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201606170

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UWHC,UWMF,

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

IP - ECMO - Pediatric - Post-Cannulation [2215]

IP - ECMO - Pediatric - Post-Cannulation [2215] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - ECMO - Pediatric - Post-Cannulation [2215]
Extracorporeal Membrane Oxygenation (ECMO) Type
Extra Corporeal Membrane Oxygenation (ECMO) Type [31437]
Venoarterial (VA) [NURCOM0022] ONCE, Starting today For 1 Occurrences
Venovenous (VV) [NURCOM0022] ONCE, Starting today For 1 Occurrences
Patient Care Orders
Vital Signs [31438]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions: No Rectal Temps
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 15 minutes times 8, then PRN.
Patient Monitoring [31439]
Assess Neurologic Status [NURMON0006] SEE COMMENTS, Starting today, Routine, Every 1 hour
times 8, then every 2 hours times 16, then every 4 hours.
Assess Pediatric Sedation Score [NURMON0060] SEE COMMENTS, Starting today, Every 1 hour times 8, then
every 2 hours times 16, then every 4 hours.
Measure Mean Arterial Pressure [NURMON0060] CONTINUOUS, Starting today
Measure Central Venous Pressure [NURMON0060] CONTINUOUS, Starting today
Activity [102173]
Range of Motion Exercises [NURACT0011] SEE COMMENTS, Starting today For Until specified, Every 8
hours
Carefully Rotate Patient With Assistance From ECMO
Specialist. Any movement of the patient's affected limbs
warrants an ECMO Specialist to assist to ensure no
issues occur with the cannulas. [NURACT0011]
CONTINUOUS, Starting today
Nutrition [31441]
For total parenteral nutrition, refer to "IP - Total Parenteral Nutrition - Pediatric - Supplemental" order set.
NPO [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25):
STRICT NPO
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
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Pr i nt ed by SPENCER, L I NDSEY M [LMS033] at 3/17/2014 4:40:08 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
detail):
Tube Feeding Management:
Room Service Class:
Site Care [31442]
Do Not Change Surgical Incision Dressing for 24 Hours,
Unless Heavily Blood Stained [NURWND0018]
CONTINUOUS, Starting today For 24 Hours
Cannulation Site Care [NURWND0015] CONTINUOUS, Starting today, Routine
Wound Type: Other (Comment)
Wound Site:
Wound Location:
Assess Frequency: EVERY 8 HOURS
Care Frequency: EVERY 24 HOURS PRN
Wash With: Other (Comment)
Irrigate/Rinse With:
Apply (Must also enter separate medication order to obtain
drug):
Primary Dressing: Gauze
Secondary Dressing:
If Patient's Chest Open, MD Must Clean Cannula Site
[NURWND0018]
CONTINUOUS, Starting today
Intake and Output [31444]
Measure Intake And Output [NURMON0005] EVERY 1 HOUR, Starting today, Routine
Hemofiltration [80177]
Hemofiltration Parameters [NURCOM0022] CONTINUOUS, Starting today, Hemofilter (HF) line to be
placed and primed in circuit by Perfusionist.
Ultrafiltrate (UF) line to IV infusion pump and urimeter.
Maintain blood flow through hemofilter at 50-100 mL/minute.
Maintain ultrafiltration rate at *** mL/hour or to achieve an
overall patient hourly balance of *** mL/hour.
For Patients 1 Month Old or Younger [31446]
Measure Head Circumference [NURMON0038] 1X DAILY, Starting today, Routine
For Temperature Greater than 38.8 Degrees Celsius [31447]
Hyperthermia Blanket (Cooling Blanket) as Needed for
Temperature Greater than 38.8 Degrees Celsius
[NURTRT0048]
CONTINUOUS, Starting today
Sponge Bath as Needed for Temperature Greater than
38.8 Degrees Celsius [NURTRT0048]
CONTINUOUS, Starting today
Decrease ECMO Circuit Heater Temperature by 0.5
Degrees Celsius as Needed for Temperature Greater
than 38.8 Degrees Celsius [NURTRT0048]
CONTINUOUS, Starting today
For Temperature Less than 36.6 Degrees Celsius [31483]
Hypothermia Blanket (Warming Blanket) as Needed for
Temperature Less than 36.6 Degrees Celsius
[NURTRT0048]
CONTINUOUS, Starting today
Increase ECMO Circuit Heater Temperature by 0.5
Degrees Celsius as Needed for Temperature Less than
36.6 Degrees Celsius [NURTRT0048]
CONTINUOUS, Starting today
For Temperature Less than 36.6 Degrees Celsius and Weight Less than 10 Kilograms [31484]
Use Radiant Warmer [NURTRT0026] CONTINUOUS, Starting today, Routine
Non-Categorized Patient Care Orders [31445]
Do Not Insert Tubes Nasally [NURTAD0046] CONTINUOUS, Starting today
No Intramuscular Medications, No Venipunctures, No
Heelsticks, No Spinal Taps [NURCOM0022]
CONTINUOUS, Starting today For Until specified
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


No Infusions into the ECMO Centrifugal Circuit.
[NURTAD0046]
ONCE, Starting today, All infusions, Heparin, Blood Product,
TPN, Inotropic and/or Vasopressors, Sedation and Analgesic
Drips. Drips should be administered directly to the patient as
venous access permits. No infusions into the ECMO
centrifugal circuit.
Do Not Insert Rectal Thermometer [NURTAD0046] CONTINUOUS, Starting today
Insert and Maintain Urinary Catheter [NURELM0013] CONTINUOUS, Starting today, Routine
Type: Indwelling Single Lumen
Indication for Placement:
Details: To Dependent Drainage
Irrigate With:
Irrigation Frequency:
Does this need to be inserted/placed?
.
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Glucose, POC [IPGLUCOSE] CONDITIONAL - RN COLLECT, Starting today For 7 Days,
Routine
If Conditional, What Condition?
ACTIVATED CLOTTING TIME, POC [HCACTPOC] EVERY 1 HOUR, Starting today For 24 Hours, Routine
If Conditional, What Condition?
ACTIVATED CLOTTING TIME, POC [HCACTPOC] CONDITIONAL - RN COLLECT, Starting today For 7 Days,
Routine
If Conditional, What Condition? Per ECMO Specialist
ACTIVATED CLOTTING TIME, POC [HCACTPOC] EVERY 4 HOURS, Starting tomorrow For 7 Days, Routine
If Conditional, What Condition?
ACTIVATED CLOTTING TIME, POC [HCACTPOC] CONDITIONAL - RN COLLECT, Starting 3/24/14 For 7 Days,
Routine
If Conditional, What Condition? Per ECMO Specialist
ACTIVATED CLOTTING TIME, POC [HCACTPOC] EVERY 4 HOURS, Starting 3/24/14 For 7 Days, Routine
If Conditional, What Condition?
Contingency Parameters [31485]
Notify Provider [NURCOM0001] 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): 38.3
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): 40
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): 1 mL/kg/hour
Other: Mean arterial pressure less than *** or greater than ***
mmHg
Intravenous Therapy
Intravenous Therapy [30843]
Note: Total IV Fluids [950004] EVERY 8 HOURS
Total IV rate *** mL/hr = *** mL/kg/day; (IV rate + TPN rate +
line maintenance rate) For CV Surgery patients
recommended fluids 2/3 maintenance rate.
Air filters on all venous lines [NURCOM0022] CONTINUOUS, Starting today For Until specified
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


IV Fluids (Single Response) [31003]
dextrose 10% infusion - Note: Order for patients 44
weeks of gestation or less [36626]
Intravenous, CONTINUOUS
dextrose 10%-NaCl 0.45% infusion - NOTE: Order for
patients between 45 weeks of gestational age and 1
year of age [700592]
Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% infusion - Note: Order for
patients greater than 1 year of age [51613]
Intravenous, CONTINUOUS
Medications - Anti-infectives
Anti-infectives [31002]
cefazolin (ANCEF) intraVENOUS [800000] 30 mg/kg, Intravenous, EVERY 8 HOURS, Post-Op/Phase II
cefuroxime (ZINACEF) intraVENOUS [800030] 50 mg/kg, Intravenous, EVERY 8 HOURS, Post-Op/Phase II
vancomycin (VANCOCIN) intraVENOUS [800084] 15 mg/kg, Intravenous, EVERY 6 HOURS, Post-Op/Phase II
Medications - General
Analgesics [31006]
MORPHine infusion PEDS - NOTE: Suggested dose
0.05-0.3 mg/kg/hr [700121]
Intravenous
NOTE: Suggested dose 0.05-0.3 mg/kg/hr
MORPHine PF injection - NOTE: Suggested dose 0.1
mg/kg/dose (Maximum 2 mg/dose) [800122]
0.1 mg/kg, Intravenous, EVERY 1 HOUR PRN, pain
NOTE: Suggested dose 0.1 mg/kg/dose (Maximum 2
mg/dose)
Anxiety/Agitation [31007]
midazolam (VERSED) infusion PEDS - NOTE:
Suggested dose 0.03-0.4 mg/kg/hr [700119]
Intravenous
NOTE: Suggested dose 0.03-0.4 mg/kg/hr
midazolam (VERSED) injection RANGE - NOTE:
Suggested dose 0.05-0.1 mg/kg (Maximum 2 mg/dose)
[750056]
0.05-0.1 mg/kg, Intravenous, EVERY 1 HOUR PRN, agitation
Neuromuscular Blocking Agents [143779]
vecuronium (NORCURON) injection [760250] 0.1 mg/kg, Intravenous, EVERY 1 HOUR PRN, Movement
Non-categorized [31020]
calcium GLUConate intraVENOUS [800105] 50 mg/kg, Intravenous, PRN, glucose < *** or SBP < ***
potassium chloride in sterile water 0.2 MEQ/ML injection
CENTRAL - NOTE: Suggested dose 0.6 mEq/kg/dose
(Maximum 10 mEq/dose) [755021]
0.5 mEq/kg, Intravenous, EVERY 4 HOURS PRN, For
potassium less than 3.2 mmol/liter
For potassium less than 3.2 mmol/liter
for 60 Minutes
NOTE: Suggested dose 0.5 mEq/kg/dose (Maximum 10
mEq/dose)
Circuit Medications (Single Response) [31021]
(ECMO) heparin 12,500 units in dextrose 10% 250 mL
infusion - NOTE: Order for patients weighing less than
10 kg [700640]
40 Units/kg/hr, Intravenous
NOTE: Order for patients weighing less than 10 kg
(ECMO) heparin 30,000 units in dextrose 5 % 250 mL
infusion - NOTE: Order for patients weighing 10-25 kg
[700640]
40 Units/kg/hr, Intravenous
NOTE: Order for patients weighing 10-25 kg
(ECMO) heparin 62,500 units in dextrose 5 % 250 mL -
NOTE: Order for patients weighing 26-49 kg [700640]
40 Units/kg/hr, Intravenous
NOTE: Order for patients weighing 26-49 kg
(ECMO) heparin 87,500 units in dextrose 5 % 250 mL -
NOTE: Order for patients weighing 50 kg or greater
[700640]
40 Units/kg/hr, Intravenous
NOTE: Order for patients weighing 50 kg or greater
Flushes
Orogastric [31029]
Flush orogastric tube [NURTAD0046] CONTINUOUS, Starting today For Until specified, Flush
orogastric tube with *** mL of water every 4 hours as needed
Arterial Line (A-line) (Single Response) [31030]
patency line fluid in 0.9 % sodium chloride 50mL syringe
PEDS [700632]
Intravenous, CONTINUOUS
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Laboratory
Laboratory ECMO days 1-7 [31488]
HEPARIN LEVEL BY ANTI-XA [XLMWH] EVERY 12 HOURS, Starting today For 7 Days, 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?
CBC WITH DIFFERENTIAL [CBC] NEXT AM, 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?
TEG- PATIENT ON HEPARIN [133836]
LabTest
Directory
URL: https://uconnect.wisc.edu/servlet/Satellite?
cid=1139396417778&aid=1126658402246&pagename=B_EXTRANET_UWH_CLIN_LAB_HANDBOOK%
2FPage%2FShow_ClinLab_TestPreview&c=Page
TEG - PATIENT ON HEPARIN [HCTEGH] CONDITIONAL - RN COLLECT, Starting today For 7 Days,
Routine
Point in Procedure:
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Excessive bleeding
THROMBOELASTOGRAM CLOT TIME AND
STRENGTH, HEP CUP [HCTGHCTS]
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? Excessive bleeding
THROMBOELASTOGRAM FIBRINOGEN ACTIVITY,
HEP. CUP [HCTGHAGL]
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? Excessive bleeding
THROMBOELASTOGRAM MAXIMUM AMPLITUDE,
HEP CUP [HCTGHMA]
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? Excessive bleeding
THROMBOELASTOGRAM FIBRINOLYSIS, HEP CUP
[HCTGHLYS]
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? Excessive bleeding
ANTITHROMBIN III, ANTIGEN [XTMBAG] 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? If bleeding or if heparin gtt
over 60 u/kg/hr
FIBRINOGEN [GM1320] 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? if bleeding or heparin gtt over
60 u/kg/hr
CULTURE, BLOOD, BACTERIA AND YEAST [GM4045] NEXT AM, Starting today For 7 Days, Routine
If Conditional, What Condition?
CULTURE, URINE [URC] CONDITIONAL - RN COLLECT, Starting today, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? draw once every 24 hours for
temperature greater than 38.5 degrees Celsius or if clinical
suspicion for infection
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


CULTURE, SPUTUM WITH GRAM STAIN [HCSPUCS] CONDITIONAL - RN COLLECT, Starting today, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Draw once every 24 hours for
temperature greater than 38.5 degrees Celsius or if clinical
suspicion for infection
BLOOD GASES AND O2 SATURATION [HCBGASOS] CONDITIONAL - RN COLLECT, Starting today For 7 Days,
STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
LACTATE [GM2255] 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?
HEMOGLOBIN, WHOLE BLOOD [HCWBHGB] 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?
CALCIUM, IONIZED, WHOLE BLOOD [HCWBICA] 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?
BLOOD GASES AND O2 SATURATION [HCBGASOS] EVERY 8 HOURS, Starting today For 7 Days, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Drawn from patient's ECMO Circuit, post membrane
ELECTROLYTES, WHOLE BLOOD [HCWBLYTS] 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?
Laboratory ECMO days 8-14 [143778]
HEPARIN LEVEL BY ANTI-XA [XLMWH] EVERY 12 HOURS, Starting 3/24/14 For 7 Days, 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?
CBC WITH DIFFERENTIAL [CBC] NEXT AM, Starting 3/24/14 For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
TEG- PATIENT ON HEPARIN [133836]
LabTest
Directory
URL: https://uconnect.wisc.edu/servlet/Satellite?
cid=1139396417778&aid=1126658402246&pagename=B_EXTRANET_UWH_CLIN_LAB_HANDBOOK%
2FPage%2FShow_ClinLab_TestPreview&c=Page
TEG - PATIENT ON HEPARIN [HCTEGH] CONDITIONAL - RN COLLECT, Starting 3/24/14 For 7
Days, Routine
Point in Procedure:
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Excessive bleeding
THROMBOELASTOGRAM CLOT TIME AND
STRENGTH, HEP CUP [HCTGHCTS]
CONDITIONAL - RN COLLECT, Starting 3/24/14 For 7
Days, Routine
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Excessive bleeding
THROMBOELASTOGRAM FIBRINOGEN ACTIVITY,
HEP. CUP [HCTGHAGL]
CONDITIONAL - RN COLLECT, Starting 3/24/14 For 7
Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Excessive bleeding
THROMBOELASTOGRAM MAXIMUM AMPLITUDE,
HEP CUP [HCTGHMA]
CONDITIONAL - RN COLLECT, Starting 3/24/14 For 7
Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Excessive bleeding
THROMBOELASTOGRAM FIBRINOLYSIS, HEP CUP
[HCTGHLYS]
CONDITIONAL - RN COLLECT, Starting 3/24/14 For 7
Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Excessive bleeding
ANTITHROMBIN III, ANTIGEN [XTMBAG] CONDITIONAL - RN COLLECT, Starting 3/24/14 For 7 Days,
Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? If bleeding or if heparin gtt
over 60 u/kg/hr
FIBRINOGEN [GM1320] CONDITIONAL - RN COLLECT, Starting 3/24/14 For 7 Days,
Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? if bleeding or heparin gtt over
60 u/kg/hr
CULTURE, BLOOD, BACTERIA AND YEAST [GM4045] NEXT AM, Starting 3/24/14 For 7 Days, Routine
If Conditional, What Condition?
CULTURE, URINE [URC] CONDITIONAL - RN COLLECT, Starting 3/24/14, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? draw once every 24 hours for
temperature greater than 38.5 degrees Celsius or if clinical
suspicion for infection
CULTURE, SPUTUM WITH GRAM STAIN [HCSPUCS] CONDITIONAL - RN COLLECT, Starting 3/24/14, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Draw once every 24 hours for
temperature greater than 38.5 degrees Celsius or if clinical
suspicion for infection
BLOOD GASES AND O2 SATURATION [HCBGASOS] CONDITIONAL - RN COLLECT, Starting 3/24/14 For 7 Days,
STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
LACTATE [GM2255] CONDITIONAL - RN COLLECT, Starting 3/24/14 For 7 Days,
STAT
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
HEMOGLOBIN, WHOLE BLOOD [HCWBHGB] CONDITIONAL - RN COLLECT, Starting 3/24/14 For 7 Days,
STAT
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] CONDITIONAL - RN COLLECT, Starting 3/24/14 For 7 Days,
Page 7 of 9
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


STAT
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
BLOOD GASES AND O2 SATURATION [HCBGASOS] EVERY 8 HOURS, Starting 3/24/14 For 7 Days, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Drawn from patient's ECMO Circuit, post membrane
ELECTROLYTES, WHOLE BLOOD [HCWBLYTS] CONDITIONAL - RN COLLECT, Starting 3/24/14 For 7 Days,
STAT
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [31570]
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
Position patient requires the assistance of an ECMO
Specialist
X-RAY CHEST AP VIEW [R71010] CONDITIONAL, Starting today, Routine
Current signs and symptoms?
What specific question(s) would you like answered by this
exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
If Conditional, What Condition? Obtain daily at 0600 and as
needed
Position patient requires the assistance of an ECMO
Specialist
Patients Less Than 1 Year [31574]
US INTRACRANIAL [R76506] ONCE-ON SPECIFIC DATE, Starting tomorrow For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by this
exam?
Relevant recent/past history?
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.
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Position patient requires the assistance of an ECMO
Specialist
US INTRACRANIAL [R76506] CONDITIONAL, Starting today For 7 Days, Routine
Current signs and symptoms?
What specific question(s) would you like answered by this
exam?
Relevant recent/past history?
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.
If being performed remotely, where?
Page 8 of 9
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


Transport Method: Floor Determined/Entered
Position patient requires the assistance of an ECMO
Specialist
Consults
Consults [31577]
Consult Physical Therapy (Inpatient) Eval and Treat
[CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: ROM/Strengthening/Endurance
For ECMO patient. Check with ECMO Specialist and nursing
staff to verify which limb(s) can have ROM done.
Consult Occupational Therapy (Inpatient) Eval and Treat
[CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Other (comment)
Page 9 of 9
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Copyright © 2014 University of Wisconsin Hospital and Clinics Authority