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/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98173-en.cckm

201707209

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

IP - Diabetes Discharge Supplies - Newly Diagnosed - Pediatric – Supplemental [4555]

IP - Diabetes Discharge Supplies - Newly Diagnosed - Pediatric – Supplemental [4555] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Diabetes Discharge Supplies - Newly Diagnosed - Pediatric - Supplemental
[4555]
Medications
Insulin - Rapid Acting [122451]
insulin aspart (NOVOLOG) 100 UNIT/ML injection
[65110]
1 Vial, 11, starting 7/27/17, Normal
Please subsitiute insurance preferred rapid-acting
insulin Humalog or Novolog okay
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection [53264]
1 Vial, 11, starting 7/27/17, Normal
Please subsitiute insurance preferred rapid-acting
insulin Humalog or Novolog okay
Insulin - Long Acting [122454]
insulin glargine (LANTUS) 100 UNIT/ML injection
[64829]
1 Vial, 11, starting 7/27/17, Normal
BASAGLAR KWIKPEN 100 UNIT/ML soln pen-
injector [174529]
DAW, starting 7/27/17, Normal
Glucagon (Single Response) [122456]
glucagon (GLUCAGEN) 1 MG injection kit-
NOTE: Use for patients <20 kg [61223]
0.5 mg, 2 Kit, 11, starting 7/27/17, Normal
glucagon (GLUCAGEN) 1 MG injection kit-
NOTE: Use for patients 20 kg or greater [61223]
1 mg, 2 Kit, 11, starting 7/27/17, Normal
One kit for home and school
Supplies
Syringes [122457]
Insulin Syringe-Needle U-100 31G X 15/64" 0.3
ML MISC [151092]
200 each, 11, starting 7/27/17, Normal
RPh: make sure to fill with one-half units scale on
syringe
Test strips and lancets must be specific to patient's meter and insurance [202323]
Verio Flex OR One Touch Verio Meter [202324]
Glucose Blood (ONETOUCH VERIO) STRP
[64259]
200 Strip, 11, starting 7/27/17, Normal
ONETOUCH DELICA LANCETS 33G MISC
[159866]
200 each, 11, starting 7/27/17, Normal
Test strips and lancets must be specific to patient’s meter and insurance [139222]
Accuchek Guide Meter [228385]
ACCU-CHEK GUIDE STRP [175581] 200 Strip, 11, DAW, starting 7/27/17, E-Prescribe
Glucose Blood (ACCU-CHEK GUIDE) STRP
[64259]
200 Strip, 11, starting 7/27/17, Normal
Dispense Accuchek Guide Glucose Test Strips
Test strips and lancets must be specific to patient’s meter and insurance [139221]
Freestyle Lite Meter [139198]
Glucose Blood (FREESTYLE LITE TEST) STRP
[64259]
200 Strip, 11, starting 7/27/17, Normal
FreeStyle Lancets MISC [64865] 200 each, 11, starting 7/27/17, Normal
Test strips and lancets must be specific to patient's meter and insurance [222080]
Bayer Contour Next One [222081]
Glucose Blood (BAYER CONTOUR NEXT TEST)
STRP [64259]
200 Strip, 11, starting 7/27/17, Normal
BAYER MICROLET LANCETS MISC [57493] 200 each, 11, starting 7/27/17, Normal
Acetone (Urine) Test Strips [122460]
Acetone (Urine) Test STRP [64253] 2 each, 11, starting 7/27/17, Normal
Please provide patient with strips for use at home and
school
Other Discharge Patient Care Instructions
Other Discharge Patient Care Instructions [135627]
Page 1 of 5
Printed by SPENCER, LINDSEY M [LMS033] at 7/27/2017 9:55:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Other Discharge Patient Care Instructions
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, @PEDSDIABETESDC@
Follow-up Care
Appointments [139202]
appointments.not already scheduled, please make the following f/u If
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment: Diabetes
self-management education/support
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty: Pediatric Sub-specialty
Clinic
This appointment should be scheduled for the SAME
DAY as the appointment with the Nutritionist in
Pediatric sub-specialty clinic.
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment: Diabetes
self-management education/support
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty: Pediatric Learning Center
(please call the Peds Learning Center directly to
schedule this appointment: 890-8039)
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment: Diabetes
self-management education/support
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty: Pediatric Sub-specialty
Clinic
This appointment should be scheduled for the SAME
DAY as the appointment with the Pediatric Diabetes
Mid-Level Provider
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment: Follow-
up from hospitalization for newly diagnosed diabetes
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty: In-patient pediatric diabetes
attending. If no appointments available, please call the
diabetes clinic at 608-263-6420 and have the diabetes
nurse paged to discuss appointment options.
Follow-up Appointments - Required Documentation
Follow Up Appointments - Diabetes (Single Response) [149021]
Joint Commission Requirement: Patients must have an appointment scheduled WITHIN 30
DAYS of discharge with a provider who will manage their diabetes care. Exclusions are allowed
based upon patient situation (e.g., discharge to skilled nursing facility, patient refusal, etc.).
Schedule Appointment with Provider to Manage
Diabetes [222085]
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Diabetes management
Which Provider:
Page 2 of 5
Printed by SPENCER, LINDSEY M [LMS033] at 7/27/2017 9:55:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@uwhealth.org

Appointment scheduled (with provider who can
manage diabetes) [COR0064]
ONCE 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)
Date of appointment (Month/Year):
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.)
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 3 of 5
Printed by SPENCER, LINDSEY M [LMS033] at 7/27/2017 9:55:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@uwhealth.org

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.
Page 4 of 5
Printed by SPENCER, LINDSEY M [LMS033] at 7/27/2017 9:55:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@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.
Page 5 of 5
Printed by SPENCER, LINDSEY M [LMS033] at 7/27/2017 9:55:45 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
07/2017CCKM@uwhealth.org