/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-98283-en.cckm

201606170

page

100

UWHC,UWMF,

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

IP – Gynecology Benign – Adult – Discharge [5961]

IP – Gynecology Benign – Adult – Discharge [5961] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Gynecology


IP - GYNECOLOGY BENIGN - ADULT - DISCHARGE [5961]
IP Gynecology Oncology - Adult VTE Algorithm URL: https://uconnect.wisc.edu/clinical/cckm-tools/order-
sets/inpatient/gynecology/resources/name-35626-en.file
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
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
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 1/29/16, No Print
acetaMINOPHEN (TYLENOL) suppository [34153] 650 mg, 1 suppository, 1, starting 1/29/16, No Print
Blood Glucose Management [111710]
glucagon 1 mg injection kit [107799] 1 mg, 1 each, 1, starting 1/29/16, No Print
Glucose 40 % oral gel [118089] 10 g, 1 Tube, 1, starting 1/29/16, 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
Bowel Management [111709]
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01/2016Lee Vermeulen, CCKM@uwhealth.org

magnesium hydroxide (MILK OF MAGNESIA) susp
[65443]
30 mL, 1 Bottle, 1, starting 1/29/16, No Print
bisacodyl (DULCOLAX) rectal suppository [35231] 10 mg, 1 suppository, 1, starting 1/29/16, No Print
Senna-Docusate Sodium 8.6-50 MG per tab [70181] 1-2 tab, 1 tab, 1, starting 1/29/16, No Print
polyethylene glycol (MIRALAX) oral powder [61353] 17 g, 1 Bottle, 1, starting 1/29/16, No Print
phosphate (FLEET) enema [37517] 1 enema, 1 enema, 1, starting 1/29/16, No Print
Non-categorized Medications [111711]
guaifenesin-dextroMETHORPHAN (ROBITUSSIN DM)
syrup [51568]
10 mL, 1 Bottle, 1, starting 1/29/16, No Print
carbamide peroxide (DEBROX) 6.5% otic soln [35545] 3 drop, 1 Bottle, 1, starting 1/29/16 until 2/3/16, No Print
alum-mag-simeth (MYLANTA ES) susp [44073] 30 mL, 1 Bottle, 1, starting 1/29/16, No Print
Patient Care Orders
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 [105164]
Activity [NURACT0008] Routine
Discharge Activity: See Instructions
If your surgery included small incision sites (laparoscopic
surgery) No lifting greater than 10 pounds for 2 weeks.
If your surgery included one large incision (open/laparotomy)
No lifting greater than 10 pounds for 6 weeks.
It is ok to walk up and down stairs and ok to walk for exercise.
Do not participate in strenuous exercise that uses your
abdominal muscles (ie- pilates,biking)
No driving for two weeks or while taking narcotics.
Do not have sexual intercourse, douche, use tampons or
insert anything into the vagina for 6 weeks - this is called
pelvic rest.
No Activity Restrictions [NURACT0011] Routine
Nutrition [105165]
General Diet Without Restrictions [NUT0006] Routine
General: General: No restrictions: See Health Facts for You
#276
Liquids and Modified Consistency:
Fluid Restriction:
Sodium:
Dysphagia:
Fat:
Renal:
Potassium:
Micronutrients:
Infant Formula Product:
Infant Formula Concentration:
Diabetes Diet [NUT0006] Routine
General: Diabetes Meal Plan: See Health Facts for You #262,
#371
Liquids and Modified Consistency:
Fluid Restriction:
Sodium:
Dysphagia:
Fat:
Renal:
Potassium:
Micronutrients:
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Infant Formula Product:
Infant Formula Concentration:
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.
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:
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 [105167]
Wound Care [NURWND0015] Routine, Keep incision line open to air.
Ok to shower. Pat gently dry.
No swimming or soaking in hot tubs.
Wound Care - Vulvar Care [NURWND0015] Routine, Each time you urinate or have a bowel movement,
you must rinse this area very well with warm water.
Use the squirt bottle or sitz bath you were given.
Pat gently dry with a soft towel to prevent any skin break
down, then dry this area very well using a blow dryer. If you
use a blow dryer, use it on "cool" setting on low for 5-10
minutes.
Wound Care - Additional Orders [NURWND0015] Routine
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 [123356]
Bowel Care [NURELM0068] Routine
Bladder Care [123374]
Bladder Care [NURELM0067] Routine
When to Call Your Doctor [200510]
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 100.4 degrees for two readings taken 4 hours apart,
increased shortness of breath, redness/drainage at incision
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01/2016Lee Vermeulen, CCKM@uwhealth.org

site, inability to tolerate food/liquid by mouth, vaginal bleeding
greater than one pad per hour.
- Call 911 for emergencies.
- Call your doctor at Gynecology clinic Monday-Friday 8:00am
to 5:00pm at 608-263-6240.
- To reach a doctor after hours or on weekends, call 608-263-
6240 and ask for the gynecology physician on call.
- For clinic appointments call 608-263-6240. Toll free phone
number is 800-323-8942. Clinic fax number is 608-265-1726.
Other Patient Care Instructions [123389]
Other Discharge Patient Care Instructions
[NURCOM0022]
Routine
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/cpg/guidelines/cardiovascular/resources/name-
28523-en.file
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
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 [200514]
Schedule Appointment [NURCOM0026] Reason for Appointment:
When do you want appointment:
Which Clinic or Specialty:
Which Provider (Optional):
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
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01/2016Lee Vermeulen, CCKM@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.
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.)
Page 5 of 7
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01/2016Lee Vermeulen, CCKM@uwhealth.org

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.
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.
Discharge 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 (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)
Page 6 of 7
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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.
Recommended Discharge Labs [NURCOM0075] Details
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01/2016Lee Vermeulen, CCKM@uwhealth.org