etc.)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 10 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 12:44:05 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

No appointment: Patient refusal [COR0064] ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
refusal
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Facility Therapy Needs [28537]
Continue Physical Therapy at Next Facility
[NURCOM0022]
Routine
Continue Occupational Therapy at Next Facility
[NURCOM0022]
Routine
Continue Speech Therapy at Next Facility
[NURCOM0022]
Routine
Discharge Labs [134929]
Page 11 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 12:44:05 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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 (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
(B)
Current Consulting Provider
UW Health Lab
Specific lab orders with
AUTHORIZING PROVIDER
CHANGED TO
CONSULTANT (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
and AUTHORIZING
PROVIDER CHANGED TO
CONSULTANT (B)
Another Provider
UW Health Lab
Recommended Discharge
Labs (C)
Non-UW Health Lab
Recommended Discharge
Labs (C)
(A) SPECIFIC LAB ORDERS:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have the labs completed at a
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient's care will be responsible for the
result, you must change the AUTHORIZING PROVIDER on the order to the CONSULTING
PROVIDER before signing the order. To do this, click the Providers button near the top of the
Review, Sign & Hold tab of the discharge navigator. Update the authorizing provider to the
consulting provider.
(B) SPECIFIC LAB ORDER WITH ORDER CLASS CHANGED TO OUTSIDE:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have labs completed at a NON-
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient’s care will be responsible for the
result, you must change the AUTHORIZING PROVIDER on the order to the CONSULTING
PROVIDER before signing the order. To do this, click the Providers button near the top of the
Review, Sign & Hold tab of the discharge navigator. Update the authorizing provider to the
consulting provider.
The patient will receive a paper order to take to the lab.
(C) RECOMMENDED DISCHARGE LABS:
This order should be used to recommend to another provider labs that a patient should have
completed after discharge. The provider designated in the 'Send Recommendations To' field is
responsible for PLACING the lab orders AND will be responsible for the RESULTS of any
ordered labs.
Page 12 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 12:44:05 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Discharge Labs Workflow URL: https://uconnect.wisc.edu/growth/training--
education/health-link/10-minutes/inpatient-
discharge-consult/resources/name-82993-en.file
Recommended Discharge Labs [NURCOM0075] Details
Laboratory [105171]
Consulting Provider will lab orders should only be used if the current Attending Provider or These
lab.be responsible for the result of the
CBC WITH DIFFERENTIAL [CBC] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
CBC WITHOUT DIFFERENTIAL [HEMO] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
BASIC METABOLIC PANEL [BMET] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
PROTHROMBIN TIME/INR [PT] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
ELECTROLYTES [LYTE] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
BUN [BUN] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
CREATININE [CRET] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
GLUCOSE [GLU] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
CALCIUM [CA] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
CA 125 [XCA125] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
BILIRUBIN, TOTAL [TBIL] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
PROTEIN, TOTAL [TP] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
ALBUMIN [ALB] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
ALKALINE PHOSPHATASE [ALKP] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
AST/SGOT [AST] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
ALT/SGPT [ALT] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
ABSOLUTE NEUTROPHIL COUNT [HCANC] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
MAGNESIUM [MAG] Status: Future Approximate, Expires: 4/10/18, Normal,
Routine
Diagnostic Tests and Imaging [20240]
X-RAY CHEST SINGLE VIEW [R71045] Status: Future, Expires: 3/10/2019, Normal, Routine
CT HEAD W & W/ O IV CONTRAST [R70470] Status: Future, Expires: 3/10/2019, Normal, Routine
CT ABDOMEN PELVIS W & W/ O IV CONTRAST
[R07033]
Status: Future, Expires: 3/10/2019, Normal, Routine
Discharge Scripts [105172]
Page 13 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 12:44:05 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Discharge - Facility [DC0003] Routine
Type:
Allied Health Services Requested:
Facility:
Facility City:
Facility Phone:
Facility Fax:
Discharge - Home Care [137330]
Both of the following orders MUST be completed in order for this patient to receive home care.
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 - Home Hospice [DC0019] Routine
Agency:
Agency City:
Agency Phone:
Agency Fax:
Discharge - Durable Medical Equipment [DC0005] Routine
Location:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Diagnosis:
Discharge - Home Infusion [DC0007] Routine
Type:
Access:
Infusion Provider:
Infusion Provider City:
Infusion Provider Phone:
Infusion Provider Fax:
Supplies:
Page 14 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 1/10/2018 12:44:05 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org