/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-98220-en.cckm

201711325

page

100

UWHC,UWMF,

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

IP - MI/Rule Out MI - Adult - Intermediate and General Care - Admission [920]

IP - MI/Rule Out MI - Adult - Intermediate and General Care - Admission [920] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - MI/Rule Out MI - Adult - Intermediate and General Care - Admission [920]
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 12
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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) [7417]
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
admission, enoxaparin a pacemaker and/or defibrillator is planned or considered during this If
not be given for 24 hours prior to the (Lovenox) or subcutaneous heparin products should
about holding the anticoagulation, this should be directly procedure. If there is a concern
the Electrophysiology (EP) service. discussed with
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
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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:
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 [10082]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital Signs [NURMON0013] EVERY 8 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Activity [10083]
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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]
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 [190823]
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?
Pulse Oximetry [NURMON0009] EVERY 4 HOURS, Starting today, Routine
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Intake and Output [10067]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine
Non-Categorized Patient Care Orders [10085]
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
INTERMITTENT (MAY REMOVE WHEN OFF
UNIT/BATHING), Starting today, Routine
Indication: Chest pain (ACS rule out) (24 hours)
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 5 of 12
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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 [9985]
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.
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
Anticoagulants - If ordering from this section - do not order DVT Px medications [10000]
-Adult -Anticoagulation Heparin -patient requires IV unfractionated heparin, refer to "IP/ED If
Set.Supplemental" Order
enoxaparin (LOVENOX) subcutanoeus injection
[800040]
1 mg/kg, Subcutaneous, EVERY 12 HOURS
warfarin (COUMADIN) tab [720161] Oral, 1 X DAILY (HS)
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 6 of 12
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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 less than 50 mL/min [11847]
eptifibatide (INTEGRILIN) injection [170954] 180 mcg/kg, Intravenous, ONCE For 1 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 [208598]
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]
4 X DAILY (NOTE ACKNOWLEDGE)
Please discontinue this NOTE order if patient is not on
enoxaparin.
Note: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]
4 X DAILY (NOTE ACKNOWLEDGE)
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]
4 X DAILY (NOTE ACKNOWLEDGE)
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]
4 X DAILY (NOTE ACKNOWLEDGE)
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.
Medications - General
Anti-emetics [9996]
Page 7 of 12
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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 [10070]
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?
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?
Page 8 of 12
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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?
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.
Diagnostic Tests and Imaging
Cardiology [10071]
Page 9 of 12
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11/2017CCKM@uwhealth.org

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 [10086]
X-RAY CHEST PA & LAT VIEWS [R71020] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Chest pain
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
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?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Page 10 of 12
Printed by LIND, JANNA S [JSL237] at 11/21/2017 1:00:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Consults
Consults [10087]
Consult Cardiac Rehab/Preventive Cardiology
(Inpatient) [CON0010]
ONCE, Routine
Reason for consult:
Consult Nutrition (Inpatient) [CON0043] ONCE, 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):
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?
Page 11 of 12
Printed by LIND, JANNA S [JSL237] at 11/21/2017 1:00:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

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?
BestPractice
No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing.
Page 12 of 12
Printed by LIND, JANNA S [JSL237] at 11/21/2017 1:00:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org