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/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98209-en.cckm

201707191

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

IP - General - Pediatric - Discharge [4897]

IP - General - Pediatric - Discharge [4897] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - General - Pediatric - Discharge [4897]
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 [131211]
Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, Your child was hospitalized for ***.
@CAPHIS@ care included ***.
Activity [131212]
Activity - Up As Tolerated [NURACT0008] Routine
Discharge Activity: Up As Tolerated
Physical Education Restrictions [NURACT0011] Routine, ***
Activity - Other [NURACT0008] Routine
Discharge Activity:
Nutrition [131213]
Diet - General (No Modifications) [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
Avoid Juice [NURDIE0013] Routine
Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Other Patient Care Instructions [131218]
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, ***
How to Take Your Child's Temperature
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, If your child is still wearing diapers,
please take his/her temperature with the thermometer
in @HIS@ bottom (rectally).
If your child is potty-trained, please take his/her
temperature with the thermometer in @HIS@ armpit
(axillary).
If your child is school-aged, please take his/her
temperature with the thermometer in @HIS@ mouth
(orally).
How to Care For Your Child's
Gastrostomy/Gastojejunostomy Tube
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, Call your doctor if the area is very red,
hard, oozing pus or foul smelling drainage, your child
develops a fever, or if there is skin break down around
the tube site.
Bronchiolitis Discharge Instructions [199315]
Bronchiolitis Discharge Instructions [199314]
Page 1 of 10
Printed by STRAKA, KEVIN F [KFS1] at 7/6/2017 9:21:00 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Care for your child with bronchiolitis
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms.
This order will appear on the patient's After Hospital
Care Plan., Routine, Bronchiolitis is a viral infection
of the lower breathing passages and affects the
entire breathing passageways, including the
bronchioles, which are the smallest air passages in
the lungs. Infection causes inflammation, which
leads to partial or complete blockage of air
passages. Many different viruses that cause colds
and flu-like illness can also cause bronchiolitis.
Respiratory Syncytial virus (RSV) is the most
frequent cause. It is a very common illness in infants
and young children less than 2 years of age.
Bronchiolitis often goes away by itself without any
additional medication. There are some things to
make your child more comfortable. When babies
have bronchiolitis, their noses often get plugged.
This can make it hard to breathe while eating. It
helps to suction the nose before feeding. It also
helps to suction before breathing treatments and any
time the child is having more trouble breathing. It
also helps to suction before naps or bedtime. You
will want to continue to suction out your baby’s nose
with saline nose drops and a blue bulb syringe (or
other similar device.)
Your baby may take longer to feed than usual.
Small, frequent feedings are helpful to stay hydrated
if you baby seems more tired with longer feeds.
It is normal for your child to have symptoms for up to
a month. Wheezing should get better within a week
or so. The stuffy nose and cough may last for
another 1-2 weeks. Sleeping and eating routines
may not return for up to a week.
Page 2 of 10
Printed by STRAKA, KEVIN F [KFS1] at 7/6/2017 9:21:00 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

When to Call Your Doctor - Bronchiolitis
[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 child is very sleepy, weak
or looks very ill
- Your child has a new fever (temperature greater
than 100.4° F or 38°C) after being fever free for at
least 24 hours, especially if your child is younger
than 60 days old
- Your child is having new problems feeding
- Your child is having fewer wet diapers than usual,
the lips and mouth are dry, there are no tears with
crying, the eyes appear sunken and dark, or the soft
spot on top of your infant’s head is sunken
- You have any questions or concerns
Seek immediate medical attention if your child
develops worsening bronchiolitis. These symptoms
include:
- Breathing that is not improving
- Pale or blue-tinged skin (cyanosis)
- Severe coughing episodes
- Severe sucking in of the skin around the ribs or
base of the throat (retractions)
- If your child stops breathing
Treatment of Bronchiolitis
[COR0068]
Routine, Treatment of Bronchiolitis
Our treatment of infants and children with bronchiolitis has changed to
reflect the AAP 2014 Guidelines for Bronchiolitis. These guidelines and
evidence-based support can be found at:
http://pediatrics.aappublications.org/content/early/2014/10/21/peds.2014-
2742.full.pdf+html
The current recommendations do not support routine laboratory or
radiology testing for this clinical diagnosis, or treatment with albuterol,
racemic epinephrine or steroids. Aggressive nasal suctioning, hydration,
and oxygen therapy as needed are the mainstays of therapy for general
care inpatients.
Though not generally recommended by the new guideline, a trial
bronchodilator may be utilized in selected cases (especially older
children, those with strong family histories and those with several
episodes of previous wheezing). In cases where a bronchodilator was
considered, a standard approach was utilized in which the infant was first
positioned and suctioned and then scored using a respiratory score.
Infants with a total score less than 3 are identified as least likely to
benefit from albuterol. If a bronchodilator was utilized then a respiratory
score was utilized to assess for sustained improvement following
albuterol trial (improvement in score by 2 following 15-30 mins). Albuterol
would continue until assessed to be no longer objectively beneficial.
When to Call Your Doctor [131219]
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Printed by STRAKA, KEVIN F [KFS1] at 7/6/2017 9:21:00 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

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, If @FNAME@ has ***, or you have
other general pediatric questions or concerns call your
Primary Care Provider, @PCP@, at @PCPPH@.
Nights and weekends:
For urgent general pediatric 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 bring your child to the
nearest emergency department.
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 child's discharging physician
was @ATTPROV@. @ATTPROV@ is a Pediatric
Hospitalist who specializes in caring for children when
they are in the hospital and has provided information
to your Primary Care Provider about your child's
hospital stay. If you have questions about your child's
hospitalization, or for any other concerns, please call
your child's Primary Care Provider at @PCPPH@.
Your doctor can contact the Pediatric Hospitalist team
if he/she has further questions. If you cannot reach a
provider, and you have a serious medical concern, call
911 or bring your child to the nearest emergency
department.
Page 4 of 10
Printed by STRAKA, KEVIN F [KFS1] at 7/6/2017 9:21:00 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

When to Call Your Doctor - Subspecialties
[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 child received care from a
pediatric subspecialist during their hospitalization. To
contact a provider from the pediatric specialty team
Monday-Friday 8:00 a.m. to 4:30 p.m., use the phone
numbers listed below:
{subspecialty phone numbers:3022232}
For urgent subspecialist medical needs during
evenings and weekends, call 608-263-6400 and ask
for the Pediatric *** provider on-call.
If you cannot reach a provider, and you have a serious
medical concern, call 911 or bring your child to the
nearest emergency department.
Page 5 of 10
Printed by STRAKA, KEVIN F [KFS1] at 7/6/2017 9:21:00 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

When to Call Your Doctor - Hematology/Oncology
[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, Phone Call Instructions for Pediatric
Hematology-Oncology Families:
If you have a NON-URGENT medical concern or a
request for an appointment, prescription, lab or test
result call 608-263-6420 and your call will be directed
to a clinic scheduler or nurse.
If you have an URGENT medical concern, call the
page operator at 608-262-0486, and ask the operator
to page your nurse practitioner {PEDS HEM/ONC
NPS:19991},
or your physician {PEDS HEM/ONC MDS:19755}.
If it is the EVENING, WEEKEND, OR HOLIDAY, call
the page operator at 608-262-0486, and ask the
operator to page the pediatric hematologist-oncologist
on call.
SYMPTOMS TO BE REPORTED IMMEDIATELY
ARE:
Temperature greater than 100.4
Shaking Chills
Excessive vomiting and/or no urine output for 12 hours
or more
A severe nosebleed or any other prolonged bleeding
Significant head injury
Extreme lethargy or dramatic change in your child's
behavior
Excessive diarrhea (greater than 3 times in 24 hours)
No bowel movement/stool for 3 days
If you do not receive a call back within 20 minutes,
please call again.
Information to have ready to tell to the on call
physician:
Your child's name and diagnosis
Type and date of most recent chemotherapy
Your child's most recent blood count
Your main concern now
Your local pharmacy and number
Wound Care [131215]
Wound Care [NURWND0015] Routine
Bladder Care [131216]
Bladder Care [NURELM0067] Routine
Page 6 of 10
Printed by STRAKA, KEVIN F [KFS1] at 7/6/2017 9:21:00 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Bowel Care [131217]
Bowel Care [NURELM0068] Routine
Follow-Up Care
Follow-Up Apoointments [131222]
Schedule Appointment With Physical Therapy
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Patient's Specific PCP/Care Team
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: Patient's Specific PCP/Care Team
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: Patient's Specific PCP/Care Team
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:
Patient to Schedule Appointment [NURCOM0056] Routine
Purpose:
With whom:
For when:
Follow Up Appointments - Diabetes (Single Response) [148552]
*** 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.
Page 7 of 10
Printed by STRAKA, KEVIN F [KFS1] at 7/6/2017 9:21:00 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Appointment scheduled (with provider who can
manage diabetes) [COR0064]
ONCE, 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.
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.
Page 8 of 10
Printed by STRAKA, KEVIN F [KFS1] at 7/6/2017 9:21:00 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Free clinic information provided [COR0064] ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Free clinic information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
No appointment: Patient discharging to a facility
(e.g., skilled nursing facility, correctional facility,
etc.) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
discharging to a facility (e.g., skilled nursing facility,
correctional facility, etc.)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
No appointment: Patient refusal [COR0064] ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
refusal
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Discharge Labs [134929]
Page 9 of 10
Printed by STRAKA, KEVIN F [KFS1] at 7/6/2017 9:21:00 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org

Please use the table below to determine what type of order to use to place discharge lab
orders.
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
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 10 of 10
Printed by STRAKA, KEVIN F [KFS1] at 7/6/2017 9:21:00 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 07/2017CCKM@uwhealth.org