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/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98239-en.cckm

20180236

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UWHC,UWMF,

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

IP – Skilled Nursing Facility (SNF) – Adult – Discharge [4146]

IP – Skilled Nursing Facility (SNF) – Adult – Discharge [4146] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Skilled Nursing Facility (SNF) - Adult - Discharge [4146]
Skilled Nursing Facility Orders
This Patient is going to a skilled nursing facilty, directly below is a group of orders commonly
associated with this patient population. Please review the orders below and select the appropriate
ones for this patient. If this patient is not going to a SNF, contact Case Management to update the
discharge plan. Updating the discharge plan will remove this set of SNF orders from the order set.
Skilled Nursing Facility Certification Statement [114940]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Certification Statement [118260]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Admit Order [114941]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Admit Order [118261]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Non-Categorized Orders [111713]
For dyspnea, Oxygen at 2 L/minute per nasal
canula; If this is an acute change for the patient
call PCP with assessment ASAP after oxygen is
started. Suction PRN to clear airways.
[NURCOM0022]
Routine
DME - Home Oxygen [1009468] Length of Need:
Patient's O2 Requirements Assessed and Meets
Criteria for Home O2:
Delivery Device:
Equipment Needed:
Continuous (liters/min):
Continuous (FiO2):
With Activity (liters/min):
With Activity (FiO2):
With Sleep (liters/min):
With Sleep (FiO2):
Length of Need:
Vendor:
DME - CPAP [1009443] Length of Need:
Formal Sleep Study Completed:
Diagnosis:
CPAP Pressure (cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
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DME - BiPAP (S) [1009441] Length of Need:
Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S):
Diagnosis:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
DME - BiPAP (S/T) [1009442] Length of Need:
Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S/T):
Diagnosis:
Respiratory Rate:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Patient may self administer medication per RN
assessment [NURCOM0022]
Routine
Patient medications (per Skilled Nursing Facility
policy) may be left at bedside [NURCOM0022]
Routine
Controlled Substances Refills (Single Response) [219976]
Patient not on controlled substance(s) upon
discharge [NURCOM0022]
Routine
Please contact listed provider for refills of
controlled substances (i.e.. PCP, UW Health
provider's name, or a baseline pain service).
[NURCOM0022]
Routine, ***
Facility Therapy Needs [113391]
Physical Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Occupational Therapy to Evaluate and Treat at
Next Facility [NURCOM0022]
Routine
Speech Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Communicable Diseases [111717]
State Law requires at least one of the following statements be checked for your patient. May check both if
applicable
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DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have any
other clinically apparent communicable diseases.
[NURCOM0022]
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Communicable Diseases [118262]
State Law requires at least one of the following statements be checked for your patient. May check both if
applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have any
other clinically apparent communicable diseases.
[NURCOM0022]
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Analgesics [246260]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, 20 tab, 0, starting 2/5/18, No Print
Blood Glucose Management [111710]
glucagon 1 mg injection kit [107799] 1 mg, 1 each, 1, starting 2/5/18, No Print
Glucose 40 % oral gel [118089] 10 g, 1 Tube, 1, starting 2/5/18, No Print
Nursing Communication [NURCOM0022] Routine, Notify {Notify for Blood Glucose:3004146} if
blood glucose is greater than 400 mg/dL or less than
40 mg/dL
Diabetes Care Instructions [NURCOM0112] Routine, - Patient's blood glucose goal range before
meals is *** mg/dL.
- Monitor patient's blood glucose {Glucose Monitoring
Frequency:25242}.
- If your patient's blood glucoses are uncontrolled
contact provider.
- "Uncontrolled" blood glucoses mean:
* Blood glucose above 150 mg/dL more than half the
time during a week.
* Blood glucose over *** mg/dL.
* Blood glucose less than 70 mg/dL two or more times
per week (or if having signs/symptoms of low blood
glucose such as shaking, sweating, or light-
headedness).
Bowel Management [240076]
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, 1 suppository, 1, starting 2/5/18, No Print
Senna-Docusate Sodium 8.6-50 MG per tab
[60530]
1-2 tab, 1 tab, 1, starting 2/5/18, No Print
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, 1 Bottle, 1, starting 2/5/18, No Print
polyethylene glycol (MIRALAX) oral powder
[61353]
17 g, 1 Bottle, 1, starting 2/5/18, No Print
Patient Care Orders
Reason For Hospitalization [129829]
Page 3 of 10
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Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Activity [20226]
Activity [NURACT0008] Routine
Discharge Activity:
Nutrition [20227]
Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Wound Care [20228]
Wound Care [NURWND0015] Routine
Bladder Care [121031]
Bladder Care [NURELM0067] Routine
Bowel Care [121030]
Bowel Care [NURELM0068] Routine
Other Patient Care Instructions [121032]
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
Follow-Up Referrals
Follow-Up Appointments - Cardiac Rehab (Single Response) [101247]
Outpatient Cardiac Rehab is recommended. Please select one of the following.
Referral Cardiac Rehab (Outpatient) [CON0174] All patients being discharged from UWHC IP CVM
with the following diagnoses should receive a referral
to cardiac rehab: Acute Myocardial Infarction (i.e. all
STEMI or NSTEMI patients), Stable Angina, Coronary
Artery Bypass Surgery, Valve Surgery (repair or
replacement), Percutaneous Coronary Angioplasty or
Stenting, or Heart Transplant, or Stable Congestive
Heart Failure.
Typically, outpatient cardiac rehab follow-up
appointments occur 3-4 weeks post-hospitalization.
Inpatient Preventive Cardiology staff clinicians will
refer and make arrangements for the patient. If you
have further questions, you may call them at 263-
6630.
Routine
Has this patient been seen by inpatient Cardiac
Rehab/Preventive Cardiology during this encounter?
Reason Cardiac Rehab Not Ordered [COR0027] Routine
Reason Not Ordered:
Follow-Up Appointments - Cardiac Rehab [101248]
Page 4 of 10
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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Referral Cardiac Rehab (Outpatient) [CON0174] All patients being discharged from UWHC IP CVM
with the following diagnoses should receive a referral
to cardiac rehab: Acute Myocardial Infarction (i.e. all
STEMI or NSTEMI patients), Stable Angina, Coronary
Artery Bypass Surgery, Valve Surgery (repair or
replacement), Percutaneous Coronary Angioplasty or
Stenting, or Heart Transplant, or Stable Congestive
Heart Failure.
Typically, outpatient cardiac rehab follow-up
appointments occur 3-4 weeks post-hospitalization.
Inpatient Preventive Cardiology staff clinicians will
refer and make arrangements for the patient. If you
have further questions, you may call them at 263-
6630.
Routine
Has this patient been seen by inpatient Cardiac
Rehab/Preventive Cardiology during this encounter?
Follow Up Appointments - Diabetes (Single Response) [148552]
*** 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 5 of 10
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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 6 of 10
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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.
Follow-Up Care
Follow-Up Appointments [20230]
Page 7 of 10
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Schedule Appointment With Physical Therapy
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Physical Therapy
Schedule Appointment With Occupational
Therapy [NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Occupational Therapy
Schedule Appointment With Speech Therapy
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Speech Therapy
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Patient to Schedule Appointment [NURCOM0056] Routine
Purpose:
With whom:
For when:
Facility Therapy Needs [28537]
Continue Physical Therapy at Next Facility
[NURCOM0022]
Routine
Continue Occupational Therapy at Next Facility
[NURCOM0022]
Routine
Continue Speech Therapy at Next Facility
[NURCOM0022]
Routine
Discharge Labs [134929]
Page 8 of 10
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Please use the table below to determine what type of order to use to place discharge lab
orders.
Who is Responsible for the
Result?
Where Will Labs be
Completed?
What Order Should You
Use?
Current Attending Provider UW Health Lab Specific lab orders (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
(B)
Current Consulting Provider
UW Health Lab
Specific lab orders with
AUTHORIZING PROVIDER
CHANGED TO
CONSULTANT (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
and AUTHORIZING
PROVIDER CHANGED TO
CONSULTANT (B)
Another Provider
UW Health Lab
Recommended Discharge
Labs (C)
Non-UW Health Lab
Recommended Discharge
Labs (C)
(A) SPECIFIC LAB ORDERS:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have the labs completed at a
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient's care will be responsible for the
result, you must change the AUTHORIZING PROVIDER on the order to the CONSULTING
PROVIDER before signing the order. To do this, click the Providers button near the top of the
Review, Sign & Hold tab of the discharge navigator. Update the authorizing provider to the
consulting provider.
(B) SPECIFIC LAB ORDER WITH ORDER CLASS CHANGED TO OUTSIDE:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have labs completed at a NON-
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient’s care will be responsible for the
result, you must change the AUTHORIZING PROVIDER on the order to the CONSULTING
PROVIDER before signing the order. To do this, click the Providers button near the top of the
Review, Sign & Hold tab of the discharge navigator. Update the authorizing provider to the
consulting provider.
The patient will receive a paper order to take to the lab.
(C) RECOMMENDED DISCHARGE LABS:
This order should be used to recommend to another provider labs that a patient should have
completed after discharge. The provider designated in the 'Send Recommendations To' field is
responsible for PLACING the lab orders AND will be responsible for the RESULTS of any
ordered labs.
Page 9 of 10
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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
Labs [20236]
Consulting Provider will lab orders should only be used if the current Attending Provider or These
lab.be responsible for the result of the
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
BASIC METABOLIC PANEL [BMET] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:3/9/19 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:3/9/19 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
BILIRUBIN, TOTAL [TBIL] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
PROTEIN, TOTAL [TP] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
ALBUMIN [ALB] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
ALKALINE PHOSPHATASE [ALKP] Status: Standing, Expires:6/7/18 MANUAL,Count:1,
Normal, Routine
AST/SGOT [AST] Status: Standing, Expires:3/9/19 MANUAL,Count:1,
Normal, Routine
ALT/SGPT [ALT] Status: Standing, Expires:3/9/19 MANUAL,Count:1,
Normal, Routine
Page 10 of 10
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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