/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-98272-en.cckm

20180112

page

100

UWHC,UWMF,

Tools,

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

IP - Cirrhosis - Adult - Admission [1673]

IP - Cirrhosis - Adult - Admission [1673] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Cirrhosis - Adult - Admission [1673]
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 [7248]
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 75
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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 Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
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:
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) [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 [244132]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [244133]
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 [244134]
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 [244135]
Page 2 of 75
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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

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 [244140]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [244141]
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 [244142]
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 [244143]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs [24631]
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:
Vital Signs for Patients in Intensive Care [24632]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every hour times 2, then every 2 hours.
Patient Monitoring [24633]
Page 3 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Cardiac Rhythm Monitoring - Adult
[NURMON0010]
INTERMITTENT (MAY REMOVE WHEN OFF
UNIT/BATHING), Routine
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
NG Tube Placement - Adult [120994]
Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Starting today, Routine
Options: Low, Continuous Suction
Flush with:
Flush Frequency: EVERY 8 HOURS
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed?
Device Status:
Refer to Policy 2.20 Enteral Tubes Used for
Instillation of Fluids, Medications, or Feeding
Recommendations for flush quantity:
For adult patients, 30 mLs of fluid should be
sufficient.
lidocaine-oxymetazoline 4%-0.05% (ADULT)
nasal spray [785081]
2 spray, Nasal, ONCE For 1 Doses
For numbing prior to feeding tube insertion.
Slowly spray the chosen nostril once, if required may
repeat x1 in opposite nostril. Angle toward back of
throat spraying the anterior nostril and wait 30-60
seconds before introducing more local
anesthetic into the nostril. Caution: Entire bottle
should not be used for insertion of tube. Discard
excess solution when procedure completed.
X-RAY ABDOMEN SINGLE VIEW [R74018] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered
by this exam? Evaluate nasogastric tube placement
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
If Conditional, What Condition? Evaluate nasogastric
tube placement. The location of nasogastric tube
should be confirmed prior to the instillation of fluids
Activity [24634]
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:
Page 4 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Bed Rest with Sitter [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:
Bed Rest with Bathroom Privileges
[NURACT0008]
CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: with bathroom privileges
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Chair with Assistance [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR: other (comment)
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Ambulate with Assistance [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: with assistance
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Ad Lib [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB: 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 [24635]
Page 5 of 75
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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

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:
NPO Except Ice Chips [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO with Ice Chips/Sips of Water
Bedside Meal Instructions:
Room Service Class:
Clear Liquid Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Clear Liquid
No Red or Purple Dye:
Liquid Thickness: Thin
Bedside Meal Instructions:
Room Service Class:
Controlled Sodium (2000 mg) Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Sodium Controlled
Sodium: 2000 mg
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:
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Respiratory [24636]
Pulse Oximetry Continuous [NURMON0009] CONTINUOUS, Starting today, Routine
Incentive Spirometry [NURTRT0018] EVERY 8 HOURS, Starting today, Routine
Aspiration Precautions [PRECAU0007] CONTINUOUS, Starting today, Routine
Solid Consistency:
Liquid Consistency:
Medication Administration:
Supervision:
Positioning Strategies:
Patient Location:
Page 6 of 75
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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

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
Intake and Output [24637]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine
Measure Intake And Output [NURMON0005] EVERY 4 HOURS, Starting today For Until specified,
Routine
Intake and Output for Patients in Intensive Care [24638]
Measure Intake And Output [NURMON0005] SEE COMMENTS, Starting today, Routine, Every
hour times 2, then every 2 hours.
Non-Categorized Patient Care Orders [24639]
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, 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?
Contingency Parameters [24640]
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): *** mL/hour
Other: Blood in stool
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.
Page 7 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

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 [23606]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Insert and Maintain Peripheral IV - Line 2
[NURVAD0013]
CONTINUOUS, Starting today For Until specified,
Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
sodium chloride 0.9% infusion [64367] at 5 mL/hr, Intravenous, CONTINUOUS
dextrose 5% infusion [36633] at 5 mL/hr, Intravenous, CONTINUOUS
dextrose 5%-NaCl 0.45% infusion [51613] at 5 mL/hr, Intravenous, CONTINUOUS
Medications - Anti-infectives - NOTE: Select one regimen
Spontaneous Bacterial Peritonitis - TREATMENT (Single Response) [23609]
ceftriaxone (ROCEPHIN) intraVENOUS [800027] 2 g, Intravenous, EVERY 24 HOURS For 5 Days
aztreonam (AZACTAM) intraVENOUS [800013] 1 g, Intravenous, EVERY 8 HOURS For 5 Days
Gastrointestinal Bleed (Single Response) [23782]
antibioticswith acute GI Bleed start on one of the following Cirrhotics
ceftriaxone (ROCEPHIN) intraVENOUS [800027] 2 g, Intravenous, EVERY 24 HOURS For 7 Days
Patient should be evaluated by prescriber daily for
appropriateness of conversion to cefpodoxime 400 mg
orally 2 times a day. Total antibiotic duration not to
exceed 7 days.
aztreonam (AZACTAM) intraVENOUS [800013] 1 g, Intravenous, EVERY 8 HOURS For 7 Days
Probiotic [200227]
-therapeutic broadconsider the use of probiotics in immunocompetent patients receiving Please
-4th generation cephalosporins, betaspectrum antibiotics, such as fluoroquinolones, 3rd and
diarrhea clindamycin to prevent antibiotic associated lactamase inhibitors, and -lactam/beta
lactobacillus rhamnosus GG (CULTURELLE) cap
[152674]
1 cap, Oral, 1 X DAILY
Medications - General
Diuretics [23763]
furosemide (LASIX) intraVENOUS [800046] Intravenous
furosemide (LASIX) tab [720061] Oral
spironolactone (ALDACTONE) tab [42320] Oral, 1 X DAILY
spironolactone (ALDACTONE) tab [42320] Oral, 2 X DAILY (AT MEALTIME)
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)
Page 8 of 75
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
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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)
Minerals/Electrolytes/Vitamins [23765]
thiamine (VITAMIN B-1) tab [43659] 100 mg, Oral, 1 X DAILY
thiamine (VITAMIN B-1) intraVENOUS [800261] 100 mg, Intravenous, 1 X DAILY
phytonadione (VITAMIN K1) soln [800250] 5 mg, Oral, 1 X DAILY
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, 1 X DAILY
multivitamin with mineral tab [800240] 1 tab, Oral, 1 X DAILY
multivitamin bag [700240] Intravenous, ONCE For 1 Doses
Proton Pump Inhibitors - For Patients With Upper Gastrointestinal Bleeding (Single Response) [23764]
Pantoprazole Injection (Single Response)
[243215]
pantoprazole (PROTONIX) intraVENOUS
[800119]
40 mg, Intravenous, 2 X DAILY
pantoprazole (PROTONIX) intraVENOUS
[800119]
80 mg, Intravenous, 2 X DAILY
pantoprazole (PROTONIX) delayed release tab
[62661]
40 mg, Oral, 2 X DAILY
For Patients With an Active Bleed [23766]
octreotide (SANDOSTATIN) injection [800200] 50 mcg, Intravenous, ONCE For 1 Doses
octreotide (SANDOSTATIN) infusion [700248] 50 mcg/hr, Intravenous, CONTINUOUS
If ordered separately, the drip usually arrives prior to
bolus.
For Patients With Hepatorenal Syndrome [23767]
octreotide (SANDOSTATIN) injection [800200] 100 mcg, Subcutaneous, 3 X DAILY
midodrine (PROAMITINE) tab [45758] 5 mg, Oral, 3 X DAILY (AT MEALTIME)
albumin human 25% infusion [44037] Intravenous, 1 X DAILY
For Patients With Hepatic Encephalopathy [23768]
Page 9 of 75
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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

lactulose (CEPHULAC) soln [75426] 20 g, Oral, 3 X DAILY
rifaXIMIN (XIFAXAN) tab [140692] 550 mg, Oral, 2 X DAILY (AT MEALTIME)
Laboratory
Collect Now (If Not Done in ED) [24641]
CBC WITH DIFFERENTIAL [CBC] 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 WITH DIFFERENTIAL [CBC] 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?
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?
BUN [BUN] 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?
CREATININE [CRET] 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?
GLUCOSE [GLU] 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?
CALCIUM [CA] 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?
BILIRUBIN, TOTAL [TBIL] 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?
PROTEIN, TOTAL [TP] 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?
ALBUMIN [ALB] 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?
ALKALINE PHOSPHATASE [ALKP] 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?
AST/SGOT [AST] 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?
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?
Page 10 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

HEMOGLOBIN A1C [HA1C] 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?
MAGNESIUM [MAG] 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?
PHOSPHATE [PHOS] 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?
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?
AMMONIA [GM2200] 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?
AFP, TUMOR MARKER, SERUM [XAFPTM] 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?
CREATININE, URINE [UCRR] 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?
SODIUM, URINE [GM2670] 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?
For Patients Undergoing Diagnostic Paracentesis [24642]
CELL COUNT, PERITONEAL FLUID [HCPECC] ONCE, Starting today For 1 Occurrences, Routine
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CYTOLOGY, NON-GYN [HCPATHM] ONCE, Starting today For 1 Occurrences, Routine,
For any questions please refer to U-Connect Test
Directory or contact UWHC Cytology at (608)263-
3205.
Specimen Source Description/Laterality: Peritoneal
Fluid
Please indicate laterality if appropriate:
Method of Collection - Urine specimens only:
Other cytology tests not related to malignancy:
Clinical History:
ALBUMIN, PERITONEAL FLUID [HCPEALB] ONCE, Starting today For 1 Occurrences, Routine
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 11 of 75
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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

PROTEIN, PERITONEAL FLUID [HCPEP] ONCE, Starting today For 1 Occurrences, Routine
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, BODY FLUID, AER/ANA WITH
GRAM STAIN [HCWABF]
ONCE, Starting today For 1 Occurrences, Routine,
UWHC Only: Use blood culture bottles for peritoneal,
pericardial, pleural, synovial and dialysate fluids.
Indicate source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
For Patients with Newly Diagnosed Liver Disease [24643]
indicated. order if not already done or clinically Only
HEPATITIS B SURFACE AG [HBSAG] 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?
HEPATITIS B SURFACE AB (IMMUNE STATUS)
[HBSABI]
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?
HEPATITIS B CORE AB, TOTAL [HBCAB] 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?
HEPATITIS C AB [HCV] 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?
HEPATITIS C RNA, QUANT, PCR [XHCVRQ] 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?
HEPATITIS A AB, IGM [XHAVM] 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?
HEPATITIS A AB, IGG [HAVIGG] 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?
ANA SCREEN WITH TITER IF POSITIVE [ANAT] 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 12 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

SMOOTH MUSCLE AB, IGG [XSMOO] 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?
LIVER-KIDNEY MICROSOME-1 AB, IGG
[HCLKM1]
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?
MITOCHONDRIAL AB [HCAMIA] 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?
ALPHA-1-ANTITRYPSIN [XA1A] 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?
CERULOPLASMIN [XCERU] 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?
IRON AND TRANSFERRIN W/ TIBC,
SATURATION [FETRANS]
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?
FERRITIN [FER] 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?
Cultures [24644]
CULTURE, BLOOD, BACTERIA/YEAST (2
SITES) [116728]
.Practices for Blood Culturing Best This order equals 2 sites (4 bottles). See link below for
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
NEXT DRAW, 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?
Page 13 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
NEXT DRAW, 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?
Conditional Labs [102509]
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? STAT every time
blood glucose monitoring (bedside) is less than 40 or
greater than 400 mg/dL
Blood Bank
Tests [12023]
TYPE AND SCREEN [HCTS] STAT, Starting tomorrow For 1 Occurrences, Routine,
As good clinical practice and for patient safety, the
Transfusion Service will automatically crossmatch 2
packed RBCs on all patients with antibodies to ensure
blood would be available in the event it is needed. If
you would like to opt out of this automatic order for this
patient please contact the UWHC Blood Bank at (608)
263-8367 or The American Center Lab at (608) 234-
6600 as appropriate.
Premedication (Single Response) [102401]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, ONCE PRN For 1 Doses, pain,
Premedication for blood product
Premedication for blood product
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Oral, ONCE PRN For 1 Doses, pain/fever,
Premedication for blood product
Premedication for blood product
Laboratory [12025]
HEMATOCRIT [HCT] CONDITIONAL, Starting tomorrow For 1 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Release 1 hour post-
infusion of red blood cells
PLATELET COUNT [PLT] CONDITIONAL, Starting tomorrow For 1 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Release 1 hour post-
infusion of platelets
PROTHROMBIN TIME/INR [PT] CONDITIONAL, Starting tomorrow For 1 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Release 1 hour post-
infusion of plasma
Red Blood Cells - Adult (Single Response) [206670]
Page 14 of 75
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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

Select indication below. When appropriate, the system will automatically suggest the appropriate number
@BUCWTMSG@of units for this patient based on the indication.
For more information about the Blood Utilization
Calculator (BUC) click here
URL: https://uconnect.wisc.edu/clinical/references/laboratory-
services/transfusion-services-uwhc/resources/name-
101746-en.file
R1-Life-threatening hemorrhage or
anticipated/ongoing surgical blood loss [207820]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R1 Life-threatening hemorrhage
or anticipated/ongoing surgical blood loss
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R2-Suspected bleeding, symptomatic or drop in
Hemoglobin >= 3 g/dL or Hematocrit drop >= 10
[207821]
Page 15 of 75
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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

Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R2 Suspected bleeding,
symptomatic or drop in Hemoglobin >= 3 g/dL or
Hematocrit drop >= 10
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [NO RECENT
HEMOGLOBIN/HEMATOCRIT, UNABLE TO
CALCULATE VOLUME] [207822]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in acute upper GI bleeds
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 16 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [NO
HEMOGLOBIN/HEMATOCRIT RESULT SINCE
LAST BLOOD ORDER, UNABLE TO
CALCULATE VOLUME] [210389]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in acute upper GI bleeds
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [CALCULATED
VOLUME FOR THIS PATIENT=0 UNITS]
[207823]
NO ORDER RECOMMENDED: Based on this
indication, the patient does not require blood at
this time because they are already above the
target hemoglobin/hematocrit level. Select a
different indication or exit the order set.
[NURCOM0022]
ONCE
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [CALCULATED
VOLUME FOR THIS PATIENT=1 UNIT] [207824]
Page 17 of 75
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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

Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in acute upper GI bleeds
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [CALCULATED
VOLUME FOR THIS PATIENT=2 UNITS]
[207825]
Red Blood Cells (Adult) [BLB0006] 2 UNITS For 2 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in acute upper GI bleeds
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 18 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 2 UNITS For 2 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [CALCULATED
VOLUME FOR THIS PATIENT=3 UNITS]
[207826]
Red Blood Cells (Adult) [BLB0006] 3 UNITS For 3 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in acute upper GI bleeds
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 3 UNITS For 3 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [CALCULATED
VOLUME FOR THIS PATIENT=4 UNITS]
[207827]
Page 19 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 4 UNITS For 4 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in acute upper GI bleeds
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 4 UNITS For 4 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [CALCULATED
VOLUME FOR THIS PATIENT=5 UNITS]
[207828]
Red Blood Cells (Adult) [BLB0006] 5 UNITS For 5 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in acute upper GI bleeds
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 20 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 5 UNITS For 5 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients [NO
RECENT HEMOGLOBIN/HEMATOCRIT,
UNABLE TO CALCULATE VOLUME] [207829]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients [NO
HEMOGLOBIN/HEMATOCRIT RESULT SINCE
LAST BLOOD ORDER, UNABLE TO
CALCULATE VOLUME] [210435]
Page 21 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients
[CALCULATED VOLUME FOR THIS
PATIENT=0 UNITS] [207830]
NO ORDER RECOMMENDED: Based on this
indication, the patient does not require blood at
this time because they are already above the
target hemoglobin/hematocrit level. Select a
different indication or exit the order set.
[NURCOM0022]
ONCE
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients
[CALCULATED VOLUME FOR THIS
PATIENT=1 UNIT] [207831]
Page 22 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients
[CALCULATED VOLUME FOR THIS
PATIENT=2 UNITS] [207832]
Red Blood Cells (Adult) [BLB0006] 2 UNITS For 2 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 23 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 2 UNITS For 2 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients
[CALCULATED VOLUME FOR THIS
PATIENT=3 UNITS] [207833]
Red Blood Cells (Adult) [BLB0006] 3 UNITS For 3 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 3 UNITS For 3 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients
[CALCULATED VOLUME FOR THIS
PATIENT=4 UNITS] [207834]
Page 24 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 4 UNITS For 4 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 4 UNITS For 4 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients
[CALCULATED VOLUME FOR THIS
PATIENT=5 UNITS] [207835]
Red Blood Cells (Adult) [BLB0006] 5 UNITS For 5 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 25 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 5 UNITS For 5 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina) [NO
RECENT HEMOGLOBIN/HEMATOCRIT,
UNABLE TO CALCULATE VOLUMEe] [207836]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
Page 26 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina) [NO
HEMOGLOBIN/HEMATOCRIT RESULT SINCE
LAST BLOOD ORDER, UNABLE TO
CALCULATE VOLUME] [210436]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=0 UNITS] [207837]
NO ORDER RECOMMENDED: Based on this
indication, the patient does not require blood at
this time because they are already above the
target hemoglobin/hematocrit level. Select a
different indication or exit the order set.
[NURCOM0022]
ONCE
Page 27 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=1 UNIT] [207838]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=2 UNITS] [207839]
Page 28 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 2 UNITS For 2 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 2 UNITS For 2 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=3 UNITS] [207846]
Page 29 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 3 UNITS For 3 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 3 UNITS For 3 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=4 UNITS] [207847]
calculation display removed
Page 30 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 4 UNITS For 4 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 4 UNITS For 4 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=5 UNITS] [207848]
Page 31 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 5 UNITS For 5 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 5 UNITS For 5 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R6 High risk patients (e.g., ECMO, TAAA,
stroke/cerebral vasospasm, Sickle Cell Disease)
[207849]
Page 32 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R6 High risk patients (e.g.,
ECMO, TAAA, stroke/cerebral vasospasm, Sickle
Cell Disease)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R7-Massive Transfusion Procedure [207850]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R7 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Page 33 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
R8-Other [207851]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R8 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed: 1/11/2018
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
Plasma - Adult (Single Response) [222745]
appropriate, the system will automatically suggest the appropriate number When Select indication below.
@BUCWTMSG@of units for this patient based on the indication.
units. calculator will suggest up to a maximum of 5 The
F1-Active hemorrhage or correction of
coagulopathy for INR >= 1.8 (NOT on warfarin)
[NO INR SINCE LAST PLASMA ORDER,
UNABLE TO CALCULATE VOLUME] [222318]
Page 34 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Plasma (Adult) [BLB0003] Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
phytonadione (VITAMIN K1) intraVENOUS
[239979]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
phytonadione (VITAMIN K1) intraVENOUS
[239980]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after final
plasma transfusion
F1-Active hemorrhage or correction of
coagulopathy for INR >= 1.8 (NOT on warfarin)
[NO RECENT INR, UNABLE TO CALCULATE
VOLUME] [222322]
Plasma (Adult) [BLB0003] Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
Page 35 of 75
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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

phytonadione (VITAMIN K1) intraVENOUS
[239979]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
phytonadione (VITAMIN K1) intraVENOUS
[239980]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after final
plasma transfusion
F1-Active hemorrhage or correction of
coagulopathy for INR >= 1.8 (NOT on warfarin)
[CALCULATED VOLUME FOR THIS
PATIENT=0 UNITS] [222324]
NO ORDER RECOMMENDED: Based on this
indication, the patient does not require plasma at
this time because their INR is already <=1.8 -
Select a different indication or exit the order set.
[NURCOM0022]
ONCE
F1-Active hemorrhage or correction of
coagulopathy for INR >= 1.8 (NOT on warfarin)
[CALCULATED VOLUME FOR THIS
PATIENT=1 UNIT] [222325]
Plasma (Adult) [BLB0003] 1 UNIT For 1 Occurrences, Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
phytonadione (VITAMIN K1) intraVENOUS
[239979]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
phytonadione (VITAMIN K1) intraVENOUS
[239980]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
Page 36 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after final
plasma transfusion
F1-Active hemorrhage or correction of
coagulopathy for INR >= 1.8 (NOT on warfarin)
[CALCULATED VOLUME FOR THIS
PATIENT=2 UNITS] [222326]
Plasma (Adult) [BLB0003] 2 UNITS For 2 Occurrences, Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] TRANSFUSE 2 UNITS For 2 Occurrences, Routine,
Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
phytonadione (VITAMIN K1) intraVENOUS
[239979]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
phytonadione (VITAMIN K1) intraVENOUS
[239980]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after final
plasma transfusion
F1-Active hemorrhage or correction of
coagulopathy for INR >= 1.8 (NOT on warfarin)
[CALCULATED VOLUME FOR THIS
PATIENT=3 UNITS] [222327]
Page 37 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Plasma (Adult) [BLB0003] 3 UNITS For 3 Occurrences, Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] TRANSFUSE 3 UNITS For 3 Occurrences, Routine,
Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
phytonadione (VITAMIN K1) intraVENOUS
[239979]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
phytonadione (VITAMIN K1) intraVENOUS
[239980]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after final
plasma transfusion
F1-Active hemorrhage or correction of
coagulopathy for INR >= 1.8 (NOT on warfarin)
[CALCULATED VOLUME FOR THIS
PATIENT=4 UNITS] [222328]
Plasma (Adult) [BLB0003] 4 UNITS For 4 Occurrences, Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Consent Status:
Page 38 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Plasma (Adult) [NURTRT0031] TRANSFUSE 4 UNITS For 4 Occurrences, Routine,
Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
phytonadione (VITAMIN K1) intraVENOUS
[239979]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
phytonadione (VITAMIN K1) intraVENOUS
[239980]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after final
plasma transfusion
F1-Active hemorrhage or correction of
coagulopathy for INR >= 1.8 (NOT on warfarin)
[CALCULATED VOLUME FOR THIS
PATIENT=5 UNITS] [222329]
Plasma (Adult) [BLB0003] 5 UNITS For 5 Occurrences, Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products): NON-SURGICAL
USE
Date Product Needed: 1/11/2018
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] TRANSFUSE 5 UNITS For 5 Occurrences, Routine,
Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
phytonadione (VITAMIN K1) intraVENOUS
[239979]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
phytonadione (VITAMIN K1) intraVENOUS
[239980]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
Page 39 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after final
plasma transfusion
F2-Invasive procedure that will begin in more
than 24 hours (on warfarin) [222319]
is not indicated.Plasma
Note: Discontinue [950016] ONCE For 1 Doses
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[239981]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
phytonadione (VITAMIN K1) intraVENOUS
[239982]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 12 hours after
phytonadione infusion
F3-Immediate reversal of warfarin [222321]
Plasma is not indicated.
Note: Discontinue [950016] ONCE
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[239981]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
phytonadione (VITAMIN K1) intraVENOUS
[239982]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
prothrombin complex PCC (KCENTRA) injection
kit [157782]
Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after PCC
administration
F3-Immediate reversal of warfarin [222895]
Plasma is not indicated.
Note: Discontinue [950016] ONCE
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[239981]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
phytonadione (VITAMIN K1) intraVENOUS
[239982]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
Page 40 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

prothrombin complex PCC (KCENTRA) injection
kit [157782]
25 Units/kg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after PCC
administration
F3-Immediate reversal of warfarin [222894]
Plasma is not indicated.
Note: Discontinue [950016] ONCE
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[239981]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
phytonadione (VITAMIN K1) intraVENOUS
[239982]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
prothrombin complex PCC (KCENTRA) injection
kit [157782]
35 Units/kg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after PCC
administration
F3-Immediate reversal of warfarin [222896]
Plasma is not indicated.
Note: Discontinue [950016] ONCE
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[239981]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
phytonadione (VITAMIN K1) intraVENOUS
[239982]
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
prothrombin complex PCC (KCENTRA) injection
kit [157782]
50 Units/kg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL, 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? 1 hour after PCC
administration
F4-Plasmapheresis [214323]
Plasma (Adult) [BLB0003] Routine
Reason for Order: F4 Plasmapheresis
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 41 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Plasma (Adult) [NURTRT0031] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
F5-Massive Transfusion Procedure [214326]
Plasma (Adult) [BLB0003] Routine
Reason for Order: F5 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
F6-Other [214328]
Plasma (Adult) [BLB0003] Routine
Reason for Order: F6 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
Platelets - Adult (Single Response) [207853]
indication below.Select
P1-Target Platelets > 10 K/µL [214329]
Page 42 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Platelets (Adult) [BLB0004] 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P1 Target Platelets > 10 K/µL
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
P2-Target Platelets >= 20 K/µL and central
venous catheter placement within 6 hours or
minor bleeding in BMT/leukemia-induction
patients [214341]
Platelets (Adult) [BLB0004] 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P2 Target Platelets >= 20 K/µL
and central venous catheter placement within 6
hours or minor bleeding in BMT/leukemia-induction
patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Page 43 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
P3-Target Platelets > 50 K/µL and significant
bleeding or invasive procedure/surgery planned
within six hours (e.g., lumbar puncture,
nonneuraxial surgery) [214342]
Platelets (Adult) [BLB0004] 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P3 Target Platelets > 50 K/µL and
significant bleeding or invasive procedure/surgery
planned within six hours (e.g., lumbar puncture,
nonneuraxial surgery)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
P4-Target Platelets > 100 K/µL with major
CNS/eye surgery, for up to 48 hrs. post op,
epidural catheters and lumbar drains [214345]
Page 44 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Platelets (Adult) [BLB0004] 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P4 Target Platelets > 100 K/µL
with major CNS/eye surgery, for up to 48 hrs. post
op, epidural catheters and lumbar drains
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
P5-Platelet dysfunction and ongoing bleeding
[214346]
Platelets (Adult) [BLB0004] 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P5 Platelet dysfunction and
ongoing bleeding
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Page 45 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
P6-Massive Transfusion Procedure [214347]
Platelets (Adult) [BLB0004] 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P6 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
P7-Other [214348]
Page 46 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Platelets (Adult) [BLB0004] 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P7 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
Cryoprecipitate - Adult (Single Response) [207854]
indication below.Select
C1-Fibrinogen deficiency (< 100 mg/dL) [214349]
Cryoprecipitate (Adult) [BLB0005] Routine
Reason for Order: C1 Fibrinogen deficiency (< 100
mg/dL)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Fibrin Glue, mLs Needed:
Transfuse Cryoprecipitate (Adult) [NURTRT0032] Routine, Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units
(approx 120mL). Standard adult dose = 10 units.
Suggested dose = 1 unit/10 kg.
Individual cryoprecipitate units are also available for
fibrin glue (approx 10-15 mL each).
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
Fibrin Glue, mLs Needed:
C2-Factor XIII deficiency [214350]
Page 47 of 75
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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

Cryoprecipitate (Adult) [BLB0005] Routine
Reason for Order: C2 Factor XIII deficiency
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Fibrin Glue, mLs Needed:
Transfuse Cryoprecipitate (Adult) [NURTRT0032] Routine, Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units
(approx 120mL). Standard adult dose = 10 units.
Suggested dose = 1 unit/10 kg.
Individual cryoprecipitate units are also available for
fibrin glue (approx 10-15 mL each).
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
Fibrin Glue, mLs Needed:
C3-Massive Transfusion Procedure [214351]
Cryoprecipitate (Adult) [BLB0005] Routine
Reason for Order: C3 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Fibrin Glue, mLs Needed:
Transfuse Cryoprecipitate (Adult) [NURTRT0032] Routine, Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units
(approx 120mL). Standard adult dose = 10 units.
Suggested dose = 1 unit/10 kg.
Individual cryoprecipitate units are also available for
fibrin glue (approx 10-15 mL each).
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
Fibrin Glue, mLs Needed:
C4-Other [214352]
Cryoprecipitate (Adult) [BLB0005] Routine
Reason for Order: C4 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Fibrin Glue, mLs Needed:
Page 48 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Cryoprecipitate (Adult) [NURTRT0032] Routine, Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units
(approx 120mL). Standard adult dose = 10 units.
Suggested dose = 1 unit/10 kg.
Individual cryoprecipitate units are also available for
fibrin glue (approx 10-15 mL each).
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
Fibrin Glue, mLs Needed:
Red Blood Cells - Pediatric (Single Response) [214402]
indication below.Select
PR1-(Patient younger than 4 months) Acute
blood loss or anticipated surgical blood loss
[214359]
Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR1 (Patient younger than 4
months) Acute blood loss or anticipated surgical
blood loss
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Page 49 of 75
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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

PR2-(Patient younger than 4 months) Target
Hemoglobin > 7 g/dL or Hematocrit > 21% in
stable patient with signs of anemia (RA or nasal
cannula with FiO2 < 25%, and reticulocyte count
< 4%) [214360]
Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR2 (Patient younger than 4
months) Target Hemoglobin > 7 g/dL or Hematocrit >
21% in stable patient with signs of anemia (RA or
nasal cannula with FiO2 < 25%, and reticulocyte
count < 4%)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR3-(Patient younger than 4 months) Target
Hemoglobin > 8 g/dL or Hematocrit > 24% with
mild lung disease, NC/CPAP/NIPPV with FiO2 <
40%, and signs of poor oxygenation [214361]
Page 50 of 75
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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

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR3 (Patient younger than 4
months) Target Hemoglobin > 8 g/dL or Hematocrit >
24% with mild lung disease, NC/CPAP/NIPPV with
FiO2 < 40%, and signs of poor oxygenation
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR4-(Patient younger than 4 months) Target
Hemoglobin > 10 g/dL or Hematocrit > 30% with
severe lung disease, intubated or on
nasopharyngeal synchronized intermittent
mandatory ventilation with FiO2 > 40%,
congenital heart disease, and/or prematurity
[214362]
Page 51 of 75
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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

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR4 (Patient younger than 4
months) Target Hemoglobin > 10 g/dL or Hematocrit
> 30% with severe lung disease, intubated or on
nasopharyngeal synchronized intermittent
mandatory ventilation with FiO2 > 40%, congenital
heart disease, and/or prematurity
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR5-Acute blood loss or anticipated surgical
blood loss [214364]
Page 52 of 75
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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

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR5 Acute blood loss or
anticipated surgical blood loss
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR6-Target Hemoglobin > 7 g/dL or Hematocrit >
21% [214365]
Page 53 of 75
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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

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR6 Target Hemoglobin > 7 g/dL
or Hematocrit > 21%
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR7-Signs of poor oxygen delivery or target
Hemoglobin > 10 g/dL or Hematocrit > 30% in
patients with severe pulmonary disease requiring
assisted ventilation or congenital heart disease
[214363]
Page 54 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR7 Signs of poor oxygen
delivery or target Hemoglobin > 10 g/dL or
Hematocrit > 30% in patients with severe pulmonary
disease requiring assisted ventilation or congenital
heart disease
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR8-Chronic transfusions in selected patients
with Sickle Cell or thalassemia syndromes OR
partial exchange or exchange transfusion
[214366]
Page 55 of 75
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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

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR8 Chronic transfusions in
selected patients with Sickle Cell or thalassemia
syndromes OR partial exchange or exchange
transfusion
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR9-Massive Transfusion Procedure [214367]
Page 56 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR9 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR10-Other [214368]
Page 57 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR10 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Plasma - Pediatric (Single Response) [214403]
indication below.Select
PF1-Elevated INR with active bleeding or
anticipated major surgery/invasive procedure
[214369]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF1 Elevated INR with active
bleeding or anticipated major surgery/invasive
procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 58 of 75
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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

Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF2-Pump prime in pediatric open heart surgery
as appropriate for neonates and lower weight
pediatric patients [214371]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF2 Pump prime in pediatric open
heart surgery as appropriate for neonates and lower
weight pediatric patients
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF3-Replacement therapy for hemostatic factor
deficiencies if concentrate not available [214373]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF3 Replacement therapy for
hemostatic factor deficiencies if concentrate not
available
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 59 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF4-Disseminated intravascular coagulation with
active bleeding [214374]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF4 Disseminated intravascular
coagulation with active bleeding
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF5-Immediate reversal of warfarin effect for
emergency surgery or active bleeding (in
combination with vitamin K) [214375]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF5 Immediate reversal of
warfarin effect for emergency surgery or active
bleeding (in combination with vitamin K)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 60 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF6-Massive Transfusion Procedure [214376]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF6 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF7-Other [214377]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF7 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 61 of 75
Printed by WILLIAMS, HEATHER R [HRS0] at 1/11/2018 9:13:06 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Platelets - Pediatric (Single Response) [214404]
indication below.Select
PP1-Target Platelets > 20 K/µL in a stable
premature infant (GA < 37 weeks) [214378]
Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP1 Target Platelets > 20 K/µL in
a stable premature infant (GA < 37 weeks)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Transfuse Platelets (Pediatric) [NURTRT0036] Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested dose
= 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP2-Target Platelets > 30 K/µL in a sick
premature infant (GA < 37 weeks) or minor signs
of bleeding [214379]
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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

Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP2 Target Platelets > 30 K/µL in
a sick premature infant (GA < 37 weeks) or minor
signs of bleeding
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Transfuse Platelets (Pediatric) [NURTRT0036] Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested dose
= 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP3-Target Platelets > 50 K/µL and extreme
prematurity (GA < 37 weeks) at high risk for IVH
or neonatal encephalopathy [214380]
Page 63 of 75
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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

Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP3 Target Platelets > 50 K/µL
and extreme prematurity (GA < 37 weeks) at high
risk for IVH or neonatal encephalopathy
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Transfuse Platelets (Pediatric) [NURTRT0036] Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested dose
= 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP4-Target Platelets > 10 K/µL in a non-bleeding
patient with failure of platelet production [214381]
Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP4 Target Platelets > 10 K/µL in
a non-bleeding patient with failure of platelet
production
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Page 64 of 75
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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

Transfuse Platelets (Pediatric) [NURTRT0036] Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested dose
= 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP5-Target Platelets > 20 K/µL in a non-bleeding
patient with failure of platelet production and risk
factors (sepsis, fever, coagulopathy, etc.)
[214382]
Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP5 Target Platelets > 20 K/µL in
a non-bleeding patient with failure of platelet
production and risk factors (sepsis, fever,
coagulopathy, etc.)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Transfuse Platelets (Pediatric) [NURTRT0036] Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested dose
= 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Page 65 of 75
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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

PP6-Target Platelets > 50 K/µL with failure of
platelet production AND active bleeding OR need
for an invasive procedure [214386]
Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP6 Target Platelets > 50 K/µL
with failure of platelet production AND active
bleeding OR need for an invasive procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Transfuse Platelets (Pediatric) [NURTRT0036] Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested dose
= 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP7-Significant bleeding in a patient with a
qualitative platelet defect, regardless of platelet
count [214389]
Page 66 of 75
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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

Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP7 Significant bleeding in a
patient with a qualitative platelet defect, regardless
of platelet count
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Transfuse Platelets (Pediatric) [NURTRT0036] Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested dose
= 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP8-Target Platelets > 75 K/µL in a non-bleeding
patient on ECMO [214390]
Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP8 Target Platelets > 75 K/µL in
a non-bleeding patient on ECMO
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Page 67 of 75
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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

Transfuse Platelets (Pediatric) [NURTRT0036] Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested dose
= 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP9-Target Platelets > 100 K/µL with major
CNS/eye/cardiac surgery (for up to 48 hrs. post-
operatively) [214391]
Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP9 Target Platelets > 100 K/µL
with major CNS/eye/cardiac surgery (for up to 48
hrs. post-operatively)
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Transfuse Platelets (Pediatric) [NURTRT0036] Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested dose
= 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP10-Massive Transfusion Procedure [214398]
Page 68 of 75
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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

Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP10 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Transfuse Platelets (Pediatric) [NURTRT0036] Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested dose
= 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP11-Other [214399]
Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP11 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Page 69 of 75
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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

Transfuse Platelets (Pediatric) [NURTRT0036] Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested dose
= 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg,
suggested dose is 1 Single Donor Unit.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Cryoprecipitate - Pediatric (Single Response) [214313]
indication below.Select
PC1-Active bleeding OR anticipated major
surgery/invasive procedure (e.g., ECMO) with
fibrinogen < 100 mg/dL or dysfibrinogenemia
[214315]
Cryoprecipitate (Pediatric) [BLB0012] Routine
Reason for Order: PC1 Active bleeding OR
anticipated major surgery/invasive procedure (e.g.,
ECMO) with fibrinogen < 100 mg/dL or
dysfibrinogenemia
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Transfuse Cryoprecipitate (Pediatric)
[NURTRT0038]
Routine, Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested dose:
1 Unit/10 kg body weight. If patient weighs less than
10 kg give 1 unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
PC2-Factor XIII deficiency [214317]
Cryoprecipitate (Pediatric) [BLB0012] Routine
Reason for Order: PC2 Factor XIII deficiency
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 70 of 75
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Transfuse Cryoprecipitate (Pediatric)
[NURTRT0038]
Routine, Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested dose:
1 Unit/10 kg body weight. If patient weighs less than
10 kg give 1 unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
PC3-Massive Transfusion Procedure [214400]
Cryoprecipitate (Pediatric) [BLB0012] Routine
Reason for Order: PC3 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Transfuse Cryoprecipitate (Pediatric)
[NURTRT0038]
Routine, Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested dose:
1 Unit/10 kg body weight. If patient weighs less than
10 kg give 1 unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
PC4-Other [214401]
Cryoprecipitate (Pediatric) [BLB0012] Routine
Reason for Order: PC4 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Transfuse Cryoprecipitate (Pediatric)
[NURTRT0038]
Routine, Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested dose:
1 Unit/10 kg body weight. If patient weighs less than
10 kg give 1 unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [24645]
Page 71 of 75
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ECG - 12 Lead [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 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? Evaluate for pneumonia
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
US KIDNEY & AORTA [R76770] 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? Assess for outflow obstruction
Relevant recent/past history?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
If being performed remotely, where?
Transport Method: Floor Determined/Entered
US DOPPLER LIMITED [R93976] 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? Recommend to assess patency
Relevant recent/past history? Patient with Prior
Transjuglar Intra Hepatic Portosystemic (TIPS)
Procedure, need for revision.
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Page 72 of 75
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ABDOMINAL PARACENTESIS W GUIDANCE
[R49083]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Is this Diagnostic, Therapeutic, or Both?
Radiology Specialty Area: ULTRASOUND
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Diagnostic paracentesis to evaluate for
spontaneous bacterial peritonitis
Relevant recent/past history?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
For Scheduling purposes, is the patient claustrophobic
or require any form of sedation? Note: ordering
provider is responsible for prescribing oral anxiolytic or
ordering sedation services.
Is patient on anticoagulation therapy? If yes, specify
coagulation disorder and current medications in
comments box at bottom.
Transport Method: Floor Determined/Entered
THORACENTESIS W GUIDANCE [R76942AH] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Is this Diagnostic, Therapeutic, or Both?
Radiology Specialty Area: ULTRASOUND
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Diagnostic paracentesis to evaluate for
spontaneous bacterial peritonitis
Relevant recent/past history?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
For Scheduling purposes, is the patient claustrophobic
or require any form of sedation? Note: ordering
provider is responsible for prescribing oral anxiolytic or
ordering sedation services.
Is patient on anticoagulation therapy? If yes, specify
coagulation disorder and current medications in
comments box at bottom.
Transport Method: Floor Determined/Entered
Consults
Consults [24646]
Consult Hepatology (Inpatient) [CON0035] 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:
Page 73 of 75
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Consult Transplant (Inpatient) [CON0082] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Consult Gastroenterology (Inpatient) [CON0027] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Consult Interventional Radiology (Inpatient)
[CON0122]
ONCE
Reason for Consult:
Modality Type:
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Recommended for Patients with Prior Transjugular
Intrahepatic Portosystemic (TIPS) Procedure, Need
for Revision.
Behavioral Health Consults (select below)
[132899]
amp, transplant), - adjustment, protocol (eg. burn, trauma, rehab, pre-Psychology Health
noncompliance, grief, pain
Addictive Disorders - alcohol or drug related problems (eg. treatment recommendations,
withdrawal mgmt)
Psychiatry - safety, agitation, capacity, med mgmt, psychotropic SE
ACE - 60 and older - delirium, dementia, depression, decisional capacity, sleep (also for non-
behavioral geriatric syndromes; overall geriatric evaluation, mobility/falls, functional decline,
social/caregiver issues, disposition, medication management)
Consult Health Psychology (Inpatient)
[CON0033]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-Friday)
or if special assessment needs.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Addictive Disorders (Inpatient)
[CON0003]
ONCE, Routine, This order is for ADULT patients.
Please use the Consult Adolescent/Pediatric AODA
Counselor order for adolescent/pediatric patients
instead.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Page 74 of 75
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Consult Psychiatry (Inpatient) [CON0064] ONCE
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Consult Ace/Geriatric (Inpatient) [CON0001] ONCE, Routine
Reason for Consult:
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 75 of 75
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Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
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