/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-98229-en.cckm

20180126

page

100

UWHC,UWMF,

Tools,

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

IP - Targeted Temperature Management - Adult - Intensive Care - Admission [701]

IP - Targeted Temperature Management - Adult - Intensive Care - Admission [701] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Targeted Temperature Management - Adult - Intensive Care - Admission
[701]
for Adult Patients OnlyIntended
should following are relative exclusion criteria. Targeted Temperature Management The
accepting Critical Care case basis, as determined by the -by-be performed on a case
Service.
Exclusions:
(ROSC)Greater than 12 hours since return of spontaneous circulation 1)
of Glasgow Coma Scale score greater than or equal to 5 (i.e.,component Motor2)
movement)purposeful
cancer)morbid cognitive status (i.e., advanced dementia, metastatic -Minimal pre3)
statecardiac primary etiology for comatose -Suspected non4)
Sepsis as cause of arrest5)
Do not resuscitate (DNR) status6)
7) Core body temperature less than 30 degrees Celsius
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]
Page 1 of 14
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [149831]
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:
Admission Status [149832]
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:
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [147942]
Padua VTE Risk Assessment Tool URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 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:
VTE Prophylaxis (Single Response) [130123]
Page 2 of 14
Printed by LIND, JANNA S [JSL237] at 1/26/2018 8:57:33 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Padua VTE Risk Assessment Tool URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 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 [7689]
Vital Signs with Temperature [NURMON0013] SEE COMMENTS, Starting today with First
Occurrence As Scheduled, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital signs with temperature every 15 minutes times 4,
then every 30 minutes times 4, then every hour during
cooling and maintenance.
Vital Signs with Temperature [NURMON0013] SEE COMMENTS, Starting today with First
Occurrence As Scheduled For Until specified, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital signs with temperature every 15 minutes times 4,
then every 30 minutes times 4, then every hour during
rewarming.
Patient Monitoring [18257]
Train of Four - After Dose Change
[NURMON0060]
SEE COMMENTS, Starting today For Until specified,
Train of four - After each change in dose of
neuromuscular blocking agent.
Train of Four - Every Hour [NURMON0060] SEE COMMENTS, Starting today For Until specified,
Every hour until twitches are at goal of 2/4, then every
4 hours.
Page 3 of 14
Printed by LIND, JANNA S [JSL237] at 1/26/2018 8:57:33 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Train of Four - Every 2 Hours [NURMON0060] SEE COMMENTS, Starting today with First
Occurrence As Scheduled For Until specified, Train of
four - Every 2 hours after discontinuation of
neuromuscular blocking agent until twitches return to
4/4.
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
CONTINUOUS, Routine
Indication: ICU/PACU patient
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Measure Hemodynamic Parameters
[NURMON0023]
CONTINUOUS, Starting today, Routine
Pulmonary Artery Systolic Pressure (mmHg):
Pulmonary Artery Diastolic Pressure (mmHg):
Pulmonary Artery Mean Pressure (mmHg):
Pulmonary Artery Wedge Pressure (mmHg):
Central Venous Pressure (mmHg):
Central Venous Pressure (mmH2O):
Cardiac Output:
Cardiac Output Method:
Cardiac Index:
Systemic Vascular Resistance:
Pulmonary Vascular Resistance:
Pulmonary Vascular Resistance Index:
Stroke Volume (mL/beat):
Stroke Volume Index:
Systemic Vascular Resistance Index:
Left Cardiac Work Index:
Right Cardiac Work Index:
Left Ventricular Stroke Work Index:
Right Ventricular Stroke Work Index:
Pulmonary Capillary Wedge Pressure (mmHg):
Measure with FloTrac? No
Use Bedside Shivering Assessment Scale
[NURCOM0022]
EVERY 1 HOUR
Activity [7691]
Bed Rest [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: other (comment)
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Elevate Head Of Bed - 30 Degrees
[NURACT0002]
Equal to (degrees): 30
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today
Nutrition [7690]
Page 4 of 14
Printed by LIND, JANNA S [JSL237] at 1/26/2018 8:57:33 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
OG Tube Placement - Adult [120995]
Insert and Maintain Orogastric Tube
[NURTAD0015]
CONTINUOUS, Starting today, Routine
Options: Low, Continuous Suction
Flush with:
Flush Frequency: EVERY 8 HOURS
Check Residual:
Does this need to be inserted/placed?
Device Status:
Refer to Policy 2.20AP Care & Maintenance of
Enteral Tubes (Adult & Pediatric)
Recommendations for flush quantity:
For adult patients, 30 mLs of fluid should be
sufficient.
X-RAY ABDOMEN SINGLE VIEW [R74018] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Orogastric tube
placement
What specific question(s) would you like answered
by this exam? Evaluate orogastric tube placement
Relevant recent/past history? Cardiac Surgery
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
If Conditional, What Condition? Evaluate orogastric
tube placement. The location of orogastric tube
should be confirmed prior to the instillation of fluids,
medications, or feedings. Refer to Policy 2.20
Enteral Tubes Used for Instillation of Fluids,
Medications, or Feeding
Respiratory [7692]
Mechanical Ventilation - Adult [117146]
Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Routine
Page 5 of 14
Printed by LIND, JANNA S [JSL237] at 1/26/2018 8:57:33 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Mechanical Ventilation [RT0028] Routine, For ADULT patients:
Chlorihexidene gluconate (PERIDEX) 0.12% soln
15ml to swab oral cavity 2x daily while on ventilation.
Oral suction. Moisturizer, mouth swab q4 hrs.
HOB 30 degrees.
Suction oropharynx prior to ETT.
Always use separate suction tubing for oral and ETT
suctioning, separate containers when possible.
Oral Suction tubing change QD by RN.
Oral canister change Q3D by RN.
In-line suction, tubing and canister changed Q3D by
RT.
Assessed to Wean.
Is this a modification to a current vent order?
Ventilator Management: Adult Vent Management
Protocol
Wean: As Tolerated per RT
Set Rate/Min:
PEEP (cmH2O):
Mode:
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):
Wean when FiO2 for a PaO2 > 85 mmHg or pulse
oximetry > 94%.
chlorhexidine (PERIDEX) 0.12 % soln
MULTIDOSE [792004]
15 mL, Other, 2 X DAILY Starting today
Use to swab oral cavity. D/C when patient no longer
on ventilation.
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine
Intake and Output [7693]
Measure Intake And Output [NURMON0005] EVERY 1 HOUR, Starting today, Routine
Non-Categorized Patient Care Orders [7694]
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS For Until specified, Routine, To
discontinue this order, enter a new order for
"Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes in
the new order.
Type: Temperature Probe
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
To urimeter.
Urinary Catheter Removal Protocol does NOT apply to
Urology, Gynecology, spinal cord injured patients or
patients with catheters placed by Urology on prior
admission.
Insert Rectal Temperature Probe [NURCOM0022] CONTINUOUS, Starting today
Page 6 of 14
Printed by LIND, JANNA S [JSL237] at 1/26/2018 8:57:33 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Insert Esophageal Temperature Probe
[NURCOM0022]
CONTINUOUS, Starting today
Glucose, POC [IPGLUCOSE] EVERY 1 HOUR, Starting today, Routine, Glucose,
POC should always be ordered in conjunction with
orders for hypoglycemia management and monitoring
as indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Draw from arterial line.
Post Cardiac Arrest Program Data [216333]
Cardiac Arrest Program Data [COR0088] ONCE
Is this a cardiac arrest patient?
Contingency Parameters [7695]
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): 32
If heart rate > (bpm): ***
If heart rate < (bpm): ***
If respiratory rate >: ***
If respiratory rate <: ***
If blood glucose > (mg/dL): 180
If blood glucose < (mg/dL): 144
If pain score >:
Pulse Oximetry < (%): ***
If urine output < (mL):
Other: Core temperature of *** degrees Celsius is not
achieved after 12 hours of rewarming.
Once patient has been rewarmed
[NURCOM0022]
ONCE For 1 Occurrences, Once patient has been
rewarmed and is off neuromuscular blocking agents
(NMBA), if patient remains vented, contact covering
physician to initiate the Pain/Agitation/Delirium (PAD)
order set.
Targeted Temperature Management
UWHC Targeted Temperature Management
Cooling Products
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/cardiovascular/related/name-
100378-en.cckm
UWHC Post Cardiac Arrest Algorithm-Adult-
Emergency Dept/Inpatient
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/cardiovascular/related/name-
103679-en.cckm
Targeted Temperature Management [149824]
Apply Cooling Blankets Above and Below Patient
[NURCOM0022]
SEE COMMENTS, Place above and below patient,
until cooling catheter is placed.
Apply Ice Pack to Affected Area [NURTRT0008] SEE COMMENTS, Routine
Site: Other (Comment) (Apply to axilla, torso, groin,
and skin until cooling catheter is placed.)
Page 7 of 14
Printed by LIND, JANNA S [JSL237] at 1/26/2018 8:57:33 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Cooling and Rewarming Process [NURCOM0022] CONTINUOUS, Starting today, Use surface cooling or
intravascular temperature management catheter to
achieve core temperature of {UWIP COOLING
TEMP:3500032} degrees Celsius within 3 hours of
initial patient presentation.
Once target temperature is achieved, maintain target
temperature for 24 hours. After target temperature has
been maintained for 24 hours, initiate rewarming using
surface cooling or intravascular temperature
management catheter.
Rewarm no faster than 0.5 degrees Celsius per hour.
Achieve a goal temperature equal to 37 degrees
Celsius within 12 hours. Maintain normothermia (37
degrees Celsius) for 48 hours after rewarming.
Contact provider team 6 hours before rewarming
and during rewarming if K < 3.5 and Mg < 1.8
[NURCOM0022]
SEE COMMENTS, Contact provider team 6 hours
before rewarming and during rewarming if K < 3.5 and
Mg < 1.8.
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 immediate.
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
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.
IV Therapy [150761]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Post-Op/Phase II
Maintain Non-Tunneled Central Venous Catheter
[NURVAD0017]
CONTINUOUS, Starting today, Routine
Device Status:
Site:
IV Fluids - NOTE: Discontinue all maintenance fluids containing dextrose (Single Response) [12614]
sodium chloride 0.9 % infusion [64367] Intravenous, CONTINUOUS
lactated ringers infusion [38890] Intravenous, CONTINUOUS
Medications - General
Platelet Inhibitors (Single Response) [109847]
Aspirin [150762]
aspirin tab [34787] 325 mg, Nasogastric Tube, ONCE For 1 Doses
Administer first dose now
Page 8 of 14
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
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01/2018CCKM@uwhealth.org

aspirin chew tab [720164] 81 mg, Nasogastric Tube, 1 X DAILY Starting
tomorrow For 7 Days
Aspirin Reason Not Ordered [COR0003] ONCE, Starting today For 1 Occurrences, Routine
Reason Not Ordered: Already on Aspirin/Ordered
Through Med Reconciliation
Analgesics (Single Response) [149827]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Nasogastric Tube, EVERY 6 HOURS For 24
Hours
acetaMINOPHEN (TYLENOL) suppository
[43994]
650 mg, Rectal, EVERY 6 HOURS For 24 Hours
Anesthetic/Sedation [145862]
FENTanyl PF injection - NOTE: Suggested dose
12.5-50 mcg [800187]
Intravenous, ONCE For 1 Doses
NOTE: Suggested dose 12.5-50 mcg
FENTanyl (50 mcg/mL) infusion [800264] Intravenous, CONTINUOUS
*** mcg/hr Titrate by *** mcg/hr every *** minutes to
maintain pain relief
NOTE: Suggested dose 12.5-50 mcg/hr to maintain
pain relief and sedation score of +1 to -1 RASS.
midazolam (VERSED) injection [800197] 0.05 mg/kg, Intravenous, ONCE For 1 Doses
IV Push rate 1 mg/minute Do NOT administer if patient
has running midazolam infusion.
midazolam (VERSED) 50 mg in dextrose 5 % 50
mL infusion - NOTE: Suggested sedation goal +1
to -1 RASS [700236]
1-10 mg/hr, Intravenous, CONTINUOUS
Initiate at 1 mg/hour (Maximum initial dose 10 mg/hour
or current rate). Titrate rate by 20% of current rate
every 4 hours to maintain sedation score of +1 to -1
RASS. Bolus by dose equal to current hourly infusion
rate every 2 hours if patient exhibits signs or
symptoms of discomfort. Contact MD with any
questions.
Neuromuscular Blocking Agents (Single Response) [149828]
vecuronium (NORCURON) vial [46843] 0.1 mg/kg, Intravenous, EVERY 1 HOUR PRN,
shivering
Must be sedated with midazolam for at least 5 minutes
prior to administration
Atracurium Panel [241301]
atracurium (TRACRIUM) vial [156562] 0.4 mg/kg, Intravenous, ONCE For 1 Doses
Prior to initiation of infusion and with each rate
increase of continuous infusion
atracurium (TRACRIUM) 200 mg in dextrose 5 %
100 mL infusion [700150]
4-15 mcg/kg/min, Intravenous, CONTINUOUS
For patients with renal or hepatic dysfunction, or
patients receiving corticosteriods. Initiate at 4
mcg/kg, titrate to Train of Four of 2 out of 4 every 15
minutes by 1 mcg/kg.
Gastric [149829]
famotidine (PEPCID) intraVENOUS [800279] 20 mg, Intravenous, EVERY 12 HOURS
Non-Categorized [149830]
artificial tears PF ophthalmic ointment [157764] Eyes (Each), EVERY 8 HOURS
Apply a thin later to inside of lower lid.
meperidine (DEMEROL) injection RANGE
[750055]
25-50 mg, Intravenous, EVERY 4 HOURS PRN,
rigors, for 4 Minutes
Note: Hold Medication Communication [950057] 4 X DAILY (NOTE ACKNOWLEDGE) For 48 Hours
Hold potassium supplementation 4 hours before
rewarming begins.
Laboratory
Obtain if Not Completed in Emergency Department [7696]
Page 9 of 14
Printed by LIND, JANNA S [JSL237] at 1/26/2018 8:57:33 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

ELECTROLYTES [LYTE] STAT, 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?
PTT [PTT] STAT, 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?
CBC WITHOUT DIFFERENTIAL [HEMO] STAT, 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 [PT] STAT, 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?
BLOOD GASES AND O2 SATURATION
[HCBGASOS]
STAT, Starting today For 1 Occurrences, Routine
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] STAT, 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] STAT 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] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATINE [HCCREATN] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LACTATE [GM2255] STAT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw Every 6 Hours [148551]
BLOOD GASES [HCBGAS] EVERY 6 HOURS, Starting today For 3 Days, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 10 of 14
Printed by LIND, JANNA S [JSL237] at 1/26/2018 8:57:33 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

ELECTROLYTES, WHOLE BLOOD
[HCWBLYTS]
EVERY 6 HOURS, Starting today For 3 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] EVERY 6 HOURS, Starting today For 3 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] EVERY 6 HOURS, Starting today For 3 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] EVERY 6 HOURS, Starting today For 3 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] EVERY 6 HOURS, Starting today For 3 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM [CA] EVERY 6 HOURS, Starting today For 3 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LACTATE [GM2255] EVERY 6 HOURS, Starting today For 3 Days, STAT
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
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw every 6 hours
times 3 or until peaked
Conditional Labs [149826]
GLUCOSE [GLU] CONDITIONAL, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Condition: Draw if
blood glucose less than 40 or greater than 400 mg/dL
Draw if blood glucose less than 40 or greater than 400
mg/dL.
BLOOD GASES AND O2 SATURATION
[HCBGASOS]
CONDITIONAL, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Vent changes
Pregnancy Test [148556]
HCG, QUALITATIVE, URINE [UPREG] STAT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Diagnostic Tests - if not already done in the Emergency Department
Cardiology [7697]
Page 11 of 14
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
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.
Rule out ischemia.
ECG - 12 Lead [EKG0008] ONCE, Starting tomorrow 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.
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?
Neurology [149834]
Bedside EEG [EEG0002] ONCE, Starting today For 1 Occurrences, Routine
Reason for Monitoring: Cardiac/Pulmonary Arrest
Radiology [18266]
X-RAY CHEST SINGLE VIEW [R71045] 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? Endotracheal tube placement and
assessment of possible aspiration.
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? Bedside
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
CT HEAD W/ O IV CONTRAST [R70450] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, STAT
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history.
Last creatinine value? (will auto pull in date and value
in comment):
Last patient weight? (will auto pull in value and date in
comment):
Transport Method:
Consults
Consults [149836]
Page 12 of 14
Printed by LIND, JANNA S [JSL237] at 1/26/2018 8:57:33 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Consult Neurology (Inpatient) [CON0040] 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:
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 13 of 14
Printed by LIND, JANNA S [JSL237] at 1/26/2018 8:57:33 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@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?
Consult Palliative Care - Adult (Inpatient)
[CON0055]
ONCE, Routine
Reason For Consult:
Can this consult be done via video?
Consult Pulmonary Critical Care [216334]
Consult Critical Care (Inpatient) [CON0018] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Ventilator
management for patient on targeted temperature
management (TTM)
Can this consult be done via video?
Call back number:
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 14 of 14
Printed by LIND, JANNA S [JSL237] at 1/26/2018 8:57:33 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org