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/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98199-en.cckm

201706167

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UWHC,UWMF,

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

IP – Diabetic Ketoacidosis – Pediatric – Intensive Care – Admission [1196]

IP – Diabetic Ketoacidosis – Pediatric – Intensive Care – Admission [1196] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Diabetic Ketoacidosis - Pediatric - Intensive Care - Admission [1196]
Admission Status
Level of Care (Single Response) [187518]
*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 [127573]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: PEDIATRIC CRITICAL CARE
Rationale for LOS greater than 2 midnights:
Admission [127574]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: PEDIATRIC CRITICAL CARE
Rationale for LOS greater than 2 midnights:
Page 1 of 16
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

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 [15078]
Vital Signs [NURMON0013] EVERY 1 HOUR, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Patient Monitoring [15079]
Assess Neurologic Status [NURMON0006] EVERY 1 HOUR, Starting today For Until specified,
Routine
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [205331]
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [NURMON0014]
CONTINUOUS, Starting today, Routine, Most
pediatric patients do NOT require rhythm analysis.
Please complete the Notify Provider order below,
including specification for apnea > *** seconds. If
indicated, order pulse oximetry separately.
Device Present:
Device Mode:
Device Low Rate Limit (BPM):
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Notify [NURCOM0001] Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds
Activity [15080]
Bedrest [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: other (comment)
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Elevate Head Of Bed [NURACT0002] Equal to (degrees):
Greater than (degrees): 30
Less than (degrees): 45
Other options:
Routine, CONTINUOUS, Starting today For Until
specified
Page 2 of 16
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Nutrition [15082]
NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Bedside Meal Instructions:
Room Service Class:
Diet Type: NPO
NPO Diet: NPO except Medications
Respiratory [17471]
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today For 24 Hours, Routine
Oxygen Therapy [RT0032] CONTINUOUS, Starting today For Until specified,
Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device:
Attempt to Wean Off Oxygen? Yes
Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Starting today For Until specified,
Routine
Intake and Output [15775]
Measure Intake And Output [NURMON0005] EVERY 1 HOUR, Starting today For Until specified,
Routine
Non-Categorized Patient Care Orders [15105]
Measure Height [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine,
On admission.
Measure Weight [NURMON0015] ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
On admission.
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today, Routine, To
discontinue this order, enter a new order for
"Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes
in the new order.
Type:
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Contingency Parameters [190931]
Page 3 of 16
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
If diastolic blood pressure > (mmHg): 65
If diastolic blood pressure < (mmHg): 45
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 180
If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 100
Pulse Oximetry < (%): 95
Other: Chest tube output is greater than *** mL/hour
Contingency Parameters [190932]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
If diastolic blood pressure > (mmHg): 65
If diastolic blood pressure < (mmHg): 45
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 180
If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 100
Pulse Oximetry < (%): 95
Other: Chest tube output is greater than *** mL/hour
Contingency Parameters [190933]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
If diastolic blood pressure > (mmHg): 65
If diastolic blood pressure < (mmHg): 45
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 180
If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 100
Pulse Oximetry < (%): 95
Other: Chest tube output is greater than *** mL/hour
Contingency Parameters [190934]
Page 4 of 16
Printed by SPENCER, LINDSEY M [LMS033] at 6/15/2017 3:56:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
If diastolic blood pressure > (mmHg): 65
If diastolic blood pressure < (mmHg): 45
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 180
If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 100
Pulse Oximetry < (%): 95
Other: Chest tube output is greater than *** mL/hour
Contingency Parameters [190935]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 100
If systolic blood pressure < (mmHg): 65
If diastolic blood pressure > (mmHg): 65
If diastolic blood pressure < (mmHg): 45
If temperature > (C): 38.2 or 38.0 sustained for over
one hour
If heart rate > (bpm): 180
If heart rate < (bpm): 90
If respiratory rate >: 50
If respiratory rate <: 25
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 100
Pulse Oximetry < (%): 95
Other: Chest tube output is greater than *** mL/hour
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
Intravenous Therapy [30836]
Page 5 of 16
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Note: IV Fluid Rate [950006] 4 X DAILY (NOTE ACKNOWLEDGE)
Total IV fluids at *** mL/hr (suggested 1.5 x
maintenance)
Fluid Titration Guideline for "2 Bag" IVF System in
Pediatric DKA
Total fluid rate for Saline Bag A and Dextrose Bag B
combined= ***ml/hr
Run each individual bag (Saline Bag A and Dextrose
Bag B) based on Pediatric's blood glucose level as
described below:
Blood Glucose (> 350) Rate of Saline Bag A (100%)
Rate of Dextrose Bag B (0%)
Blood Glucose (301-350) Rate of Saline Bag A (75%)
Rate of Dextrose Bag B (25%)
Blood Glucose (251-300) Rate of Saline Bag A (50%)
Rate of Dextrose Bag B (50%)
Blood Glucose (201-250) Rate of Saline Bag A (25%)
Rate of Dextrose Bag B (75%)
Blood Glucose (101-200) Rate of Saline Bag A (0%)
Rate of Dextrose Bag B (100%)
Blood Glucose (<100) Rate of Saline Bag A (0%)
Rate of Dextrose Bag B (125% and call physician)
Each single bag rate = Total fluid rate x Percent
indicated.
*Please call physician if blood glucose falling more
than 100mg/dl per hour.
*Please call physician if blood glucose less than
100mg/dl.
Example:
Consider a sample patient with a total fluid rate of
100ml/hr currently has a blood glucose of 225.
Per the table above:
The Saline Bag A should run at 25%, so 100ml x 25%
= 25ml/hr.
The Dextrose Bag B should run at 75%, so 100ml x
75%= 75ml/hr.
The patient is still getting 100ml/hr total fluids.
IV Fluids - Saline Bag A (Single Response) [30834]
sodium chloride 0.9% with KCl 20 mEq/L infusion
[46261]
Intravenous, CONTINUOUS
Refer to IV Fluid Rate Order to determine
appropratiate dose rate for Saline Bag A
administration Page Pharmacy at 7589 to expedite
bag preparation.
Page Pharmacy at 7589 to expedite bag preparation.
IV Fluids- Dextrose Bag B (Single Response) [30835]
dextrose 10% 1,000 mL with sodium chloride 154
mEq, potassium chloride 20 mEq phosphate
potassium 13.6 mmol infusion [710000]
Intravenous, CONTINUOUS
Refer to IV Fluid Rate Order to determine appropriate
dose rate for Dextrose Bag B administration. Page
Pharmacy at 7589 to expedite bag preparation
Medications - General
Insulin Infusion [26530]
Page 6 of 16
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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06/2017CCKM@uwhealth.org

insulin regular (HUMAN) infusion PEDS PANEL
[191555]
Pediatric Hypoglycemia Algorithm URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/diabetes-and-
endocrinology/related/name-97515-en.cckm
insulin regular (human) infusion PEDS [800147] 0.1 Units/kg/hr, Intravenous, CONTINUOUS
Do NOT titrate
Glucose, POC [IPGLUCOSE] EVERY 1 HOUR, 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, 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] 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?
glucagon injection kit - Maximum Dose = 1 mg
[107799]
0.03 mg/kg, Subcutaneous, PRN, For blood
glucose less than or equal to 60 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 older than 3 years, give 1 mg.
dextrose injection - Maximum Dose = 25 grams
[800233]
0.5-1 g/kg, Intravenous, PRN, For blood glucose
less than or equal to 60 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.
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today
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.
Page 7 of 16
Printed by SPENCER, LINDSEY M [LMS033] at 6/15/2017 3:56:31 PM
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06/2017CCKM@uwhealth.org

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, 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, 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.
Medications - Electrolyte Supplementation
Potassium Chloride [149998]
potassium chloride intraVENOUS PEDS
PERIPHERAL [800208]
0.5 mEq/kg, Intravenous, PRN - NOTIFY
PHARMACY WHEN NEEDED, For potassium
replacement when serum levels < 3.1 mmol/L or < 4
mmol/L and NPO
NOTIFY PHARMACIST TO SCHEDULE DOSES
(Pager 7589). For serum potassium 3.1-4 mmol/L and
NPO, administer 0.5 mEq/kg intravenous x1 dose.
For serum potassium < 3.1 mmol/L, administer 1
mEq/kg intravenous in divided doses (max dose =
10 mEq per dose)
potassium chloride soln [800226] 1 mEq/kg, Oral, PRN - NOTIFY PHARMACY WHEN
NEEDED, For potassium replacement when serum
levels 3.1-4 mmol/L AND patient able to eat
NOTIFY PHARMACIST TO SCHEDULE DOSES
(Pager 7589). For serum potassium 3.6-4 mmol/L,
administer 2.5 mEq/kg orally in divided doses (max
dose = 20 mEq per dose, max total dose = 40 mEq).
For serum potassium 3.1-3.5 mmol/L, administer 5
mEq/kg orally in divided doses (max dose = 20 mEq
per dose, max total dose = 40 mEq)
Phosphate Sodium [222174]
Page 8 of 16
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

phosphate SODIUM intraVENOUS PEDS
PERIPHERAL [800215]
0.24 mmol/kg, Intravenous, PRN, For phosphate
replacement when serum levels < 1 mg/dL or 1-2
mg/dL and NPO
NOTIFY PHARMACIST TO SCHEDULE DOSES
(Pager 7589). For serum phosphate 1.6-2 mg/dL and
strict NPO or failure of enteral repletion or the patient
has clinical signs/symptoms of hypophosphatemia,
administer 0.24 mmol/kg IV x1 dose. For serum
phosphate 1-1.5 mg/dL and strict NPO or failure of
enteral repletion or the patient has clinical
signs/symptoms of hypophosphatemia, administer
0.24 mmol/kg IV x2 doses. For serum phosphate < 1
mg/dL, administer 0.24 mmol/kg IV x3 doses. (max
dose = 15 mmol/dose. Must provide as 7.5 mmol x 2
doses)
phosphorus (K-PHOS NEUTRAL) tab [45503] 1-2 tab, Oral, PRN - NOTIFY PHARMACY WHEN
NEEDED, For phosphate replacement when serum
levels 1-3 mg/dL AND patient able to eat.
For serum phosphate 2.6-3 mg/dL, administer 0.5
mmol/kg once. For serum phosphate 2.1-2.5 mg/dL,
administer 0.5 mmol/kg every 6 hours x2 doses. For
serum phosphate 1.6-2 mg/dL, administer 0.5
mmol/kg every 6 hours x3 doses. For serum
phosphate 1-1.5 mg/dL, administer 0.5 mmol/kg every
6 hours x4 doses. (max dose = 16 mmol/dose).
Round down to nearest tablet size.
Note: each TAB contains 8 mmol phosphorus and 1.1
mEq of potassium
Calcium [150568]
calcium GLUConate intraVENOUS - Maximum
Dose - 2000 mg [800105]
50 mg/kg, Intravenous, PRN - NOTIFY PHARMACY
WHEN NEEDED, For calcium replacement when
ionized calcium levels < 4.2 mg/dL or NPO
For ionized calcium < 4.2 mg/dL, administer 50 mg/kg
IV. Must discuss with provider prior to administration if
no central line available.
calcium carbonate (TUMS) chew tab - Maxumum
Dose - 1500 mg [44477]
500 mg, Oral, PRN, heartburn, For calcium
replacement when ionized calcium serum levels
4.2-4.8 mg/dL
For ionized calcium 4.5-4.8 mg/dL, administer 50
mg/kg PO in divided doses. For ionized calcium
4.2-4.5 mg/dL, administer 100 mg/kg PO in divided
doses.
Laboratory
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?
Every 2 Hours [15086]
Page 9 of 16
Printed by SPENCER, LINDSEY M [LMS033] at 6/15/2017 3:56:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

BLOOD GASES [HCBGAS] EVERY 2 HOURS, Starting today For 12 Hours,
Routine
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES, WHOLE BLOOD
[HCWBLYTS]
EVERY 2 HOURS, Starting today For 12 Hours,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GLUCOSE, WHOLE BLOOD [HCWBGLU] EVERY 2 HOURS, Starting today For 12 Hours,
STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Every 6 Hours [15087]
CREATININE [CRET] EVERY 6 HOURS, Starting today For 12 Hours,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] EVERY 6 HOURS, Starting today For 12 Hours,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM, IONIZED, WHOLE BLOOD
[HCWBICA]
EVERY 6 HOURS, Starting today For 12 Hours,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] EVERY 6 HOURS, Starting today For 12 Hours,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] EVERY 6 HOURS, Starting today For 12 Hours,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] EVERY 6 HOURS, Starting today For 12 Hours,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Next AM [150571]
BUN [BUN] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] NEXT AM 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 10 of 16
Printed by SPENCER, LINDSEY M [LMS033] at 6/15/2017 3:56:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

CREATININE [CRET] NEXT AM 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] NEXT AM 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] NEXT AM 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 [150570]
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL - RN COLLECT, Starting today For
24 Hours, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Condition: Draw if
blood glucose less than 100 mg/dL or greater than
400 mg/dL
BLOOD GASES [HCBGAS] CONDITIONAL - RN COLLECT, Starting today For
24 Hours, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if pH < 7.3
ELECTROLYTES, WHOLE BLOOD
[HCWBLYTS]
CONDITIONAL - RN COLLECT, Starting today For
24 Hours, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw post
supplementation if potassium < 3.5 or bicarb < 20
CALCIUM, IONIZED, WHOLE BLOOD
[HCWBICA]
CONDITIONAL - RN COLLECT, Starting today For
24 Hours, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw post
supplementation
BUN [BUN] CONDITIONAL - RN COLLECT, Starting today For
24 Hours, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if BUN > 20
CREATININE [CRET] CONDITIONAL - RN COLLECT, Starting today For
24 Hours, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw with BUN
PHOSPHATE [PHOS] CONDITIONAL - RN COLLECT, Starting today For 7
Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw post
supplementation
Laboratory [15088]
Page 11 of 16
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

TSH [TSH] 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?
T4, FREE [FT4] 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?
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?
URINALYSIS, NO MICROSCOPY [UACHEM] ONCE, 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?
HCG, QUALITATIVE, URINE [UPREG] ONCE, 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 [15092]
Consult Pediatric Diabetes (Inpatient) [CON0090] ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis): Diabetic
ketoacidosis
Can this consult be done via video?
Consult Diabetes Education - AFCH (Inpatient)
[CON0127]
ONCE, 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:
New diagnosis of diabetes (any type):
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Page 12 of 16
Printed by SPENCER, LINDSEY M [LMS033] at 6/15/2017 3:56:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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:
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Consult Child Life Specialist (Inpatient)
[CON0014]
ONCE, Starting today For 1 Occurrences, Routine
Activity Level:
Reason for Consult: ADAPTING TO
HOSP/ILLNESS/TX
Can this consult be done via video?
Comfort with new diagnosis. Introduce patient to
pediatric diabetes website
http://www.uwhealthkids.org/type1diabetes
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: Diabetic ketoacidosis
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
BestPractice
No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
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
Schedule Appointment - Diabetes Follow-up [149023]
Schedule Appointment with Provider to Manage
Diabetes [NURCOM0026]
Reason for Hospital Follow Up Appointment: Diabetes
management
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty:
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]
Page 13 of 16
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06/2017CCKM@uwhealth.org

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.
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 14 of 16
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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 15 of 16
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@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 16 of 16
Printed by SPENCER, LINDSEY M [LMS033] at 6/15/2017 3:56:31 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org