/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-98219-en.cckm

201711325

page

100

UWHC,UWMF,

Tools,

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

IP – MI/Rule Out MI – Adult – Intensive Care – Admission [923]

IP – MI/Rule Out MI – Adult – Intensive Care – Admission [923] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - MI/Rule Out MI - Adult - Intensive Care - Admission [923]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [186484]
*An admit patient order has already been written, but the level of care at which the patient
should be placed still needs to be identified.
Place Patient on General Care [ADT0018] General Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Place Patient on Intermediate Care (IMC)
[ADT0018]
Intermediate Care, has already been signed. This
order will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intensive Care (ICU) [ADT0018] Intensive Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Admit to Inpatient (Single Response) [188296]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-
only surgery, or a previously-authorized inpatient
stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [82665]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Page 1 of 14
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Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [20869]
Admit To Inpatient Status [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit To Observation Status [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [130119]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
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VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis (Single Response) [150156]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs [10063]
Vital Signs [NURMON0013] EVERY 2 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Activity [10064]
Activity [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition [10065]
Page 3 of 14
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Cardiac Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Heart Healthy
Heart Healthy Options: DASH
Bedside Meal Instructions:
Room Service Class:
NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Diabetes Meal Plan [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Diabetes
Bedside Meal Instructions:
Room Service Class:
Respiratory [10066]
-Intubated Patients Pain/Agitation/Delirium in -intubated patients refer to order set IP For
[4738] Supplemental -ICU -Adult
Mechanical Ventilation - Adult [117146]
Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Routine
Mechanical Ventilation [RT0028] Routine, For ADULT patients order chlorihexidene
gluconate (PERIDEX) 0.12% soln 15 mL to swab
oral cavity 2x daily while on ventilation.
Is this a modification to a current vent order?
Ventilator Management: Adult Vent Management
Protocol,Adult Vent Management Protocol
Wean: Per Cardiology Protocol
Set Rate/Min: 10
PEEP (cmH2O):
Mode: PRVC/PCVG,PRVC/PCVG
Tidal Volume Multiplier: 6
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Pressure Support:
Pressure Control:
P High (cmH20):
P Low (PEEP) (cmH20):
T High (sec):
T Low (T PEEP) (sec):
PS above P High (cmH2O):
PS above PEEP (cmH2O):
NAVA Level (µV):
Tidal Volume (6 x IBW) mL:
Tidal Volume (8 x IBW) mL:
chlorhexidine (PERIDEX) 0.12 % soln
MULTIDOSE [792004]
15 mL, Other, 2 X DAILY Starting today
Use to swab oral cavity. Discontinue when patient no
longer on ventilation.
Page 4 of 14
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11/2017CCKM@uwhealth.org

Biphasic Positive Airway Pressure (BIPAP)
[RT0004]
Routine
Mode:
IPAP (cm H2O):
EPAP (cm H2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Set Rate/Min:
Titrate oxygen to maintain O2 sat at (%):
Self Administered (Only RT may document in this box
after patient assessment): RT Approval Required
CPAP Continuous [RT0009] Routine
PEEP (cmH2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Titrate oxygen to maintain O2 sat at (%):
Self Administered (Only RT may document in this box
after patient assessment): RT Approval Required
Pulse Oximetry [NURMON0009] EVERY 4 HOURS, Starting today, Routine
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 90
O2 Delivery Device:
Attempt to Wean Off Oxygen?
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Intake and Output [144340]
Measure Intake And Output [NURMON0005] EVERY 2 HOURS, Starting today, Routine
Non-Categorized Patient Care Orders [10068]
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
CONTINUOUS, Starting today, Routine
Indication: ICU/PACU patient
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Contingency Parameters [10069]
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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): ***
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): 240 mL over 8 hours or less
than 30 mL/hour for 2 hours
Other: Chest pain or any significant changes in
status,Greater than 6 premature ventricular
contractions/minute, R on T, multiformed, coupled, or
runs of premature ventricular contractions,Potassium
less than 4.0 millimole/deciliter,Magnesium less than
2.0 milligrams/deciliter
Intravenous Therapy
Premedications for Needle Insertion [106310]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is within 1 minute. Choice of medication should be based on patient’s previous
experience/preference, history of lidocaine allergy and ease of access.
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, peripheral line
insertion - see Admin Instructions
Do NOT apply to area greater than 200 square
centimeters (maximum 2.5 g/site; maximum 4 sites
per hour, 6 times per day). Do NOT leave on longer
than 2 hours. Use for stable patient, no allergies to
lidocaine, with at least 30 minutes time prior to IV use
lidocaine (XYLOCAINE) 1% injection [39034] 0.1-0.4 mL, Intradermal, PRN, peripheral line insertion
- see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
Choice of medication should be based on patient’s
previous experience/preference, history of lidocaine
allergy and ease of access
Page 6 of 14
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sodium chloride (bacteriostatic) 0.9 % injection
[50585]
0.05-0.1 mL, Intradermal, PRN, peripheral line
insertion - see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
Choice of medication should be based on patient’s
previous experience/preference, history of lidocaine
allergy and ease of access
IV Fluids [143978]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Check and document patency, tubing change, site
assessment, and dressing change per policy.
Insert and Maintain Peripheral IV (Second Line)
[NURVAD0013]
CONTINUOUS, Starting today, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Check and document patency, tubing change, site
assessment, and dressing change per policy.
sodium chloride 0.9% infusion [64367] Intravenous, CONTINUOUS
Medications - Admission - specific
Angiotensin-Converting Enzyme Inhibitors [9987]
captopril (CAPOTEN) soln [780028] 3.125 mg, Oral, 3 X DAILY
captopril (CAPOTEN) tab [720027] 6.25 mg, Oral, 3 X DAILY
captopril (CAPOTEN) tab [720027] 12.5 mg, Oral, 3 X DAILY
captopril (CAPOTEN) tab [720027] 25 mg, Oral, 3 X DAILY
Angiotensin Receptor Blockers [9988]
losartan (COZAAR) tab [50482] 25 mg, Oral, 1 X DAILY
losartan (COZAAR) tab [50482] 50 mg, Oral, 1 X DAILY
valsartan (DIOVAN) tab [70379] 40 mg, Oral, 2 X DAILY
Anti-coagulants - If ordering from this section do NOT order VTE prophylaxis medications [143980]
-Adult -Anticoagulation Heparin -patient requires IV unfractionated heparin, refer to "IP/ED If
Set.Supplemental" Order
enoxaparin (LOVENOX) subcutaneous injection
[800040]
1 mg/kg, Subcutaneous, EVERY 12 HOURS
Beta-Blockers [9990]
carvedilol (COREG) tab [54511] 3.125 mg, Oral, 2 X DAILY
Hold for heart rate less than *** beats/minute or
systolic blood pressure less than *** mmHg.
carvedilol (COREG) tab [54511] 6.25 mg, Oral, 2 X DAILY
Hold for heart rate less than *** beats/minute or
systolic blood pressure less than *** mmHg.
metoprolol (LOPRESSOR) injection [800274] 5 mg, Intravenous, EVERY 5 MINUTES For 3 Doses
Hold for heart rate less than *** beats/minute or
systolic blood pressure less than *** mmHg
metoprolol (LOPRESSOR) tab [720094] 12.5 mg, Oral, EVERY 6 HOURS
Hold for heart rate less than *** beats/minute or
systolic blood pressure less than *** mmHg
metoprolol (LOPRESSOR) tab [720094] 25 mg, Oral, EVERY 6 HOURS
Hold for heart rate less than *** beats/minute or
systolic blood pressure less than *** mmHg
Beta-Blocker Reason Not Ordered [COR0002] ONCE, Starting today For 1 Occurrences, Routine
Reason Not Ordered:
Page 7 of 14
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Lipid-Regulating Agents [9991]
atorvastatin (LIPITOR) tab [720017] 40 mg, Oral, 1 X DAILY
atorvastatin (LIPITOR) tab [720017] 80 mg, Oral, 1 X DAILY
Nitrates [9992]
nitroglycerin (NITROSTAT) sublingual tab 0.4 mg
[40283]
0.4 mg, Sublingual, PRN, chest pain, angina
nitroglycerin (NITRO-BID) 2 % ointment [40285] 1 inch, Transdermal, EVERY 6 HOURS
nitroglycerin 50 mg in dextrose 5% 250 mL
infusion [51611]
5-200 mcg/min, Intravenous, CONTINUOUS
Initial dose 10 mcg/min. Increase by 10 mcg/min every
5 minutes for chest pain.
Platelet Inhibitors - Aspirin [9993]
aspirin chew tab [720014] 81 mg, Oral, 1 X DAILY Starting tomorrow with First
Dose As Scheduled
aspirin tab [34787] 325 mg, Oral, ONCE Starting today For 1 Doses
Administer STAT
Aspirin Reason Not Ordered [COR0003] ONCE, Starting today For 1 Occurrences, Routine
Reason Not Ordered:
Platelet Inhibitors - Clopidogrel [10305]
clopidogrel (PLAVIX) tab [58345] 600 mg, Oral, ONCE For 1 Doses
clopidogrel (PLAVIX) tab [58345] 75 mg, Oral, 1 X DAILY Starting tomorrow
Eptifibatide - for creatinine clearance equal to or greater than 50 mL/min [9994]
eptifibatide (INTEGRILIN) injection [170954] 180 mcg/kg, Intravenous, EVERY 10 MINUTES For 2
Doses
Maximum 22.6 mg/dose
for 1 Minutes
eptifibatide (INTEGRILIN) 75 mg in 100 mL
infusion [59379]
2 mcg/kg/min, Intravenous, CONTINUOUS
Maximum 15 mg/hour
Eptifibatide - for creatinine clearance equal to or less than 50 mL/min [12319]
eptifibatide (INTEGRILIN) injection [170954] 180 mcg/kg, Intravenous, EVERY 10 MINUTES For 2
Doses
Maximum 22.6 mg/dose
for 1 Minutes
eptifibatide (INTEGRILIN) 75 mg in 100 mL
infusion [59379]
1 mcg/kg/min, Intravenous, CONTINUOUS
Maximum 7.5 mg/hour
Non-categorized [208875]
NOTE: If a patient is on enoxaparin for acute
coronary syndrome, enoxaparin does NOT need
to be held on the morning of a diagnostic
coronary angiogram (cardiac cath). [950018]
2 X DAILY
Please discontinue this NOTE order if patient is not on
enoxaparin.
NOTE: If an order for enoxaparin is still active
after the patient has received a percutaneous
coronary intervention (PCI), page the provider for
clarification prior to administering the enoxaparin.
[950018]
2 X DAILY
Please discontinue this NOTE order if patient is not on
enoxaparin.
NOTE: If patient is scheduled for a procedure with
anesthesia (or if anesthesia participation is
uncertain), do not administer the ACE or ARB the
morning of the procedure. [950018]
2 X DAILY
Please discontinue this NOTE order if patient is not on
ACE or ARB.
NOTE: If there is an active order for enoxaparin
(Lovenox) or subcutaneous heparin and a
pacemaker and/or defibrillator is planned or being
considered during this admission, please discuss
anticoagulation plan with the primary
team/ordering providers. [950018]
2 X DAILY
Enoxaparin (Lovenox) and subcutaneous heparin are
generally NOT administered for 24 hours prior to the
planned pacemaker/defibrillator implants.
Please discontinue this NOTE order if the patient is
NOT being considered for a pacemaker or defibrillator.
General Medications
Page 8 of 14
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Analgesics [9995]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain/fever
Anti-emetics [9996]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 24 HOURS PRN,
nausea/vomiting, First Line Agent
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 24 HOURS PRN,
nausea/vomiting, First line agent, if unable to tolerate
oral administration
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN, nausea
Second Line Agent
prochlorperazine (COMPAZINE) rectal
suppository [46323]
25 mg, Rectal, EVERY 12 HOURS PRN, nausea
Second line agent If unable to take orally
Bowel Management [9998]
senna-docusate (SENOKOT S) 8.6-50 MG per
tab [60530]
2 tab, Oral, 2 X DAILY PRN, constipation, First line
agent
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY PRN, constipation, Second line
agent if inadequate response to first line agent
Anti-Ulcer Agents [9997]
Consider pantoprazole for patients on dual antiplatelet therapy with one or more of the following:
coagulants, steroids, or NSAIDs; -1) concomitant use of oral anti
2) History of GI bleeding or current H. pylori infection;
Dyspesia/GERD3)
Age 60 years old or greater 4)
pantoprazole (PROTONIX) delayed release tab
[62662]
40 mg, Oral, 1 X DAILY
alum-mag-simeth (MYLANTA ES) 400-400-40
MG/5ML susp [44073]
15-30 mL, Oral, EVERY 4 HOURS PRN, dyspepsia
Hypnotics [144257]
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see IPOC supplemental Sleep/Rest
Disturbance Adult)
Laboratory
Laboratory [144341]
CBC WITH DIFFERENTIAL [CBC] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 9 of 14
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GLUCOSE [GLU] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM [CA] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR - NOTE: For patients
on warfarin [PT]
NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
TROPONIN [GM2447] EVERY 6 HOURS, Starting today For 3 Occurrences,
Routine
Is this an add-on order? (Make sure frequency above
is set to ONCE):
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LIPID PANEL [LIPID] NEXT DRAW For 1 Occurrences, Routine, Test
includes Cholesterol, Total; HDL Cholesterol;
Triglyceride; LDL cholesterol, calculated; and non-
HDL cholesterol.
Patient must fast for a minimum of 10 hours and be
heparin free for 48 hours prior to specimen collection.
The patient can only have water during the fasting
period.
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]
CONDITIONAL - RN COLLECT, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen? Next AM draw
If Conditional, What Condition? Vent changes
Obtain If Not Done In Past 90 Days [144338]
HEMOGLOBIN A1C [HA1C] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Obtain if not done within the past 90 days.
Page 10 of 14
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Diagnostic Tests and Imaging
Cardiology [10071]
ECG - 12 Lead Without Rhythm [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
On admission
ECG - 12 Lead Without Rhythm [EKG0008] 1X DAILY, Starting today For 2 Days, Routine
Reason for exam:
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
In the morning
ECG - 12 Lead Without Rhythm [EKG0008] PRN, Starting today For Until specified, STAT
Reason for exam: CHEST PAIN
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
Transthoracic Resting Echocardiogram
[ECH0003]
ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
Do you want Agitated Bubble Study?
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Radiology [10072]
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, 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
Consults
Consults [10073]
Page 11 of 14
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Pulmonary Critical Care Medicine (PPCM) consultation is expected for the following intubated
and mechanically ventilated Cardiac ICU patients:
hours, ORPatients that are intubated/anticipated to be intubated for more than 24 a.
b. Patients with moderate to severe hypoxemia (require >=60% FIO2) within the first 24 hours of
intubation that is not rapidly improving with initial management (e.g. not improving with treatment
of ACS, diuresis)
Consult Pulmonary Critical Care Medicine
[CON0018]
ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Consult Cardiac Rehab/Preventive Cardiology
(Inpatient) [CON0010]
ONCE, Starting today For 1 Occurrences, Routine
Reason for consult:
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Can this consult be done via video?
Diabetes Consult Order Panel (Adult) [188497]
Diabetes Management Service : Will provide management or treatment recommendations for
patients with hyperglycemia and/or those who report outpatient use of insulin or other diabetes
medications. Patients should be expected to remain inpatient > 24 hrs from time of consult.
Consult is required for patients with insulin pumps or who use U-500 insulin. Consult Endocrine
for any non-diabetes-related endocrine questions.
Learning Center - Diabetes Education (Adult): Diabetes Education (Adult): Diabetes education
(meter/insulin skills/other diabetes survival skills) for patients/families with knowledge deficits
and/or need for diabetes knowledge assessment. Recommended for all new diagnoses or
patients with A1C > 9.
Diabetes Education – Nutrition: Diabetes nutrition therapy including nutrition assessment,
carbohydrate education (consistent carbohydrate meals, use of insulin-to-carbohydrate ratio),
and/or individualized, nutritious meal planning for carbohydrates, portions, or considering other
comorbidities. Recommended for all new diagnoses or patients with A1C > 9
Consult Diabetes Management Service (DMS)
(Inpatient) [CON0022]
ONCE
Can this consult be done via video?
Call back number:
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Page 12 of 14
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11/2017CCKM@uwhealth.org

Consult Learning Center - Diabetes Education
(Adult) [CON0021]
ONCE, Routine, - If patient is newly diagnosed or is
new to insulin, provide 24 hours notice to allow
adequate time for education,
- Indicate diabetes medication/treatment plan if
known.
- Consults requested after 1600 on Fridays may not
be seen until following Monday. Learning Center
available Mon-Sat 0800-1630 (only 1 RN available
on Saturday for CSC and AFCH).
- Staff may be contacted by Pager 7927 on
weekdays and Pager 3276 on weekends.
- Learning Center staff are not available on holidays.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Consult Diabetes Education - Nutrition (Inpatient)
[CON0126]
ONCE, Routine, · If your patient is newly diagnosed
and/or is new to insulin therapy, provide 24 hours
notice to allow adequate time for nutrition education.
· Indicate diabetes medication/treatment plan if
known.
· Consults requested after 1300 on Friday may not
be completed until the following Monday.
· If you are placing a consult on a weekend day for a
patient who will be discharging that weekend, please
have the Paging Center contact the on-call dietitian
to help you facilitate the diabetes nutrition education
session prior to the patient's discharge.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Consult Cardiac Electrophysiology (Inpatient)
[CON0102]
ONCE
Purpose of Consult:
Consulting Provider:
Reason for Consult:
Consult Congestive Heart Failure (Inpatient)
[CON0017]
ONCE
Purpose of Consult:
Consulting Provider:
Reason for Consult:
Consult Transplant (Inpatient) [CON0082] ONCE
Purpose of Consult:
Consulting Provider:
Reason for Consult:
Consult Cardiac Surgery (Inpatient) [CON0011] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
BestPractice
Page 13 of 14
Printed by LIND, JANNA S [JSL237] at 11/21/2017 1:01:50 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
Page 14 of 14
Printed by LIND, JANNA S [JSL237] at 11/21/2017 1:01:50 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org