/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/hospital-wide/,

/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-113249-en.cckm

201709262

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Hospital-wide

ED/IP - Child Abuse - Pediatric - Supplemental [3539]

ED/IP - Child Abuse - Pediatric - Supplemental [3539] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


ED/IP - Child Abuse - Pediatric - Supplemental [3539]
prior to 2122) has been consulted -262-ensure that UW Child Protection Program (608Please
using this order set.
Intravenous Therapy
Premedication for Needle Insertion [30232]
Lidocaine [152737]
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, prior to needle sticks
to reduce pain. See "LMX Use Instructions" order in
Active Orders report or the Admin Instructions for
application details
FOR PATIENTS 5 Kg OR LESS: Do NOT apply to
area greater than 100 square centimeters.
(maximum 1 g/site; maximum 1 site per hour, 6
times per day).
FOR PATIENTS 5.1-10 Kg: Do NOT apply to area
greater than 100 square centimeters. (maximum 1
g/site; maximum 2 sites per hour, 6 times per day).
FOR PATIENTS GREATER THAN 10 Kg: Do NOT
apply to area greater than 200 square centimeters.
(maximum 2.5 g/site; maximum 4 sites per hour, 6
times per day).
For patients less than 1 year old do NOT leave on
longer than 1 hour. For patients 1 year or older do
NOT leave on longer than 2 hours
LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Details
Medications
Inhalers [221793]
albuterol HFA 108 (90 BASE) MCG/ACT
(VENTOLIN HFA) inhaler [53730]
2 puff, Inhalation, EVERY 4 HOURS PRN, dyspnea
Prescriptions [228328]
clobetasol (TEMOVATE) 0.05 % ointment [44733] 60 g, 0, starting 9/19/17, Normal
estrogens, conjugated (PREMARIN) 0.625
MG/GM vaginal cream [45098]
30 g, 0, starting 9/19/17 until 10/3/17, Normal
Radiology
Radiology [205895]
NON ACCIDENTAL TRAUMA CT HEAD
[149087]
Page 1 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

CT HEAD W/ O IV CONTRAST [R70450] ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms? Evaluate for abuse
What specific question(s) would you like answered
by this exam? Evaluate for abuse
Relevant recent/past history? Evaluate for abuse
Is patient pregnant?
Allergies to IV contrast or iodine?
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 3D RECONSTRUCTION ON
WORKSTATION [R76377]
ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms? Evaluate for abuse
What specific question(s) would you like answered
by this exam? Evaluate for abuse
Relevant recent/past history? Evaluate for abuse
Is patient pregnant?
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:
X-RAY SKELETAL SURVEY COMPLETE
[R77075]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, STAT
Current signs and symptoms? Evaluate for abuse
What specific question(s) would you like answered by
this exam? Evaluate for abuse
Relevant recent/past history? Evaluate for abuse
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
Page 2 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

MRI HEAD W & W/ O CONTRAST [R70553] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, STAT
Current signs and symptoms? Evaluate for abuse
What specific question(s) would you like answered by
this exam? Evaluate for abuse
Relevant recent/past history? Evaluate for abuse
Is patient pregnant?
Does patient have a pacemaker or defibrillator?
Allergy to Gadolinium (MRI) contrast?
For Scheduling purposes, is the patient claustrophobic
or require any form of sedation? Note: ordering
provider is responsible for prescribing oral anxiolytic or
ordering sedation services.
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.
Relevant Surgical History (Select all applicable or
None):
Implanted Devices? (Select all applicable or None):
History of Metal in Body? (Select all applicable or
None):
Has patient had a colonoscopy/endoscopy in the last 8
weeks?
Study Needed Within:
Last creatinine value? (will auto pull in date and value
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
Last patient height? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Page 3 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

MRI TOTAL SPINE W & W/ O CONTRAST
[R07013]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, STAT
Current signs and symptoms? Evaluate for abuse
What specific question(s) would you like answered by
this exam? Evaluate for abuse
Relevant recent/past history? Evaluate for abuse
Is patient pregnant?
Does patient have a pacemaker or defibrillator?
Allergy to Gadolinium (MRI) contrast?
For Scheduling purposes, is the patient claustrophobic
or require any form of sedation? Note: ordering
provider is responsible for prescribing oral anxiolytic or
ordering sedation services.
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.
Relevant Surgical History (Select all applicable or
None):
Implanted Devices? (Select all applicable or None):
History of Metal in Body? (Select all applicable or
None):
Has patient had a colonoscopy/endoscopy in the last 8
weeks?
Study Needed Within:
Last creatinine value? (will auto pull in date and value
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
Last patient height? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Page 4 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

MRI ABDOMEN PELVIS W & W/ O CONTRAST
[R07020]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, STAT
Current signs and symptoms? Evaluate for abuse
What specific question(s) would you like answered by
this exam? Evaluate for abuse
Relevant recent/past history? Evaluate for abuse
Is patient pregnant?
Does patient have a pacemaker or defibrillator?
Allergy to Gadolinium (MRI) contrast?
For Scheduling purposes, is the patient claustrophobic
or require any form of sedation? Note: ordering
provider is responsible for prescribing oral anxiolytic or
ordering sedation services.
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.
Relevant Surgical History (Select all applicable or
None):
Implanted Devices? (Select all applicable or None):
History of Metal in Body? (Select all applicable or
None):
Has patient had a colonoscopy/endoscopy in the last 8
weeks?
Study Needed Within:
Last creatinine value? (will auto pull in date and value
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
Last patient height? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Ophthalmology
Consults [204957]
CONSULT TO PEDS OPHTHALMOLOGY
[1009097]
Details
Consult Ophthalmology Resident (ED Only)
[CON0518]
ONCE
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Dilated Ophtho exam,
Evaluate for retinal hemorrages/intraoccular injury
Can this consult be done via video?
Physical Abuse
Laboratory - Hematology [104013]
PROTHROMBIN TIME/INR [PT] STAT - RN COLLECT, 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 5 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

THROMBIN TIME [HCCTT] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FACTOR VIII ACTIVITY [HCF8A] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
VON WILLEBRAND AG [XVWFAG] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
VON WILLEBRAND FACTOR ACTIVITY
[HCVWFACT]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PLATELET FUNCTION SCREEN [116741]
containing medications for 7 -Fasting specimen preferred. Patient ingestion of aspirin or aspirin
narcotic analgesics, or NSAIDs for 48 hours prior to specimen -days and/or antihistamines, non
collection may cause abnormal results.
if von Willebrand disease is suspected.Indicate
PLATELET FUNCTION SCREEN, ADP
[HCPFAADP]
NEXT AM For 1 Occurrences, Routine, Fasting
specimen preferred. Patient ingestion of aspirin or
aspirin-containing medications for 7 days and/or
antihistamines, non-narcotic analgesics, or NSAIDS
for 48 hours prior to specimen collection may cause
abnormal
results.
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
PLATELET FUNCTION SCREEN,
EPINEPHRINE [HCPFAEPI]
NEXT AM For 1 Occurrences, Routine, Fasting
specimen preferred. Patient ingestion of aspirin or
aspirin-containing medications for 7 days and/or
antihistamines, non-narcotic analgesics, or NSAIDS
for 48 hours prior to specimen collection may cause
abnormal
results.
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
Laboratory - Abusive Head Trauma [204958]
Page 6 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

CBC WITH DIFFERENTIAL [CBC] STAT - RN COLLECT, 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?
RETICULOCYTE COUNT [RET] STAT - RN COLLECT, 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] STAT - RN COLLECT, 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] STAT - RN COLLECT, 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?
THROMBIN TIME [HCCTT] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FACTOR VIII ACTIVITY [HCF8A] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
VON WILLEBRAND AG [XVWFAG] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
VON WILLEBRAND FACTOR ACTIVITY
[HCVWFACT]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
TYPE AND SCREEN [HCTS] STAT - RN COLLECT, 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.
Page 7 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

PROTEIN C ACTIVITY [XPCF] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTEIN S ACTIVITY [XPSF] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, Patient must not be on
Warfarin therapy.
Patient must be off Warfarin therapy for at least one
week.
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FACTOR IX ACTIVITY [XFAC9] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FACTOR XI ACTIVITY [HCF11A] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
Is the patient receiving any anticoagulant?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FACTOR XIII AG [F13AG] STAT - RN COLLECT, 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?
Laboratory - Abdominal [204959]
AST/SGOT [AST] STAT - RN COLLECT, 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] STAT - RN COLLECT, 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?
LIPASE [LIPS] STAT - RN COLLECT, 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?
AMYLASE [AMYL] STAT - RN COLLECT, 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 8 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

URINALYSIS WITH MICROSCOPY [UA] STAT - RN COLLECT, 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?
Laboratory - Bone Mineralization [204960]
CALCIUM [CA] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] STAT - RN COLLECT, 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] STAT - RN COLLECT, 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] STAT - RN COLLECT, 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?
PTH [HCPTHIN] STAT - RN COLLECT, 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 9 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

VITAMIN D, 25-HYDROXY BY HPLC (Peds
Patients ONLY) [HCLCD25]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, Screening for Vitamin D
deficiency is not covered by Medicare. If this is the
reason for the test, please advise the patient of non-
coverage via the ABN process. Coverage is allowed in
some other circumstances. If one of these diagnoses
is appropriate for your patient, please associate the
corresponding code with this order.
252.00 (ICD-9); E21.3 (ICD-10) Hyperparathyroidism,
unspecified
252.01 (ICD-9); E21.0 (ICD-10) Primary
Hyperparathyroidism
252.02 (ICD-9); E21.1 (ICD-10) Secondary
Hyperparathyroidism, Non-Renal
252.08 (ICD-9); E21.2 (ICD-10) Other
Hyperparathyroidism
252.1 (ICD-9); E20.9 (ICD-10) Hypoparathyroidism
268.0 (ICD-9); E55.0 (ICD-10) Rickets Active
268.2 (ICD-9); M83.9 (ICD-10) Osteomalacia
Unspecified
268.9 (ICD-9); E55.9 (ICD-10) Established Vitamin D
Deficiency (monitoring efficacy of replacement
therapy)
275.3 (ICD-9); E83.30 (ICD-10) Disorders of
Phosphorus Metabolism
275.41 (ICD-9); E83.51 (ICD-10) Hypocalcemia
275.42 (ICD-9); E83.52 (ICD-10) Hypercalcemia
585.3 (ICD-9); N18.3 (ICD-10) Chronic Kidney
Disease, Stage III (Moderate)
585.4 (ICD-9); N18.4 (ICD-10) Chronic Kidney
Disease, Stage IV (Severe)
585.5 (ICD-9); N18.5 (ICD-10) Chronic Kidney
Disease, Stage V
585.6 (ICD-9); N18.6 (ICD-10) End Stage Renal
Disease
588.81 (ICD-9); N25.81 (ICD-10) Secondary
Hyperparathyroidism (of Renal Origin)
733.00 (ICD-9); M81.0 (ICD-10) Osteoporosis
Unspecified
Page 10 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

733.01 (ICD-9); M81.0 (ICD-10) Senile Osteoporosis
733.02 (ICD-9); M81.8 (ICD-10) Idiopathic
Osteoporosis
733.03 (ICD-9); M81.8 (ICD-10) Disuse Osteoporosis
733.09 (ICD-9); M81.8 (ICD-10) Other Osteoporosis
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Laboratory - Rhabdomyolysis [204961]
ELECTROLYTES [LYTE] STAT - RN COLLECT, 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] STAT - RN COLLECT, 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] STAT - RN COLLECT, 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] STAT - RN COLLECT, 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] STAT - RN COLLECT, 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] STAT - RN COLLECT, 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] STAT - RN COLLECT, 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?
BILIRUBIN, TOTAL [TBIL] STAT - RN COLLECT, 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] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 11 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

ALT/SGPT [ALT] STAT - RN COLLECT, 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] STAT - RN COLLECT, 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?
CK, TOTAL [CPK] STAT - RN COLLECT, 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?
Sexual Abuse
Laboratory [104008]
CULTURE, YEAST, VAGINAL WITH SMEAR
[HCYSTCS]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, Simultaneous Testing for
Culture, Trichmonas with Wet Prep; Culture, Yeast,
Vaginal with Smear; and Gram Stain for Bacterial
Vaginosis is highly recommended.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GRAM STAIN VAGINAL FOR BACTERIAL
VAGINOSIS [HCGSVG]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, Simultaneous Testing for
Culture, Trichmonas with Wet Prep; Culture, Yeast,
Vaginal with Smear; and Gram Stain for Bacterial
Vaginosis is highly recommended.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
TRICHOMONAS VAGINALIS BY AMPLIFIED
PROBE TECHNIQUE (vagina) [TVAPT]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, This test is for vaginal,
endocervical and urine specimens. For male urethral
specimens see Trichomonas vaginalis by TMA
[UTVTMA].
If the specimen is urine, then the patient should not
urinate for at least one hour prior to the collection of
urine specimen. Collect the first 10-50 mL into a urine
container.
Simultaneous testing for Trichomonas vaginalis by
Amplified Probe Technique; Culture, Yeast, Vaginal
with Smear and Gram Stain for Bacterial Vaginosis is
highly recommended.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 12 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

T. vaginalis by NAAT (male or female urine)
[RMISC]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
What lab test would you like to have performed?
Trichomonas vaginalis by NAAT
For questions I can be reached at:
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, TRICHOMONAS VAGINALIS (Male
urine) [TVAGCX]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, This test is to be ordered only
for cases of suspected child abuse. A vaginal swab or
male urine collection are the only acceptable
specimen types.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, TRICHOMONAS VAGINALIS
(Vagina) [TVAGCX]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, This test is to be ordered only
for cases of suspected child abuse. A vaginal swab or
male urine collection are the only acceptable
specimen types.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
C TRACHOMATIS AND N GONORRHOEAE BY
AMPLIFIED PROBE TECHNIQUE [HCCGAPT]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, Unacceptable sources include
throat (or any oropharyngeal sites), rectal and eye.
If the specimen is urine, then the patient should not
urinate for at least one hour prior to the collection of
urine specimen. Collect the first 10-50 mL into a urine
container.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
C. TRACHOMATIS AND N. GONORRHOEAE BY
TMA, RECTAL AND THROAT SPECIMENS
(Throat) [HCCGTMA]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, Intended specimen type for this
test is throat swabs and rectal specimens only.
Requires special media available in UWHC Central
Services. Order supply 4013141. For urine or
genitourinary specimens, refer to C. trachomatis and
N. gonorrhoeae by Amplified Probe Technique
[HCCGAPT].
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 13 of 17
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09/2017CCKM@uwhealth.org

C. TRACHOMATIS AND N. GONORRHOEAE BY
TMA, RECTAL AND THROAT SPECIMENS
(Rectum) [HCCGTMA]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, Intended specimen type for this
test is throat swabs and rectal specimens only.
Requires special media available in UWHC Central
Services. Order supply 4013141. For urine or
genitourinary specimens, refer to C. trachomatis and
N. gonorrhoeae by Amplified Probe Technique
[HCCGAPT].
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
C TRACHOMATIS BY AMPLIFIED PROBE
TECHNIQUE (Endocervix) [HCCTAPT]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, Testing for both Neisseria
gonorrhoeae and Chlamydia trachomatis is highly
recommended. If the specimen is urine, then the
patient should not urinate for at least 1 hour prior to
the collection of urine specimen. Collect the first 10-
50 mL into a urine container.
Unacceptable sources include throat (or any
oropharyngeal sites), rectal and eye.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, CHLAMYDIA TRACHOMATIS
(Rectum) [XCHLAM]
STAT - RN COLLECT, 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?
CULTURE, CHLAMYDIA TRACHOMATIS
(Vagina) [XCHLAM]
STAT - RN COLLECT, 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?
CULTURE, N GONORRHOEAE (Rectum) [GC] STAT - RN COLLECT, 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?
CULTURE, N GONORRHOEAE (Vagina) [GC] STAT - RN COLLECT, 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?
CULTURE, N GONORRHOEAE (Throat) [GC] STAT - RN COLLECT, 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?
CULTURE, BETA STREPTOCOCCUS, RECTAL
[HCSSREC]
STAT - RN COLLECT, 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 14 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

HIV AB/AG COMBO [HIVABAG] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, I, the ordering provider, have
verified that the patient/patient's authorized
representative was:
1. Notified that the patient will be subjected to an HIV
test unless the patient/rep declines the test;
2. Given educational materials on HIV and HIV testing;
3. Notified that they may decline the test and health
care providers may not use the fact that the
patient/rep declined an HIV test as a basis for denying
other services; and
4. Provided an opportunity to ask questions and to
decline the HIV test.
The ordering provider verifies:
5. The patient/patient's authorized representative
understands that an HIV test will be performed; and
6. The decision of the patient/rep regarding whether to
have an HIV test performed was not coerced or
involuntary.
Pt/Pt's Rep did not opt out. Steps listed in instructions
taken. If test is declined, type ".HIVTESTDECLINE" in
progress note.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
RPR, CONFIRM IF POSITIVE [RPRFTA] STAT - RN COLLECT, 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?
HEPATITIS C AB [HCV] STAT - RN COLLECT, 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?
HEPATITIS B SURFACE AB [HBSABI] STAT - RN COLLECT, 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?
HEPATITIS B SURFACE AG [HBSAG] STAT - RN COLLECT, 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 15 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

Drug Facilitated Sexual Assault Lab Test(s)
[RMISC]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
What lab test would you like to have performed?
MedTox test #19253
For questions I can be reached at:
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Specimen Type: Aliquot of random or spot urine
collection
Tube Type: Urine transfer tube without preservative
Specimen Volume: 10 mL
Collection Time: Random
Storage and Transport Temperature: Ambient
temperature is acceptable for shipping and/or short-
term storage (up to 3 days); specimen may also be
refigerated or frozen.
QUANTIFERON-TB GOLD [GM8455] STAT - RN COLLECT, 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?
PAP TEST [HCPATHP] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, Diagnostic: Previous Abnormal
Pap, History of GYN Cancer, Abnormal Complaints or
Findings;
Screening, HIGH RISK: DES Daughter, History of
STD, Multiple Partners, Early Onset of Sexual Activity
Screening, LOW RISK: Routine Exam
If an HPV reflex option is not ordered at the time of the
Pap test it can be ordered as an "add on" test within 3
weeks of collection of the Pap test specimen.
HPV requests on conventional Paps require additional
sample collection in a ThinPrep PreservCyt Solution
vial.
Specimen Site:
HPV Reflex:
Clinical History- Select all that apply:
Menstrual Status:
Previous Procedures:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HCG, QUALITATIVE, URINE [UPREG] STAT - RN COLLECT, 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?
Drug Ingestion / Drug Endangered Child
Laboratory [204962]
Page 16 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org

DRUG SCREEN, URINE [HCUPNL] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, Test includes:
Amphetamines/Methamphetamines, Barbiturates,
Benzodiazepine, Cocaine, and Opiates (primarily
targets morphine, codeine, and heroin).
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
DRUG SCREEN, GC/MS, SERUM [HCTSPNL] STAT - RN COLLECT, 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?
DRUG SCREEN GC/MS, URINE [HCTUPNL] STAT - RN COLLECT, 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?
Drug Facilitated Sexual Assault Lab Test(s)
[RMISC]
STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
What lab test would you like to have performed?
MedTox test #19253
For questions I can be reached at:
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Specimen Type: Aliquot of random or spot urine
collection
Tube Type: Urine transfer tube without preservative
Specimen Volume: 10 mL
Collection Time: Random
Storage and Transport Temperature: Ambient
temperature is acceptable for shipping and/or short-
term storage (up to 3 days); specimen may also be
refigerated or frozen.
Synthetic Marijuana Lab Test [RMISC] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
What lab test would you like to have performed?
ARUP test lab #2008091
For questions I can be reached at:
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Specimen: Aliquot of random or spot urine collection
Volume: 10 mL, 1.0 mL minimum volume
Handling: Refrigerate; Specimen may also be frozen
CANNABINOIDS SCREEN [GM5300] STAT - RN COLLECT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CANNABINOIDS, CONFIRMATION/QUANT,
URINE [HCUTHC]
STAT - RN COLLECT 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 17 of 17
Printed by STRAKA, KEVIN F [KFS1] at 9/19/2017 2:45:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
09/2017CCKM@uwhealth.org