/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-98193-en.cckm

201706156

page

100

UWHC,UWMF,

Tools,

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

IP - Diabetes - Newly Diagnosed - Pediatric - Admission [1235]

IP - Diabetes - Newly Diagnosed - Pediatric - Admission [1235] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Diabetes - Newly Diagnosed - Pediatric - Admission [1235]
ordersPeds Endo/Diabetes fellow on call for assistance with these Contact
Admission Status
Level of Care (Single Response) [186484]
*An admit patient order has already been written, but the level of care at which the patient
should be placed still needs to be identified.
Place Patient on General Care [ADT0018] General Care, has already been signed. This order
will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intermediate Care (IMC)
[ADT0018]
Intermediate Care, has already been signed. This
order will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intensive Care (ICU) [ADT0018] Intensive Care, has already been signed. This order
will ensure that the patient is placed at the
appropriate level of care.
Admit to Inpatient (Single Response) [188296]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically
necessary because of either an anticipated LOS >2
midnights, complexity and/or severity of illness, an
inpatient-only surgery, or a previously-authorized
inpatient stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [143599]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: PEDIATRIC DIABETES
Rationale for LOS greater than 2 midnights:
Anticipated Discharge Date:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service: PEDIATRIC DIABETES
Page 1 of 14
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Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service: PEDIATRIC DIABETES
Admission Status (Single Response) [82665]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Patient Care Orders
Vital Signs [15503]
Vital Signs [NURMON0013] EVERY 8 HOURS, Starting today For 24 Hours,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital Signs [NURMON0013] DAILY, Starting today with First Occurrence As
Scheduled For Until specified, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Activity [103829]
Page 2 of 14
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05/2017CCKM@uwhealth.org

Ad Lib [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB: ad lib
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition [15504]
Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: NPO
NPO Diet: Strict NPO
Bedside Meal Instructions:
Room Service Class:
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Non-Categorized Patient Care Orders [15505]
Glucose, POC [IPGLUCOSE] COLLECT UPON ADMISSION, Starting today For 1
Occurrences, Routine, Glucose, POC should always
be ordered in conjunction with orders for
hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Glucose, POC [IPGLUCOSE] BEFORE MEALS AND BEDTIME, Starting today For
Until specified, Routine, Glucose, POC should always
be ordered in conjunction with orders for
hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Glucose, POC [IPGLUCOSE] SUPPLEMENTAL CHECK AT 0200, Starting today,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today For Until specified,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Page 3 of 14
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA
TREATMENT, Starting today, Routine, Glucose, POC
should always be ordered in conjunction with orders
for hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Assess Neurologic Status [NURMON0006] EVERY 8 HOURS, Starting today For 24 Hours,
Routine
Measure Height - On Admission
[NURMON0052]
ONCE For 1 Occurrences, Routine, On admission,
standing height preferred
Measure Weight [NURMON0015] ONCE For 1 Occurrences, Routine
Weigh With? Other (Comment) (On admission, weigh
using standing scale.)
Weigh when?
On admission, weigh using standing scale.
Contingency Parameters [15506]
Notify Provider [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 70
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: For blood glucose less than 100
milligrams/deciliter from midnight to 0600 am, If
seizure or unconsciousness
Intravenous Therapy
Premedication for Needle Insertion [30232]
Lidocaine [152737]
Page 4 of 14
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

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 - Scheduled Insulin
Rapid-acting - Lispro - Insulin to Carbohydrate Ratio [103977]
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection - NOTE: Mealtime carbohydrate
counting dose [53264]
1-10 units, Subcutaneous, 3 X DAILY (AT
MEALTIME)
Patient-determined dose using ratio of 1unit/*** g
carbohydrate. Give PRIOR to starting meal.
Document carbohydrate grams eaten in Doc
Flowsheet.
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection - NOTE: Snack carbohydrate counting
dose [53264]
1-10 units, Subcutaneous, 3 X DAILY PRN, snacks -
see administration instructions
Patient-determined dose using ratio of 1 unit/*** g
carbohydrate for snacks greater than *** g. Give
PRIOR to starting meal.
Document carbohydrate grams eaten in Doc
Flowsheet.
Long-acting - Glargine [103976]
insulin glargine (LANTUS) 100 UNIT/ML injection
- BEDTIME [64829]
Subcutaneous, 1 X DAILY (HS)
Administer at bedtime. Administer even if NPO. Do
NOT mix with other insulins
Medications - Correction Insulin
Correction Insulin [125154]
Page 5 of 14
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection - DAYTIME [53264]
0-20, Subcutaneous, 3 X DAILY (AT MEALTIME)
For daytime hyperglycemia ONLY
For blood sugar units;
For blood sugar 151-200 mg/dL give *** units;
For blood sugar 201-250 mg/dL give *** units;
For blood sugar 251-300 mg/dL give *** units;
For blood sugar 301-350 mg/dL give *** units;
For blood sugar 351-400 mg/dL give *** units;
For blood sugar 401-450 mg/dL give *** units;
For blood sugar 451-500 mg/dL give *** units;
For blood sugar 501-550 mg/dL give *** units;
For blood sugar 551-600 mg/dL give *** units;
For blood sugar 601-650 mg/dL give *** units;
For blood sugar 651 mg/dL or higher, give *** units.
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection - BEDTIME [53264]
0-20, Subcutaneous, 1 X DAILY (HS)
For bedtime hyperglycemia ONLY
For blood sugar units;
For blood sugar 201-250 mg/dL give *** units;
For blood sugar 251-300 mg/dL give *** units;
For blood sugar 301-350 mg/dL give *** units;
For blood sugar 351-400 mg/dL give *** units;
For blood sugar 401-450 mg/dL give *** units;
For blood sugar 451-500 mg/dL give *** units;
For blood sugar 501-550 mg/dL give *** units;
For blood sugar 551-600 mg/dL give *** units;
For blood sugar 601-650 mg/dL give *** units;
For blood sugar 651 mg/dL or higher, give *** units.
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection - OVERNIGHT [53264]
0-20, Subcutaneous, 1 X DAILY
For overnight hyperglycemia ONLY. RPh to schedule
doses for 0200
For blood sugar units;
For blood sugar 201-250 mg/dL give *** units;
For blood sugar 251-300 mg/dL give *** units;
For blood sugar 301-350 mg/dL give *** units;
For blood sugar 351-400 mg/dL give *** units;
For blood sugar 401-450 mg/dL give *** units;
For blood sugar 451-500 mg/dL give *** units;
For blood sugar 501-550 mg/dL give *** units;
For blood sugar 551-600 mg/dL give *** units;
For blood sugar 601-650 mg/dL give *** units;
For blood sugar 651 mg/dL or higher, give *** units.
Medications - Hypoglycemia Treatment
Pediatric Hypoglycemia Treatment Algorithm URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/diabetes-and-
endocrinology/related/name-97515-en.cckm
Patient Unable to Eat/Swallow Safely and No IV Access (Single Response) [143430]
Page 6 of 14
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glucagon 1 mg injection kit - NOTE: Maximum
Dose = 1 mg [107799]
0.03 mg/kg, Subcutaneous, PRN, for blood glucose
less than or equal to 69 mg/dL AND patient is unable
to eat/swallow safely, NPO or unconscious AND has
NO IV access.
Reconstituted concentration equals 1 mg/mL. If no
weight entered and patient 3 years or younger, give
0.5 mg. If no weight entered and patient older than 3
years, give 1 mg.
Patient Unable to Eat/Swallow Safely and Has IV Access [143431]
dextrose injection - NOTE: Maximum Dose = 25
g [800233]
0.5-1 g/kg, Intravenous, PRN, For blood glucose less
than or equal to 69 mg/dL AND patient is unable to
eat/swallow safely, NPO or unconscious AND has IV
access.
Repeat every 15 minutes until blood glucose greater
than 70 mg/dL
Oral Treatment [26524]
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? For blood glucose
less than 40 mg/dL and patient able to eat/swallow
safely
Give 30 grams of carbohydrate (6-8 oz. of fruit juice).
Repeat treatment every 15 minutes until glucose is 70
mg/dL or greater. Give 15 gram carbohydrate and
protein snack if meal or snack is not scheduled within
1 hour of hypoglycemic episode.
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today
If Conditional, What Condition? For blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely
Give 15 grams of carbohydrate (3-4 oz. of fruit juice).
Repeat treatment every 15 minutes until glucose is 70
mg/dL or greater. Give 15 gram carbohydrate and
protein snack if meal or snack is not scheduled within
1 hour of hypoglycemic episode.
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN, hypoglycemia,
For blood glucose 40-69 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater
glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN, hypoglycemia,
For blood glucose less than 40 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater
Laboratory
On Admission [15507]
ELECTROLYTES [LYTE] COLLECT UPON ADMISSION, 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 7 of 14
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

BUN [BUN] COLLECT UPON ADMISSION, 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] COLLECT UPON ADMISSION, 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] COLLECT UPON ADMISSION, 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] COLLECT UPON ADMISSION, 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] COLLECT UPON ADMISSION, Starting today For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
URINALYSIS WITH MICROSCOPY [UA] COLLECT UPON ADMISSION, 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?
IMMUNOGLOBULIN A [XIGA] COLLECT UPON ADMISSION, 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?
TISSUE TRANSGLUTAMINASE AB, IGA
[XTTGA]
COLLECT UPON ADMISSION, 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?
GAD AB [HCGAD65] COLLECT UPON ADMISSION, 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?
ISLET CELL AB, IGG [HCISLET] COLLECT UPON ADMISSION, 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?
T4, FREE [FT4] COLLECT UPON ADMISSION, 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 14
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05/2017CCKM@uwhealth.org

TSH [TSH] COLLECT UPON ADMISSION, 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?
IA-2 AB [HCIA2AB] COLLECT UPON ADMISSION, 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?
ZINC TRANSPORTER 8 AB [HCZNT8AB] COLLECT UPON ADMISSION, 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?
Conditional Labs [144856]
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL - RN COLLECT, Starting today For 7
Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if blood glucose
is less than 40 mg/dL or greater than 400 mg/dL
Obtain if Not Done Within Last 90 Days [19217]
HEMOGLOBIN A1C [HA1C] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Consults
Consults [15508]
Consult Learning Center - Diabetes Education
(Pediatric) [CON0127]
ONCE For 1 Occurrences, Routine, - If patient is
newly diagnosed or is new to insulin, provide 24
hours notice to allow adequate time for education,
- Indicate diabetes medication/treatment plan if
known.
- Consults requested after 1600 on Fridays may not
be seen until following Monday. Learning Center
available Mon-Sat 0800-1630 (only 1 RN available on
Saturday for CSC and AFCH).
- Staff may be contacted by Pager 7927 on weekdays
and Pager 3276 on weekends.
- Learning Center staff are not available on holidays.
Type of Education: Diabetes Self-Management
Education
Reason For Consult: New/recent diagnosis
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Consult Pediatric Health Psychology (Inpatient)
[CON0202]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-Friday)
or if special assessment needs.
Reason for Consult: New diagnosis chronic disease
Page 9 of 14
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05/2017CCKM@uwhealth.org

Consult Diabetes Education - Nutrition (Inpatient)
[CON0126]
ONCE, Starting today For 1 Occurrences, Routine, ·
If your patient is newly diagnosed and/or is new to
insulin therapy, provide 24 hours notice to allow
adequate time for nutrition education.
· Indicate diabetes medication/treatment plan if
known.
· Consults requested after 1300 on Friday may not
be completed until the following Monday.
· If you are placing a consult on a weekend day for a
patient who will be discharging that weekend, please
have the Paging Center contact the on-call dietitian to
help you facilitate the diabetes nutrition education
session prior to the patient's discharge.
Type of Education: Diabetes Self-Management
Education
Reason For Consult: New/recent diagnosis
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Consult Child Life Specialist (Inpatient)
[CON0014]
ONCE, Routine
Activity Level: ABLE TO ATTEND PLAY
ROOM/TEEN ROOM
Reason for Consult: ADAPTING TO
HOSP/ILLNESS/TX
Comfort with new diagnosis. Introduce patient to
pediatric diabetes website
http://www.uwhealthkids.org/type1diabetes
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: OTHER
Is this a STAT consult?
Can this consult be done via video?
Adjustment to new diagnosis
Follow-up Appointments - Required Documentation
discharge with a up appointment must be scheduled BEFORE -Joint Commission, a followPer
Complete the following orders as provider who will manage a patient's diabetes care.
the appropriate circumstance.appropriate to schedule and/or document
Follow-up Care [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)
Page 10 of 14
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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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 - 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 [221272]
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Diabetes management
Which Provider:
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.
Page 11 of 14
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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.
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.
Page 12 of 14
Printed by SPENCER, LINDSEY M [LMS033] at 5/26/2017 5:14:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

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.
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.
BestPractice
No Hospital Problems have yet been identified. [107035]
Page 13 of 14
Printed by SPENCER, LINDSEY M [LMS033] at 5/26/2017 5:14:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
Page 14 of 14
Printed by SPENCER, LINDSEY M [LMS033] at 5/26/2017 5:14:46 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org