/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-98208-en.cckm

20180236

page

100

UWHC,UWMF,

Tools,

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

IP - General - Adult - Discharge [1495]

IP - General - Adult - Discharge [1495] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - General - Adult - Discharge [1495]
Skilled Nursing Facility Orders
This Patient is going to a skilled nursing facilty, directly below is a group of orders commonly
associated with this patient population. Please review the orders below and select the appropriate
ones for this patient. If this patient is not going to a SNF, contact Case Management to update the
discharge plan. Updating the discharge plan will remove this set of SNF orders from the order set.
Skilled Nursing Facility Certification Statement [114940]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Certification Statement [118260]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Admit Order [114941]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Admit Order [118261]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Patient Care Orders [111713]
For dyspnea, Oxygen at 2 L/minute per nasal
canula; If this is an acute change for the patient
call PCP with assessment ASAP after oxygen is
started. Suction PRN to clear airways.
[NURCOM0022]
Routine
DME - Home Oxygen [1009468] Length of Need:
Patient's O2 Requirements Assessed and Meets
Criteria for Home O2:
Delivery Device:
Equipment Needed:
Continuous (liters/min):
Continuous (FiO2):
With Activity (liters/min):
With Activity (FiO2):
With Sleep (liters/min):
With Sleep (FiO2):
Length of Need:
Vendor:
DME - CPAP [1009443] Length of Need:
Formal Sleep Study Completed:
Diagnosis:
CPAP Pressure (cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Page 1 of 32
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

DME - BiPAP (S) [1009441] Length of Need:
Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S):
Diagnosis:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
DME - BiPAP (S/T) [1009442] Length of Need:
Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S/T):
Diagnosis:
Respiratory Rate:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Patient may self administer medication per RN
assessment [NURCOM0022]
Routine
Patient medications (per Skilled Nursing Facility
policy) may be left at bedside [NURCOM0022]
Routine
Facility Therapy Needs [113391]
Physical Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Occupational Therapy to Evaluate and Treat at
Next Facility [NURCOM0022]
Routine
Speech Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Communicable Diseases [111717]
State Law requires at least one of the following statements be checked for your patient. May check both if
applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have any
other clinically apparent communicable diseases.
[NURCOM0022]
Routine
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Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Communicable Diseases [118262]
State Law requires at least one of the following statements be checked for your patient. May check both if
applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have any
other clinically apparent communicable diseases.
[NURCOM0022]
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Analgesics [111708]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, 1 tab, 1, starting 2/2/18, No Print
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, 1 suppository, 1, starting 2/2/18, No Print
Blood Glucose Management [111710]
glucagon 1 mg injection kit [107799] 1 mg, 1 each, 1, starting 2/2/18, No Print
Glucose 40 % oral gel [118089] 10 g, 1 Tube, 1, starting 2/2/18, No Print
Nursing Communication [NURCOM0022] Routine, Notify {Notify for Blood Glucose:3004146} if
blood glucose is greater than 400 mg/dL or less than
40 mg/dL
Diabetes Care Instructions [NURCOM0112] Routine, - Patient's blood glucose goal range before
meals is *** mg/dL.
- Monitor patient's blood glucose {Glucose Monitoring
Frequency:25242}.
- If your patient's blood glucoses are uncontrolled
contact provider.
- "Uncontrolled" blood glucoses mean:
* Blood glucose above 150 mg/dL more than half the
time during a week.
* Blood glucose over *** mg/dL.
* Blood glucose less than 70 mg/dL two or more times
per week (or if having signs/symptoms of low blood
glucose such as shaking, sweating, or light-
headedness).
Bowel Management [111709]
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, 1 suppository, 1, starting 2/2/18, No Print
Senna-Docusate Sodium 8.6-50 MG per tab
[70181]
1-2 tab, 1 tab, 1, starting 2/2/18, No Print
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, 1 Bottle, 1, starting 2/2/18, No Print
polyethylene glycol (MIRALAX) oral powder
[61353]
17 g, 1 Bottle, 1, starting 2/2/18, No Print
Non-categorized Medications [111711]
guaifenesin-dextroMETHORPHAN (ROBITUSSIN
DM) syrup [51568]
10 mL, 1 Bottle, 1, starting 2/2/18, No Print
carbamide peroxide (DEBROX) 6.5% otic soln
[35545]
3 drop, 1 Bottle, 1, starting 2/2/18 until 2/7/18, No Print
alum-mag-simeth (MYLANTA ES) susp [44073] 30 mL, 1 Bottle, 1, starting 2/2/18, No Print
Page 3 of 32
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

Patient Care Orders
Confirmed Discharge Date/Time [151653]
Confirmed Discharge Date/Time [ADT0013] Confirmed Discharge Date:
Confirmed Discharge Time:
Conditions for Discharge:
Provider to be Present at Discharge?
Reason For Hospitalization [129829]
Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Activity [20226]
Activity [NURACT0008] Routine
Discharge Activity:
Nutrition [20227]
Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Diabetes Care [192619]
Diabetes Care Instructions [NURCOM0112] Routine, - Your blood sugar goal range before meals
is *** mg/dL.
- Monitor your blood sugar {UWIP Glucose Monitoring
Frequency:23755}.
- Your blood sugar should be 100 mg/dL or higher
before driving, exercise and at bedtime.
- If your blood sugars are uncontrolled after you leave
the hospital, contact your provider who manages your
diabetes. Your medicine doses may need to be
changed.
- UNCONTROLLED blood sugars mean:
- Blood sugar above 150 mg/dL more than half the
time during a week.
- Blood sugar over *** mg/dL.
- Blood sugar less than 70 mg/dL two or more times
per week (or if having signs/symptoms of low blood
sugar such as shaking, sweating, or light-
headedness).
- To learn more about diabetes, check out
uwhealth.org/diabetes.
Line and Drain Care [192611]
Maintain Gastrostomy Tube For Alimentation
[NURTAD0007]
Routine
Tube Indications: Feeding
Flush With:
Flush Volume (mL):
Flush Frequency:
Site Assessment Frequency:
Care Frequency: EVERY 3 DAYS
Wash With:
Primary Dressing: Gauze
Secondary Dressing: Transparent Dressing
(TEGADERM)
Page 4 of 32
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

Maintain Gastrostomy Tube For Decompression
[NURTAD0007]
Routine
Tube Indications:
Flush With:
Flush Volume (mL):
Flush Frequency:
Site Assessment Frequency:
Care Frequency: EVERY 3 DAYS
Wash With:
Primary Dressing: Gauze
Secondary Dressing: Transparent Dressing
(TEGADERM)
Maintain Gastrostomy Jejunostomy Tube
[NURTAD0008]
Routine
Gastrostomy Port Indications:
Flush G-Port With:
G-Port Flush Volume (mL):
G-Port Flush Frequency:
Jejunostomy Port Indications:
Flush J-Port With:
J-Port Flush Volume (mL):
J-Port Flush Frequency:
Site Assessment Frequency:
Care Frequency: EVERY 3 DAYS
Wash With:
Primary Dressing: Gauze
Secondary Dressing: Transparent Dressing
(TEGADERM)
Maintain Abscess Drain [NURTAD0034] Routine
Drain Site:
Location:
Drainage Options:
Flush With(Must also enter seperate medication order
to obtain drug):
Site Assessment Frequency:
Care Frequency: EVERY 3 DAYS
Wash With: Chlorhexidine Sponge
Primary Dressing: Gauze
Secondary Dressing: Transparent Dressing
(TEGADERM)
Maintain Nephrostomy Tube [NURTAD0025] Routine
Location:
Drainage Options:
Flush With(Must also enter seperate medication order
to obtain drug):
Site Assessment Frequency:
Care Frequency: EVERY 3 DAYS
Wash With: Chlorhexidine Sponge
Primary Dressing: Gauze
Secondary Dressing: Transparent Dressing
(TEGADERM)
Page 5 of 32
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

Maintain Biliary/Gall Bladder Tube
[NURTAD0033]
Routine
Location:
Drainage Options:
Flush With(Must also enter seperate medication order
to obtain drug):
Site Assessment Frequency:
Care Frequency: EVERY 3 DAYS
Wash With: Chlorhexidine Sponge
Primary Dressing: Gauze
Secondary Dressing: Transparent Dressing
(TEGADERM)
May Shower - Keep Drain/Line Clean and Dry
[NURCOM0022]
Routine
May Shower - Clean Drain/Line Site with Soap
and Warm Water [NURCOM0022]
Routine
Maintain Urinary Catheter [NURELM0013] Routine, Indwelling single lumen catheter with
dependent drainage. Secure to leg as instructed.
Overnight bag is okay. May flush with normal saline as
directed.
Maintain PICC [NURVAD0050] Routine, PICC Line secured with Statlock. Change
with routine dressing changes. Flush with Heparinized
Saline.
Home Supplies [192620]
Home Dressing Supplies for 3 Dressing Changes
[NURCOM0022]
Routine
Wound Care [193971]
Wound Care [NURWND0015] Routine
Bladder Care [121031]
Bladder Care [NURELM0067] Routine
Bowel Care [121030]
Bowel Care [NURELM0068] Routine
Other Patient Care Instructions [220251]
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
Heart Failure Discharge Instructions [233839]
Page 6 of 32
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Heart Failure Discharge Instructions
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Key points to keep you healthy
with heart failure.
CLINIC VISITS/WHO AND WHEN TO CALL
• Be sure to go to all of your clinic visits.
• Call your provider with any problems. We want to
help you stay healthy so that you don't have to come
to the hospital.
• If you see a heart specialist (cardiologist, NP or PA)
for heart failure and have problems or questions
about heart failure, call them first. If you do not have
a heart specialist or cannot reach them, call your
primary care provider.
HEART FAILURE ACTION PLAN
GREEN ZONE - This zone is your GOAL. Your
symptoms are under control.
• No weight gain of more than 3 lbs. in 1 day or 5 lbs.
or more in a week
• No shortness of breath
• No swelling of your feet, ankles, legs, arms, or belly
• No chest pain
• No decrease in your energy level
• No light-headedness when you do your normal
activities
EVERY DAY:
• Weigh yourself in the morning before breakfast.
Write it down.
• Take your medicine as prescribed
• Check for swelling in your feet, ankles, legs, arms,
and belly.
• Limit the salt (sodium) in your diet to 2000 mg or
less each day.
• Look for the milligrams (mg) of sodium on all food
labels.
YELLOW ZONE - This zone is a WARNING ZONE.
Some of your symptoms may not be well-controlled.
Call your doctor if you:
• Have a weight gain of 3 lbs. in 1 day or 5 lbs. or
more in a week
• Feel bloated or full after you eat just a few bites
• Are more short of breath than normal
• Find it harder to breathe when lying flat
• Have more swelling in your feet, ankles, legs, arms,
or belly
• Are coughing more than normal
• Feel more tired or have no energy
• Are light-headed when you do your normal
activities
RED ZONE - This is an EMERGENCY ZONE. You
need a doctor's help right away.
Page 7 of 32
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Call 911 if you have:
• Severe chest pain
• Severe shortness of breath
• Wheezing or tightness in your chest
• Difficulty breathing
• Confusion or can't think clearly
DIET AND LIFESTYLE
• Limit the salt (sodium) in your diet to 2000 mg or
less each day.
• Read food labels. Any labels that say "sodium"
count as salt.
• Do not use salt at the table or in cooking.
• Limit what and how much you drink as you are told
by your health care team. For some people, you may
be asked to limit the amount you drink to 2 liters in
one day.
• Get regular exercise. Talk to your health care team
about an exercise program before you start.
• Weigh yourself every day, first thing upon waking,
AFTER you empty your bladder and BEFORE you
eat or drink anything. Wear the same amount of
clothing when weighing yourself each day. PLEASE
write your weights in a daily log.
• *CALL YOUR PROVIDER IF YOU HAVE SUDDEN
WEIGHT GAIN OF MORE THAN 3 LBS. IN 1 DAY.
• Quit smoking. If you need help quitting, talk to your
health care team.
• Limit or do not drink alcohol.
• Keep track of symptoms and talk to your health
care team if you have any questions or concerns.
• Avoid or reduce stress.
MEDICINE
• Take all of your medicines as prescribed by your
health care team.
• Do NOT stop taking your heart medicines without
talking to your health care team first. It can be
dangerous to change or skip doses.
• Medicines to avoid:
o Medicines that contain ibuprofen, naproxen, or
other non-steroidal anti-inflammatory drugs
o Medicines that contain pseudoephedrine
o Medicines with sodium in them such as antacids
o Calcium channel blockers such as nifedipine,
diltiazem, and verapamil
• Use tools, such as a daily or weekly pill box, to
organize your medicines.
• Keep your medicine containers in a place where
you will see them every day.
• Make reminders for yourself to take your
medicines.
• Read the prescription label that comes with each
medicine. Call your doctor if it does not match what
you think you should be taking.
• Make a list of all the medicines you take. Keep one
Page 8 of 32
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

copy at home and one in your wallet.
• Bring a bag with all of your medicines with you to
your clinic visits.
Decompensated Cirrhosis Discharge Instructions
[221472]
Page 9 of 32
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

Decompensated Cirrhosis Discharge Instructions
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, It is important for you to go to
all your doctor's appointments and call your doctor if
you are having any problems. We want to help you
stay healthy so that you don't have to come to the
hospital.
If you have a liver doctor at UW and need to talk to
someone, please call and ask to talk to the nurse. If
you do not have a liver doctor at UW but have
questions and want to talk to someone, call and ask
to talk to the nurse. The number for the UW
Digestive Health Center/Liver Clinic is 608-890-
5000.
MEDICATIONS
-Take your medicines exactly the way they are
prescribed. Call your liver doctor before you take
ANY medicine that is not prescribed to you.
-Do not take Tylenol (acetaminophen) without talking
to your liver doctor first. Tylenol can hurt your liver
but sometimes it is ok to take. You should check
with your doctor first, and discuss the dose that is
correct for you.
-Do not take any medicines that could thin your
blood because you are already more likely to bleed
when you have problems with your liver. Some of
these medicines are Aspirin or Ibuprofen (Motrin or
Advil).
-If you are prescribed a medicine called Lactulose,
this medicine will help get rid of the toxins (ammonia)
in your blood. Some of the side effects of Lactulose
can include gas, stomach cramps, and bloating. Do
not stop taking the Lactulose if you are having these
symptoms because you may get sleepy or confused.
If the symptoms become too bad, call your liver
doctor to talk about it.
-There are many medications that you might be
taking to help your liver do its job. If you stop taking
these medicines, or take them in a different way than
what is ordered, you could get sick and have to
come back into the hospital. Call your liver doctor if
you have problems with any of your medicines.
SWELLING IN YOUR BELLY (ASCITES)
-If your liver doesn't work well, you can get swelling
in your belly. This swelling is called ascites. If you
get too much fluid in your belly, you may have to
have a procedure (called a paracentesis) to remove
the fluid.
-These are some things that you might feel if you
have swelling in your belly. If you have any of these
things, call your liver doctor right away: your pants
feel tighter or you have trouble buttoning them, your
weight goes up, you are short of breath or feel like
Page 10 of 32
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

your belly is pushing up on your lungs, or you are full
after eating only a little bit of food.
-It is important to call your liver doctor at the Liver
Clinic if you feel like you are getting more fluid in
your belly. We want to be able to help you and treat
the fluid so that you can stay at home and not have
to come to the hospital.
MANAGING FLUID IN YOUR BODY
-Your body may have trouble balancing fluid if your
liver does not work well.
-You might be taking medicine that will help you get
rid of fluid. Some medicine makes you get rid of fluid
in your urine ("water pills" or "diuretics"). Other
medicine makes you get rid of fluid in your bowel
movements ("lactulose").
-Your liver doctor will help you adjust your medicines
to get rid of fluid if you need to. They will also help
make sure you don't get rid of too much fluid
because that could hurt your kidneys.
-We would like you to weigh yourself every day and
write down your weight in a book. Please bring that
book to all of your doctor's appointments.
-Call your liver doctor if you gain or lose more than 5
pounds in 1 week, or if you gain or lose more than 3
pounds in 1 day.
-Call your liver doctor if you feel dizzy, if you pee
less than normal, or if you think that your pee is
darker than normal. These things can happen if you
are getting rid of too much fluid with your medicines.
Your liver doctor may need to change how much
medicine you are taking.
-Write down how much sodium (in mg) you eat each
day. It is best to eat less than 2000 mg of sodium
each day to help avoid swelling in your legs and
belly.
-Read all food labels and choose food and drinks
that have lower sodium levels.
WHEN SHOULD YOU CALL YOUR DOCTOR?
When to Call Your Liver Doctor (The Liver Clinic
number is 608-890-5000)
-If you are more confused or can't think clearly
-If your skin or the white parts of your eyes get
yellow, or are more yellow than usual
-If you gain or lose more than 3 pounds in 1 day
-If you gain or lose more than 5 pounds in 1 week
-If you have more than 4 bowel movements in 1 day
-If you have more swelling in your belly, legs, or
arms
-If you are peeing less than you usually do
When to Go to The Closest Emergency Room
Page 11 of 32
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-If you are short of breath
-If you have new or worse belly pain
-If you have a fever
-If you are not able to get ahold of your liver doctor at
the Liver Clinic
WHEN YOU OR SOMEONE ELSE SHOULD CALL
911
-If you start throwing up and there is bright red blood
or stuff that looks like coffee-grounds in your vomit
-If you have black or bloody bowel movements
-If you pass out (lose consciousness)
COPD Discharge Instructions [221473]
Page 12 of 32
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COPD Discharge Instructions [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, It is important for you to go to
all your doctor’s appointments and call your doctor if
you are having any problems. We want to help you
stay healthy so that you don’t have to come to the
hospital. If you have a lung doctor (pulmonologist)
who manages your chronic obstructive pulmonary
disease (COPD), call them first if you are having
problems with symptoms or have questions about
your COPD. If you do not have a lung doctor or can’t
get ahold of your lung doctor, call your primary
doctor if you need help.
MEDICATIONS
-Take your medicines exactly the way they are
prescribed. Call your doctor before you take ANY
medicine that is not prescribed to you. Also call
before taking any medications that you buy at the
pharmacy or any herbal supplements.
-Know how and when to take your COPD medicines.
Talk to your doctor or the pharmacist if you have any
questions.
-If you have a prescription for a long-term inhaler,
take that every day, even if you are feeling good.
-If you have a prescription for a quick-relief inhaler,
this medicine will help to improve coughing,
wheezing, shortness of breath, chest tightness, and
trouble breathing.
-Do not take any medicine more than it is prescribed.
If you have symptoms that are not controlled with the
prescription you have, call your doctor to talk about
other options.
-Keep a list of all of your medicines (prescribed and
over the counter) and bring them with you to all of
your doctor’s appointments.
AVOIDING A COPD ATTACK (“EXACERBATION”)
-Talk to your doctor about a safe exercise program
to build up your strength and keep you strong.
-If you smoke, quitting smoking is one of the best
ways to protect your lungs from being damaged
more. See the “Quitting Smoking” section below for
more information and tips.
-It is important to avoid infections because having
COPD makes it easier for you to get infections.
Here are some things you can do to keep from
getting infections:
*Get a flu shot every year
*Ask your doctor if you should get a pneumococcal
(pneumonia) vaccine
*Wash your hands a lot
*Stay away from crowds and other people who are
sick
-Try to stay away from very cold air. If you go outside
Page 13 of 32
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when it is cold, wear a loose scarf or mask over your
face to protect you.
-Talk to your doctor about pulmonary rehabilitation.
This program can give you exercise, breathing, and
nutrition tips.
-See your doctor at least 1 to 2 times per year for
check-ups.
-Use oxygen if your doctor recommends it (NEVER
use oxygen if you or someone near you is smoking).
QUITTING SMOKING
-Quitting smoking is the best thing that you can do to
stop or slow down the damage to your lungs.
-Stay away from other people who smoke when you
are out, and do not allow other people who smoke to
come into your home
-There are medicines that can help you with the
cravings to smoke. If you are interested in these
medications, talk to your doctor.
-If you live in Wisconsin, there is a FREE program
called the Wisconsin Tobacco Quit Line that can
help you quit smoking. The phone number is 1-800-
QUIT-NOW
(1-800-784-8669).
WHEN SHOULD YOU CALL YOUR DOCTOR?
When to Call Your Doctor
-If you have to lean forward to breathe easier when
you are sitting down
-If you are having headaches more often
-If you are coughing up dark mucus
-If you have a fever (greater than 100.5 degrees
Fahrenheit)
When to Go to the Closest Emergency Room
-If your breathing gets harder, faster, or you cannot
get a deep breath
-If you are more sleepy or confused
-If your fingertips, or the skin around your fingernails
start turning blue
-You have a tight feeling in your chest
-You cannot speak in full sentences
WHEN YOU OR SOMEONE ELSE SHOULD CALL
911
-If you can’t breath
-If you have chest pain
-If you are unresponsive
AODA Discharge Instructions [221475]
Page 14 of 32
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AODA Discharge Instructions [NURCOM0071] Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, It is important for you to go to
all your doctor’s appointments and call your doctor if
you are having any problems. We want to help you
stay healthy so that you don’t have to come to the
hospital.
MEDICATIONS
-Take your medicines exactly the way they are
prescribed. Call your doctor before you take ANY
medicine that is not prescribed to you.
-Do not take any medicine more than it is prescribed.
-Keep a list of all of your medicines (prescribed and
over the counter) and bring them with you to all of
your doctor’s appointments
THINGS TO KNOW ABOUT STAYING SOBER
-DO NOT use alcohol and other drugs (AODA).
-When you are sober, you have taken the first step
towards recovery
-It is important to focus on staying alcohol-free and
drug-free, or staying “sober”
-Most people need support to stay sober. This can
include support groups, personal counseling, and
family and friend support.
-Recovery is a long-term process and not something
that can be done in days or weeks.
-If you need help with an alcohol or drug problem,
call your doctor or one of the numbers listed below
for more help.
RESOURCES
**INSURANCE NOTE: Please check with your
insurance company to determine where to go for
service and whether or not a referral is needed.
Physicians Plus and Unity Health Insurance
members should contact Behavioral Health
Consultation Services (BHCS). BHCS will refer
member to the appropriate level of care and
provider.
-Meriter New Start (608-417-8144) Outpatient
services: Only accepting PPIC
-Journey Mental Health Center, Inc (608-280-2700)
PPICMA/Unity MA/BadgerCare of Dane County.
Adolescents and Adults
-Pauquette Addiction Research and Recovery
Center (Baraboo: 608-356-9055) (Columbus: 920-
623-5578) (Portage: 608-742-5518) Outpatient
treatment and evaluation services for adults,
adolescents, and children with AODA issues
Page 15 of 32
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-UW Health Behavioral Health and Recovery (608-
282-8270)
FOR THOSE PATIENTS WITHOUT INSURANCE
-Alcoholics Anonymous (608-222-8989 and
www.aa.org) Alcohol counseling and support.
Meetings available in most areas with special groups
for women, teens, and members of the lesbian, gay,
bisexual, transsexual (LGBT) community
-ARC House (608-283-6430) Services for women
with AODA problems
-Access Community Health Centers (608-443-5480)
Providing care in several locations around Madison
and Dodgeville, WI
-Addictive Disorders Treatment Program (608-280-
7073) Veterans honorably discharged with AODA
issues. If born after 1980, need 2 years of active
duty
-Adolescent Alcohol and Drug Abuse Intervention
Program (AADAIP) (608-262-1111) Assessment for
AODA problems, referral services for treatment
-Connections Counseling (608-221-1500) Alcohol
problem counseling; focuses on adolescents but also
serves adults
-Dane County Funded Residential Treatment AODA
Assessment Clinic
2914 Industrial Drive (Tellurian Detox Building)
Madison, WI Assessment takes place in the
Administration site of the building. You must be on
time: 9am on Monday’s only (no phone calls)
-Hope Haven, Inc. (608-251-8881) Residential
treatment program for men and women
-Hope Haven; North Bay Lodge (608-249-2600)
Long-term residential program for chemically
dependent men and women ages 55 and older
(located on Mendota’s grounds)
-Hope Haven; Rebos Chris Farley House (608-255-
5922) Halfway house for men and women
-Journey Mental Health Center, Inc (608-280-2520)
Serves Medicaid and the uninsured. Friday is crisis
clinic for new patients. Serves adolescent and
adults.
-Lake Monona Psychotherapy and Recovery Center
(608-256-5030) Provides mental health and
Page 16 of 32
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addiction counseling
-Lutheran Social Services (608-277-0610) AODA
services and counseling. Locations in Madison, Sun
Prairie, and Stoughton
-Madison Health Services (608-242-0220) Provides
Methadone maintenance, Suboxone replacement
therapy and substance counseling
-Midwest Center for Human Services (608-231-
3300) Adult intensive outpatient program
-Narcotics Anonymous (608-258-1747 and
www.na.org) Narcotics counseling and support
-OceanHawk Counseling Alternatives (608-873-
7838) Outpatient mental health and substance
abuse counseling for adults and young adults
-Oxford House Sober Living Homes
www.oxfordhouse.org - Look under Houses on the
Home page - select Directory for a list of houses by
state - each house has its own phone number.
There are houses in several states
- Pauquette Addiction Research and Recovery
Center (Baraboo: 608-356-9055) (Columbus: 920-
623-5578) (Portage: 608-742-5518) Outpatient
treatment and evaluation services for adults,
adolescents, and children with AODA issues
-Prairie Counseling Services (608-837-4814) Mental
health and substance abuse outpatient counseling
-Porchlight, Inc. (608-257-2534, extension 9) Call
for a list of services. Provides sober housing, case
management and support services. Drop-in shelter
at 116 West Washington Ave, Madison
608-255-2960 (evening only). Hospitality House has
day services at 1490 Martin Street, Madison
-Quality Addiction Management (608-250-2512)
Methadone maintenance and individual counseling
-Recovery Dane (608-237-1661) Number needed to
access case management services
-Tellurian UCAN, Inc (Crisis Line 608-223-3311,
General 608-222-7311) Provides detox and
treatment for adolescents and adults
-If you live in Wisconsin, there is a FREE program
called the Wisconsin Tobacco Quit Line that can
help you quit smoking. The phone number is 1-800-
QUIT-NOW (1-800-784-8669)
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WHEN SHOULD YOU CALL YOUR DOCTOR?
When to Call Your Doctor
-If you need help quitting drinking or using drugs
-If you have questions about how to get in contact
with any of the resources listed above
When to go to the closest emergency room
-If you or someone you know is injured and has been
drinking alcohol or using drugs as they may not feel
pain like normal
-If you are having symptoms of alcohol withdrawal
such as confusion, nausea or vomiting, shaking,
sweating, or if you are hearing or seeing things that
are not actually there
WHEN YOU OR SOMEONE ELSE SHOULD CALL
911
-If you are unable to wake up even if someone is
gently shaking you or shouting at you
-If you are having trouble breathing or not breathing
normally
-If you have a seizure
Pneumonia Discharge Instructions [221480]
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Pneumonia Discharge Instructions
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, It is important for you to go to
all your doctor’s appointments and call your doctor if
you are having any problems. We want to help you
get well and stay healthy.
What is Pneumonia?
-Pneumonia is an infection in your lungs.
Pneumonia can be caused by bacteria, a virus, or
after food accidentally goes down your windpipe.
Sometimes mucous can fill the air space in your
lungs and prevent you from getting air/oxygen. Not
enough air/oxygen can make you feel short of
breath.
-You can spread pneumonia to other people when
you cough. It is important to cover your mouth when
you cough and wash your hands a lot.
What Happens Now?
Now that you are leaving the hospital, here are some
things you can do to keep getting well:
Activity
-Take deep breaths and cough every hour to get the
mucous out of your lungs.
-Get plenty of rest. It may take a few days before you
are feeling better again.
Food and Drink
-Drink 6-8 glasses of water, tea, or juice every day
-Eat plenty of fruits and vegetables. If you don’t feel
like eating, try warm or cold food like soup or yogurt.
-Do NOT drink alcohol.
Good Habits and Hygiene
-Cough or sneeze into a tissue or your sleeve.
-Wash your hands a lot (before you eat, after you
cough, and after you use the bathroom).
-Do NOT smoke. Avoid smoky environments.
-Get your flu shot every year
-Stay active.
Your Medicine
-It is very important to take all of your medicine as
ordered. Your doctor may give you antibiotics to
help kill the germs that cause pneumonia.
-DO NOT skip any of the antibiotic pills. Take the
antibiotics until the pills are gone, even if you are
feeling better.
-DO NOT take any cough medicine unless your
provider says it is ok. Coughing helps to get the
mucous out of your lungs.
-Call your doctor before you take ANY medicine that
is not prescribed to you. Also call before taking any
medicine that you buy at the pharmacy or any herbal
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supplements.
-Keep a list of all of your medicines (prescribed and
over the counter) and bring them with you to all of
your doctor’s appointment.
When Should You Call Your Doctor?
WHEN TO CALL YOUR DOCTOR
-You have no appetite and don’t want to eat
-You are having problems taking your medications
(throwing up or can’t swallow pills)
-Your cough is getting worse
-The mucous you are coughing up has changed
colors from clear to yellow or green
-You are feeling worse
-You are having more than 3 watery stools every
day.
-You are having fevers higher than 100.4 degrees
Fahrenheit
WHEN TO GO TO THE CLOSEST EMERGENCY
ROOM
-Your breathing gets harder, faster, or you cannot
get a deep breath
-You are more sleepy or confused
-Your fingertips, or the skin around your fingernails
start turning blue
-You have a tight feeling in your chest
-You cannot speak in full sentences
-You feel dizzy or have fallen down
WHEN YOU OR SOMEONE ELSE SHOULD CALL
911
-You can’t breathe
-You have chest pain
-You are unresponsive
Clostridium Difficile (C. diff) Infection Discharge
Instructions [240684]
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Clostridium Difficile (C. diff) Infection Discharge
Instructions [NURCOM0071]
Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Be sure you to go to all of your
clinic visits and appointment. Call your doctor if you
are having any problems. We want to help you stay
healthy so that you don't have to come to the
hospital.
Symptoms of Clostridium Difficile (C. diff) Infection
- Watery diarrhea
- Belly pain or tenderness
- Fever
- Loss of appetite / not wanting to eat
- Nausea
People at Risk
- Those using antibiotics for a long time
- The elderly
- Those who've had a recent stay at a hospital
- Those who have a severe illness
- Those with weakened immune systems
- People who use medicine to control stomach acid
How It Spreads
C.diff is a germ that is in the stool. The germs can
spread to surfaces (such as toilets, handles,
chairs, bedding). These germs can spread when
someone touches those surfaces and then touches
their mouth or nose before washing their hands. This
person is at risk for getting the C.diff infection.
Lowering the Risk of Spreading C.diff at Home
- If you are getting treatment for C.diff, take all of the
medicine exactly as directed.
- Wash your hands with soap and water often. Be
sure to wash after you go to the bathroom and
before you touch food or other people.
- People that you live with should wash their hands
often.
- Remind visitors to wash their hands often.
- If you are able, make one bathroom in your house
for your use only while you are sick. (Others should
use a different bathroom.)
- Clean the bathrooms that you use. This includes
light switches, handles, and door knobs. Use a 1:10
bleach solution (1 cup bleach, 9 cups water).
- Steps for washing objects/clothing that have stool
on them:
1. Rinse with water.
2. Wash using hot water and soap.
3. If able, add some bleach to the water to help kill
the germs.
4. Use the hottest dryer setting possible (without
causing damage to the clothes)
Who and When to Call
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Call your primary doctor if:
- You develop a fever.
- Your stomach/belly pain does not get better or if it
gets worse.
- Your diarrhea does not get better.
- You are unable to eat or drink enough.
- You cannot take your prescribed medicines.
Go to the Emergency Room if:
- Your stomach/belly pain cannot be controlled.
- You cannot eat or drink and become light-headed
or dizzy.
- You have any blood in your stool.
CALL 911 or have someone else CALL 911 if:
You pass out (lose consciousness) or become
unresponsive.
Home Care [192621]
Discharge - Home Care [137330]
Both of the following orders MUST be completed in order for this patient to receive home care.
Discharge - Home Care [DC0001] Routine
Type (Each Agency Requires a Separate Order):
Agency:
Agency City:
Agency Phone:
Agency Fax:
Discharge - Home Care Justification [DC0032] Details
When To Call Your Doctor [136507]
When to Call Your Doctor [NURCOM0079] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, ***
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When to Call Your Doctor - PCP [NURCOM0079] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Please contact your Primary Care
Provider, @PCP@, at @PCPPH@ with any of the
following signs or symptoms OR general questions
• Persistent nausea and vomiting.
• Pain not relieved with pain medications.
• Fever over 101.5 degrees F (by mouth) for two
readings taken four hours apart.
• Incision or drain sites become more painful, swollen,
red and/or feel warmer than usual.
• Severe chest pain or shortness of breath - call 911.
Nights and weekends:
For urgent general needs during evenings and
weekends, call your Primary Care Provider's office
(@PCPPH@) and ask to be connected to their after
hours line.
If you cannot reach a provider, and you have a serious
medical concern, call 911.
When to Call Your Doctor - Hospitalist
[NURCOM0079]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Your discharging physician was
@ATTPROV@. @ATTPROV@ is an Adult Hospitalist
who specializes in caring for adults when they are in
the hospital and has provided information to your
Primary Care Provider about your hospital stay. If you
have questions about your hospitalization, or for any
other concerns, please call your Primary Care
Provider at @PCPPH@. Your doctor can contact the
Hospitalist team if he/she has further questions. If you
cannot reach a provider, and you have a serious
medical concern, call 911 or show up to the nearest
emergency department.
When to Call Your Doctor [193970]
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When to Call Your Doctor [NURCOM0079] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, ***
When to Call Your Doctor - Hospitalist
[NURCOM0079]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Your discharging physician was
@ATTPROV@. @ATTPROV@ is an Adult Hospitalist
who specializes in caring for adults when they are in
the hospital and has provided information to your
Primary Care Provider about your hospital stay. If you
have questions about your hospitalization, or for any
other concerns, please call your Primary Care
Provider at @PCPPH@. Your doctor can contact the
Hospitalist team if he/she has further questions. If you
cannot reach a provider, and you have a serious
medical concern, call 911 or show up to the nearest
emergency department.
When to Call Your Doctor - PCP [NURCOM0079] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Please contact your Primary Care
Provider, @PCP@, at @PCPPH@ with any of the
following signs or symptoms OR general questions.
***
When to Call Your Doctor - Family Practice [245373]
When to Call Your Doctor [NURCOM0079] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, ***
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When to Call Your Doctor - Family Practice
[NURCOM0079]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, If you have ***, or you have other
general medical questions or concerns call your
Primary Care Provider, @PCP@, at @PCPPH@.
Nights and weekends: For urgent general medical
needs during evenings and weekends, call your
Primary Care Provider's office (@PCPPH@) and ask
to be connected to their after hours line. If you cannot
reach a provider, and you have a serious medical
concern, call 911 or go to the nearest emergency
department.
Heart Failure Recommended Care
These order groups are showing because either your patient has an EF < 40% documented or
has Heart Failure on their problem list.
UW Health HF guideline URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/cardiovascular/name-97485-
en.cckm
Heart Failure Discharge Instructions [190359]
Weigh yourself daily or as directed
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
When to Call Your Doctor [NURCOM0079] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Call your doctor if you have any of
these symptoms as they may indicate worsening
Heart Failure:
- Increased shortness of breath
- Cough or chest congestion
- Swelling in your abdomen or legs
- Any increase or decrease in weight of more than 3
pounds in a day or 5 pounds total
If you do not have a scheduled return
appointment, please schedule an appointment
with your primary physician [NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Core Measure Documentation - ACE Inhibitor/ARB (Single Response) [150651]
Core Measures - This Does NOT Generate A Medication Order (Use Med Reconciliation To
Prescribe Medications)
ACE Inhibitor/ARB Reason Not Ordered
[COR0001]
ONCE, Starting today For 1 Occurrences, Routine
Reason Not Ordered:
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ACE Inhibitor/ARB Already Ordered [COR0001] ONCE, Starting today For 1 Occurrences, Routine
Reason Not Ordered: Other (Comments required for
not ordering BOTH an ACEI and an ARB)
Follow-Up Referrals
Follow Up Appointments - Cardiac Rehab (Single Response) [101247]
Outpatient Cardiac Rehab is recommended. Please select one of the following.
Referral Cardiac Rehab (Outpatient) [CON0174] All patients being discharged from UWHC IP CVM
with the following diagnoses should receive a referral
to cardiac rehab: Acute Myocardial Infarction (i.e. all
STEMI or NSTEMI patients), Stable Angina, Coronary
Artery Bypass Surgery, Valve Surgery (repair or
replacement), Percutaneous Coronary Angioplasty or
Stenting, or Heart Transplant, or Stable Congestive
Heart Failure.
Typically, outpatient cardiac rehab follow-up
appointments occur 3-4 weeks post-hospitalization.
Inpatient Preventive Cardiology staff clinicians will
refer and make arrangements for the patient. If you
have further questions, you may call them at 263-
6630.
Routine
Has this patient been seen by inpatient Cardiac
Rehab/Preventive Cardiology during this encounter?
Reason Cardiac Rehab Not Ordered [COR0027] Routine
Reason Not Ordered:
Follow Up Appointments - Cardiac Rehab [101248]
Referral Cardiac Rehab (Outpatient) [CON0174] All patients being discharged from UWHC IP CVM
with the following diagnoses should receive a referral
to cardiac rehab: Acute Myocardial Infarction (i.e. all
STEMI or NSTEMI patients), Stable Angina, Coronary
Artery Bypass Surgery, Valve Surgery (repair or
replacement), Percutaneous Coronary Angioplasty or
Stenting, or Heart Transplant, or Stable Congestive
Heart Failure.
Typically, outpatient cardiac rehab follow-up
appointments occur 3-4 weeks post-hospitalization.
Inpatient Preventive Cardiology staff clinicians will
refer and make arrangements for the patient. If you
have further questions, you may call them at 263-
6630.
Routine
Has this patient been seen by inpatient Cardiac
Rehab/Preventive Cardiology during this encounter?
Follow Up Appointments - Diabetes (Single Response) [148552]
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*** RESPONSE REQUIRED *** This order facilitates documentation (only) about follow-up
appointments for patients with diabetes. 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., discharge to a skilled nursing facility, patient refusal, etc.). Only select “Appointment
Scheduled” if an appointment has already been scheduled, and use the Schedule Appointment
order as needed to request assistance in scheduling
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.
Appointment scheduled (with provider who can
manage diabetes) [COR0064]
ONCE, Starting today 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 27 of 32
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

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 IN COMMENTS)
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 28 of 32
Printed by WILLIAMS, HEATHER R [HRS0] at 2/2/2018 2:22:20 PM
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@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.
Follow-Up Care
Follow-Up Appointments - Ambulatory [20230]
Schedule Appointment With Physical Therapy
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Physical Therapy
Schedule Appointment With Occupational
Therapy [NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Occupational Therapy
Schedule Appointment With Speech Therapy
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Speech Therapy
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Page 29 of 32
Printed by WILLIAMS, HEATHER R [HRS0] at 2/2/2018 2:22:20 PM
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

Patient to Schedule Appointment [NURCOM0056] Routine
Purpose:
With whom:
For when:
Facility Therapy Needs [28537]
Continue Physical Therapy at Next Facility
[NURCOM0022]
Routine
Continue Occupational Therapy at Next Facility
[NURCOM0022]
Routine
Continue Speech Therapy at Next Facility
[NURCOM0022]
Routine
Discharge Labs [134929]
Page 30 of 32
Printed by WILLIAMS, HEATHER R [HRS0] at 2/2/2018 2:22:20 PM
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

Please use the table below to determine what type of order to use to place discharge lab
orders.
Who is Responsible for the
Result?
Where Will Labs be
Completed?
What Order Should You
Use?
Current Attending Provider UW Health Lab Specific lab orders (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
(B)
Current Consulting Provider
UW Health Lab
Specific lab orders with
AUTHORIZING PROVIDER
CHANGED TO
CONSULTANT (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
and AUTHORIZING
PROVIDER CHANGED TO
CONSULTANT (B)
Another Provider
UW Health Lab
Recommended Discharge
Labs (C)
Non-UW Health Lab
Recommended Discharge
Labs (C)
(A) SPECIFIC LAB ORDERS:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have the labs completed at a
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient's care will be responsible for the
result, you must change the AUTHORIZING PROVIDER on the order to the CONSULTING
PROVIDER before signing the order. To do this, click the Providers button near the top of the
Review, Sign & Hold tab of the discharge navigator. Update the authorizing provider to the
consulting provider.
(B) SPECIFIC LAB ORDER WITH ORDER CLASS CHANGED TO OUTSIDE:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have labs completed at a NON-
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient’s care will be responsible for the
result, you must change the AUTHORIZING PROVIDER on the order to the CONSULTING
PROVIDER before signing the order. To do this, click the Providers button near the top of the
Review, Sign & Hold tab of the discharge navigator. Update the authorizing provider to the
consulting provider.
The patient will receive a paper order to take to the lab.
(C) RECOMMENDED DISCHARGE LABS:
This order should be used to recommend to another provider labs that a patient should have
completed after discharge. The provider designated in the 'Send Recommendations To' field is
responsible for PLACING the lab orders AND will be responsible for the RESULTS of any
ordered labs.
Page 31 of 32
Printed by WILLIAMS, HEATHER R [HRS0] at 2/2/2018 2:22:20 PM
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org

Discharge Labs Workflow URL: https://uconnect.wisc.edu/growth/training--
education/health-link/10-minutes/inpatient-
discharge-consult/resources/name-82993-en.file
Recommended Discharge Labs [NURCOM0075] Details
Laboratory [20236]
Consulting Provider will lab orders should only be used if the current Attending Provider or These
lab.be responsible for the result of the
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:6/4/18 MANUAL,Count:1,
Normal, Routine
BASIC METABOLIC PANEL [BMET] Status: Standing, Expires:6/4/18 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:3/6/19 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:6/4/18 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:6/4/18 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:3/6/19 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:6/4/18 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:6/4/18 MANUAL,Count:1,
Normal, Routine
BILIRUBIN, TOTAL [TBIL] Status: Standing, Expires:6/4/18 MANUAL,Count:1,
Normal, Routine
PROTEIN, TOTAL [TP] Status: Standing, Expires:6/4/18 MANUAL,Count:1,
Normal, Routine
ALBUMIN [ALB] Status: Standing, Expires:6/4/18 MANUAL,Count:1,
Normal, Routine
ALKALINE PHOSPHATASE [ALKP] Status: Standing, Expires:6/4/18 MANUAL,Count:1,
Normal, Routine
AST/SGOT [AST] Status: Standing, Expires:3/6/19 MANUAL,Count:1,
Normal, Routine
ALT/SGPT [ALT] Status: Standing, Expires:3/6/19 MANUAL,Count:1,
Normal, Routine
Page 32 of 32
Printed by WILLIAMS, HEATHER R [HRS0] at 2/2/2018 2:22:20 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2018CCKM@uwhealth.org