/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-98260-en.cckm

201712341

page

100

UWHC,UWMF,

Tools,

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

IP - Surgical - Adult - Intermediate Care - Admission/Transfer [5345]

IP - Surgical - Adult - Intermediate Care - Admission/Transfer [5345] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Surgical - Adult - Intermediate Care - Admission/Transfer [5345]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [187520]
*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 [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 [30262]
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 13
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12/2017CCKM@uwhealth.org

Admit To Observation [ADT0002] 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:
Admit To Observation [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) [211046]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS
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
High Bleed 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
Page 2 of 13
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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) [211047]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Moderate VTE Risk with Low Bleed Risk (Single
Response) [209954]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High VTE with Low Bleed Risk [211018]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
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
High Bleed 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 [30290]
1 Hour x 4, Then Every -patient is being admitted or transferred to IMC order "Vital Signs If
Every 2 Hours"
Every 2 Hours"-Signs patient is being transferred from a higher level of care order "Vital If
Vital Signs - Every 1 Hour x 4, Then Every 2
Hours [NURMON0013]
SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 1 hour x 4, then every 2 hours
Page 3 of 13
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:28:54 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Vital Signs - Every 2 Hours [NURMON0013] EVERY 2 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital Signs - Every 4 Hours [NURMON0013] EVERY 4 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Patient Monitoring [30291]
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
CONTINUOUS, Routine
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Neurovascular Checks [NURMON0045] EVERY 2 HOURS, Routine
Location:
Check Pulse [NURMON0008] EVERY 2 HOURS, Routine
Method:
Pulse Side:
Pulse Location:
Activity [30292]
Bed Rest [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: strict bedrest
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 [NURACT0002] Equal to (degrees): 30
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today
Chair 3x Daily [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR: 3x daily
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Page 4 of 13
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:28:54 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Ambulate 3x Daily [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: 3x daily
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 [30293]
Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
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:
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
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:
Heart Healthy [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Heart Healthy
Heart Healthy Options: Custom
Sodium: NAS (2400 mg)
Fat: Low Saturated Fat/Low Cholesterol
Fluid Restriction Total mLs/24H (IV/PO):
Caffeine: Low Caffeine
Bedside Meal Instructions:
Room Service Class:
Respiratory [30294]
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Pulse Oximetry [NURMON0009] CONTINUOUS, 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 (%):
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Page 5 of 13
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:28:54 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Cough And Deep Breathe [NURTRT0019] EVERY 2 HOURS, Starting today, Routine
Incentive Spirometry [NURTRT0018] EVERY 2 HOURS, Starting today, Routine
CPAP Continuous [RT0009] Routine
PEEP (cmH2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Titrate oxygen to maintain O2 sat at (%): 91
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
Intake and Outout [30295]
Measure Intake And Output [NURMON0005] EVERY 2 HOURS, Starting today, Routine
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today, Routine
Non-Categorized Patient Care Orders [30296]
Monitoring and Insulin Supplemental" Order Set for all Glucose -Adult -to "Diabetes Management Refer
Therapy
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Starting on admission.
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today 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: Indwelling Single Lumen
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Contingency Parameters [30297]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 100
If diastolic blood pressure < (mmHg): 50
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 40
If respiratory rate >: 25
If respiratory rate <: 10
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 88
If urine output < (mL): <0.5 cc/kg/hr for patients with
indwelling catheters or <4 cc/kg/8hrs for patients
without one
Other:
Page 6 of 13
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

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 Fluids [30119]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today For Until specified,
Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
dextrose 5% infusion [36633] Intravenous, CONTINUOUS
sodium chloride 0.9% infusion [64367] Intravenous, CONTINUOUS
sodium chloride 0.45% infusion [42187] Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.9% infusion [51641] Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% with KCl 20 mEq/L
infusion [44910]
Intravenous, CONTINUOUS
Flushes [29948]
Initiate Venous Access Device Flushing Protocol
[NURVAD0053]
ONCE, Starting today For 1 Occurrences
Medications
Analgesics - Acetaminophen - Oral - As Needed (Single Response) [30122]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain
Fever greater than 38.2C or See Pain Management
Algorithm for the Selection of As-Needed Analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Oral, EVERY 4 HOURS PRN, pain
Fever greater than 38.2C or See Pain Management
Algorithm for the Selection of As-Needed Analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg
acetaMINOPHEN (TYLENOL) suppository
[43994]
650 mg, Rectal, EVERY 4 HOURS PRN, pain
Fever greater than 38.2C or See Pain Management
Algorithm for the Selection of As-Needed Analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg
Analgesics - Opioids - Intravenous - As Needed [30123]
Page 7 of 13
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12/2017CCKM@uwhealth.org

MORPHine PF injection RANGE [750057] 1-4 mg, Intravenous, EVERY 2 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
for 4 Minutes
Analgesics - Opioids - Oral - As Needed (Single Response) [30125]
hydrocodone-acetaMINOPHEN (NORCO) 5-325
mg per tab RANGE [750021]
1-2 tab, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg
oxycodone 5 MG/5ML soln RANGE [750031] 5-10 mg, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
oxycodone tab RANGE [750032] 5-10 mg, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
MORPHine tab RANGE [750028] 7.5-15 mg, Oral, EVERY 3 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
Anti-emetics [30143]
Adult - Standard - Anti-emetics [240445]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line if unable to take medications by mouth
or enteral tube OR if immediate effect is needed.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line if there is inadequate response to
first line anti-emetic within 30 minutes. If there is no
response to second line therapy within 30 minutes,
notify provider
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line. Use if there is inadequate
response to first line anti-emetic within 30 minutes
and if unable to take medications by mouth or
enteral tube OR if immediate effect is needed. If
there is no response to second line therapy within 30
minutes, notify provider
Bowel Management - Scheduled [9845]
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 2 X DAILY (AT MEALTIME)
Bowel Management - As Needed [242059]
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Oral, 1 X DAILY PRN, constipation
Administer as first line therapy
May dilute with a small amount of water prior to
administration. Follow administration with a full glass
of water
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation
Second Line Therapy, if no response to first line
therapy after 6 hours OR if patient unable to take
medications by mouth or enteral tube OR if needed
immediate laxation.
Page 8 of 13
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Hypnotics (Single Response) [228331]
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
melatonin tab [119466] 3 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Trazodone - Melatonin [227992] "And" Linked Panel
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use first line.
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
melatonin tab [119466] 3 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use second line if failure to respond to trazodone
within 60 minutes
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Hypnotics (Single Response) [228334]
traZODONE (DESYREL) tab [720150] 25 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
If needed, give prior to midnight if possible. May
contribute to sedation the following day.
melatonin tab [119466] 1 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Antacids (Single Response) (Single Response) [149702]
calcium carbonate (TUMS) chew tab [44477] 500 mg, Oral, EVERY 4 HOURS PRN, dyspepsia
Laboratory
Draw on Admission [149703]
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?
CBC WITHOUT DIFFERENTIAL [HEMO] 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?
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 9 of 13
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:28:54 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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?
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?
ALBUMIN [ALB] 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?
PROTEIN, TOTAL [TP] 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?
BILIRUBIN, TOTAL [TBIL] 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?
AST/SGOT [AST] 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?
ALKALINE PHOSPHATASE [ALKP] 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 [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?
GGT [GGT] 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 10 of 13
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12/2017CCKM@uwhealth.org

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?
PHOSPHATE [PHOS] 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?
URINALYSIS WITH MICROSCOPY [UA] ONCE, 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?
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
NEXT DRAW, Starting today For 1 Occurrences,
Routine, For optimum diagnosis of sepsis, sample 3-4
sites only on the first day of a septic episode. Cultures
on subsequent days are of minimal diagnostic value.
Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
BLOOD GASES - ARTERIAL [HCBGAS] CONDITIONAL, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BLOOD GASES - VENOUS [HCBGAS] CONDITIONAL, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw Once, Morning After Admission [30299]
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT AM, Starting tomorrow at 5:00 AM 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 AM, Starting tomorrow at 5:00 AM 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 AM, Starting tomorrow at 5:00 AM 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 AM, Starting tomorrow at 5:00 AM 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 11 of 13
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:28:54 PM
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CREATININE [CRET] NEXT AM, Starting tomorrow at 5:00 AM 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 AM, Starting tomorrow at 5:00 AM 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] NEXT AM, Starting tomorrow at 5:00 AM For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [30301]
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.
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 [30302]
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: OTHER
Indication: Evaluate and Treat.
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy 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?
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult:
Consult Swallow Therapy (Inpatient) [CON0079] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Evaluate and Treat Patient
May the Speech Pathologist and Registered Dietician
place diet orders on your behalf?
Is this a potential new stroke patient?
Page 12 of 13
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:28:54 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Consult Hospitalist (Inpatient) [CON0134] 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:
Best Practice
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 13 of 13
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:28:54 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org