/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/neonatal/,

/clinical/cckm-tools/content/order-sets/inpatient/neonatal/name-98128-en.cckm

201711317

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UWHC,UWMF,

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Neonatal

IP – Intensive Care – Neonatal – Admission [5028]

IP – Intensive Care – Neonatal – Admission [5028] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Neonatal


IP - Intensive Care - Neonatal - Admission [5028]
Admission Status
Admission Status (Single Response) [147792]
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:
Admission Status [144372]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: NEONATAL INTENSIVE CARE
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:
Patient Care Orders
Vital Signs [142907]
Page 1 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Vital Signs [NURMON0013] SEE COMMENTS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Once on admission, then every 30 minutes times 2,
then every 3 hours. Temperature measurement
method: axillary, skin, and esophageal
Assess Physiologic Systems [NURCOM0022] ONCE, Once upon admission, then every 30 minutes
times 2, then every 3 hours and PRN.
Patient Monitoring [142890]
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [139419]
Cardio-Respiratory Monitor - Pediatric - With
Rhythm [NURMON0014]
CONTINUOUS, Routine, Most pediatric patients do
NOT require rhythm analysis. Please complete the
Notify Provider order below, including specification
for apnea > *** seconds. If indicated, order pulse
oximetry separately.
Device Present:
Device Mode:
Device Low Rate Limit (BPM):
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Notify [NURCOM0001] Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds
HeRO Monitoring [NURMON0066] CONTINUOUS, Routine
Notify Provider:
Functional Cardiac Defibrillator Present:
Pulse Oximetry [NURMON0091] CONTINUOUS, Routine
High saturation limit:
Low saturation limit:
Mother-Baby Care Profiles SpO2 Goal Alarm Limits
(Meriter and AFCH)
<37 weeks RA/FiO2 21% 90-94% 88-100%
<37weeks FiO2 >21% 90-94% 88-95%
>/= 37 weeks RA/FiO2 21% >/= 95% 92-100%
>/= 37 weeks FiO2 >21% >/= 95% 92-98%
Measure Length [NURMON0052] ONCE For 1 Occurrences, Routine
Measure With? Length Board
Measure when?
Upon Admission
Measure Length [NURMON0052] EVERY SUNDAY, Routine
Measure With? Length Board
Measure when?
Measure Weight [NURMON0015] ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
Upon Admission
Measure Weight - Daily [NURMON0015] 1X DAILY, Starting tomorrow, Routine
Weigh With?
Weigh when? PM
Measure Head Circumference [NURMON0038] ONCE For 1 Occurrences, Routine, Upon Admission
Page 2 of 34
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Measure Head Circumference [NURMON0038] EVERY SUNDAY, Routine
Activity [144572]
Elevate Head Of Bed [NURACT0002] Equal to (degrees):
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today, Ventilator-
Associated Pneumonia Bundle elevate HOB 30
degrees for patients who are endotracheally intubated
Reposition Patient [NURACT0005] Type:
Routine, SEE COMMENTS, Reposition patient every
3 hours and PRN as tolerated to avoid skin break
down
Nutrition [144347]
Diet - Neonatal - Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Neonatal
NPO: STRICT NPO
Infant Nutrition Primary:
Infant Nutrition Secondary:
Fortification:
Calories per Ounce:
Route:
Route (Comments):
Frequency:
Frequency (Comments):
Total Volume per Feeding (mL):
Diet - Neonatal [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Neonatal
NPO:
Infant Nutrition Primary:
Infant Nutrition Secondary:
Fortification:
Calories per Ounce:
Route:
Route (Comments):
Frequency:
Frequency (Comments):
Total Volume per Feeding (mL):
Enteral Tube Placement - Neonatal [148848]
Insert and Maintain Orogastric/Nasogastric Tube
[NURTAD0058]
CONTINUOUS, Routine
Check Residual:
Does this need to be inserted/placed? Yes
For tubes with 30 day dwell time, recheck for growth
2 weeks after placement.
Page 3 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

X-RAY ABDOMEN AP VIEW (KUB) [R74000] 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 orogastric tube placement
Relevant recent/past history?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date
in comment):
Transport Method: Floor Determined/Entered
If Conditional, What Condition? Evaluate orogastric
tube placement. The location of orogastric tube
should be confirmed prior to the instillation of fluids,
medications, or feedings. Refer to Policy 2.20
Enteral Tubes Used for Instillation of Fluids,
Medications, or Feeding
Is patient pregnant?
Drain/Tube Care [144576]
Insert and Maintain Gastric Tube - Neonatal
[147852]
Insert and Maintain Neonatal Tube for Gastric
Decompression [NURTAD0066]
CONTINUOUS, Routine
Options:
Flush with: Sterile Water
Flush Frequency: PRN
Check Residual:
Does this need to be inserted/placed?
X-RAY ABDOMEN AP VIEW (KUB) [R74000] ONCE-RAD NEXT AVAILABLE, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Decompression tube
What specific question(s) would you like answered
by this exam? 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
Respiratory [140281]
Provide Manual Resuscitator at Bedside [RT0039] CONTINUOUS, Routine
Respiratory Therapy - Neonatal [147419]
Suction Airway - Neonatal [NURTAD0017] PRN, Starting today, Routine
Location: Other (Comment)
Per RN/RT discretion.
Oxygen Therapy - Neonatal [RT0032A] CONTINUOUS, Starting today For Until specified,
Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
High Flow Nasal Cannula - Neonatal [RT0071A] CONTINUOUS, Starting today For Until specified,
Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Page 4 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Non-Invasive Ventilation - Neonatal [RT0081] CONTINUOUS, Starting today, Routine, HOB 15
degrees
Ventilator Management: Per MD
Mode:
Set Rate/Min: 40
PEEP (cmH2O): 5
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Pressure Support:
PIP (Pressure Control + PEEP): 20
Peak Inspiratory Pressure:
Inspiratory Time: 0.5
NAVA Level (µV):
Mechanical Ventilation - Neonatal [RT0080] Routine, For ADULT patients order chlorihexidene
gluconate (PERIDEX) 0.12% soln 15 mL to swab
oral cavity 2x daily while on ventilation.
Ventilator Management:
Mode:
Volume Guarantee:
Set Rate/Min:
Tidal Volume (mL) (4-6 mL/kg of Ideal Body Weight
for neonatal):
PEEP (cmH2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Pressure Support:
PIP (Pressure Control + PEEP):
Inspiratory Time:
NAVA Level (µV):
High Frequency Oscillatory Ventilation (HFOV)
[RT0066]
CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
I-Time (%):
MAP (cmH2O):
Hertz:
Delta P (cmH2O):
Intake and Output [144575]
Measure Intake [NURMON0053] EVERY 1 HOUR, Routine
Weigh Diapers [NURELM0038] CONTINUOUS, Routine, After each elimination
Non-Categorized Patient Care Orders [150920]
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Routine, To discontinue this order,
enter a new order for "Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes in
the new order.
Type:
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Newborn Hearing Screen [AUD0002] ONCE, Routine, Notify Care Team Leader to perform
hearing screen.
Complete order when screen has been performed.
Notify Provider if patient refers twice on Newborn
Hearing Screen. Provider to order Outpatient
Audiology Screening.
Contingency Parameters [144577]
Page 5 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Notify [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): 38.0
If temperature < (C): 36.0
If heart rate > (bpm): 200
If heart rate < (bpm): 60
If respiratory rate >: 85
If respiratory rate <: 20
If blood glucose > (mg/dL):
If blood glucose < (mg/dL): 50
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): 1 mL/kg/hr
Other: Symptomatic for hypoglycemia,Unable to
maintain saturation within target range,If saturation
outside of target range,If mean arterial pressure >
***,If mean arterial pressure < ***,If blood glucose < 50
mg/dL or > 200 mg/dL or if patient is symptomatic for
hypoglycemia
Intravenous Therapy
IV Fluids [144384]
URL:
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
heparin in sodium chloride 0.9 % 50 mL patency
line [700923]
Intraarterial, CONTINUOUS
neonatal arterial solution [700636] Intraarterial, CONTINUOUS
neonatal arterial trophamine 3% - heparin
[700635]
Intraarterial, CONTINUOUS
neonatal venous maintenance solution [700858] Intravenous, CONTINUOUS
dextrose 10 % infusion [36626] Intravenous, CONTINUOUS
sodium chloride 0.9 % infusion [64367] Intravenous, CONTINUOUS
Medications
Sucrose for Oral Analgesia [110384]
sucrose (SWEET-EASE) 24% buccal soln
[794009]
Oral, PRN, pain, mild pain or potentially painful
procedures. See Admin Instructions
Anti-infectives [134968]
ampicillin (OMNIPEN) intraVENOUS [800009] 100 mg/kg, Intravenous
ceftazidime (FORTAZ) intraVENOUS [800025] 50 mg/kg, Intravenous
gentamicin (GARAMYCIN) intraVENOUS
[800049]
Intravenous
fluconazole (DIFLUCAN) intraVENOUS [800044] Intravenous
vancomycin (VANCOCIN) intraVENOUS [800084] Intravenous
Continuous Infusions [148430]
DOBUTamine (DOBUTREX) infusion PEDS
[800136]
Intravenous, CONTINUOUS
DOPamine (INTROPIN) infusion PEDS [800137] Intravenous, CONTINUOUS
epiNEPHrine infusion PEDS [800138] Intravenous, CONTINUOUS
FENTanyl infusion PEDS [800143] Intravenous, CONTINUOUS
Page 6 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

midazolam (VERSED) infusion PEDS [800154] Intravenous, CONTINUOUS
MORPHine infusion PEDS [800156] 0.01 mg/kg/hr, Intravenous, CONTINUOUS
Birth Medications [148434]
erythromycin (ROMYCIN) ophthalmic ointment
[37228]
Eyes (Each)
phytonadione (VITAMIN K1) injection - For infants
< 1.5 kg [800219]
0.3 mg/kg, Intramuscular, ONCE For 1 Doses
phytonadione (VITAMIN K1) injection - For infants
1.5 kg or more [800219]
1 mg, Intramuscular, ONCE For 1 Doses
Immunizations and Immunoglobulins [148431]
hepatitis B vaccine (ENGERIX-B) 10 mcg/0.5 mL
vial SUSP - For HEP B positive mothers [63826]
10 mcg, Intramuscular, ONCE For 1 Doses
If mother is HepBSAg positive = Hepatitis B Immune
Globulin give by age 8 hours. If mother's HBsAg
status is unknown AND baby is less than 2000 g, give
by age 12 hours.
Oral Analgesia [197615]
sucrose (SWEET-EASE) 24% buccal soln
[794009]
Oral, PRN, pain, mild pain or potentially painful
procedures. See Admin Instructions
Breast Milk for Painful Procedure [NURCOM0085] Reason for Breast Milk: Pain
Other Medications [148433]
vitamin A (AQUASOL A) 50000 UNIT/ML injection
[46851]
5,000 units, Intramuscular, EVERY MON, WED, FRI
For 12 Doses
poractant alfa (CUROSURF) neb susp [175476] Endotracheal, ONCE For 1 Doses
sodium chloride flush 0.9% 2.5 mL injection
[785199]
Flush, PRN, flush/line care
sodium chloride flush 0.9% 10 mL injection
[785055]
Flush, PRN, flush/line care
heparin lock flush 1 UNIT/ML injection [119591] 1-5 units, Flush, EVERY 8 HOURS PRN, flush/line
care
Laboratory
Whole Blood Testing on Unit [147673]
Glucose, POC [IPGLUCOSE] SEE COMMENTS, 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?
Obtain with every lab draw and signs/symptoms of
hypo/hyperglycemia. May result on Nova meter or
ABL90 Blood Gas Analyzer.
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
With every Whole Blood lab draw
BLOOD GASES AND O2 SATURATION
[HCBGASOS]
STAT For 1 Occurrences, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES, WHOLE BLOOD
[HCWBLYTS]
STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 7 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

CALCIUM, IONIZED, WHOLE BLOOD
[HCWBICA]
STAT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEMOGLOBIN, WHOLE BLOOD [HCWBHGB] STAT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LACTATE [GM2255] STAT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL, WHOLE BLOOD
[HCWBTBIL]
STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Must send tube to core lab
Labs [144335]
BUN [BUN] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALBUMIN [ALB] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTEIN, TOTAL [HCGTSP] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, DIRECT [DBIL] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
AST/SGOT [AST] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 8 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

ALT/SGPT [ALT] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALKALINE PHOSPHATASE [ALKP] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
C REACTIVE PROTEIN [CRPN] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
NEONATAL SCREEN [NEOSCR] STAT For 1 Occurrences, Routine, This test is to be
used for a complete Wisconsin State Newborn
Screen. Do not use to order other testing to be
collected using dried blood spots.
Last patient weight? (will auto pull in value and date in
comment):
Has pt EVER been transfused? (If YES enter date of
last transfusion below):
Date of Last Transfusion:
Date of last newborn screen:
Timing of Collection (See WSLH Collection Info
reference link below):
CBC WITHOUT DIFFERENTIAL [HEMO] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITH DIFFERENTIAL [CBC] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
URINALYSIS WITH MICROSCOPY [UA] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Cultures [148227]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
STAT For 1 Occurrences, Routine, For optimum
diagnosis of sepsis, sample 3-4 sites only on the first
day of a septic episode. Cultures on subsequent days
are of minimal diagnostic value. Culture detects
bacteria, Candida and Cryptococcus. If filamentous
fungi are suspected see Culture, Blood, Filamentous
Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
ONCE For 1 Occurrences, Routine, For patients with
an ET tube or tracheostomy, quantitative mini-BAL by
RT or bronchoscopic BAL are the preferred methods
of specimen collection.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 9 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

CULTURE, URINE WITH GRAM STAIN
[HCURNCS]
ONCE For 1 Occurrences, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MRSA BY PCR [HCMRSA] CONDITIONAL For 7 Days, Routine, There is no need
to obtain repeated surveillance tests to clear patients
from MRSA isolation. Once a patient is flagged as
MRSA positive it will remain in the HealthLink header
indefinitely.
For NICU patients: left and right nares only.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Perform on all patients. Patient must be 48 hours of
age for initial screen.
NICU Nutrition Lab Panel [144336]
NICU Nutrition Lab Panel [144324]
BUN [BUN] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
CALCIUM [CA] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
AST/SGOT [AST] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
GLUCOSE [GLU] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
BILIRUBIN, DIRECT [DBIL] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
Page 10 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

ALBUMIN [ALB] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
ALKALINE PHOSPHATASE [ALKP] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
TRIGLYCERIDE [TRIG] NEXT AM For 1 Occurrences, Routine, Fasting
specimen is preferred.
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
GGT [GGT] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
C REACTIVE PROTEIN [CRPN] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
Coagulation [144339]
PROTHROMBIN TIME/INR [PT] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PTT [PTT] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FIBRINOGEN [GM1320] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
D-DIMER, QUANT [GM1332] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FIBRIN MONOMER [HCFIBMON] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Blood Bank
Tests [144387]
TYPE AND SCREEN, NEONATAL [HCNTS] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 11 of 34
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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11/2017CCKM@uwhealth.org

Red Blood Cells (Single Response) [214405]
indication below.Select
PR1-(Patient younger than 4 months) Acute
blood loss or anticipated surgical blood loss
[214406]
Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
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:
Consent Status:
Total Volume to be transfused (mL):
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): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
ONCE, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
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%) [214407]
Page 12 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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11/2017CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
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:
Consent Status:
Total Volume to be transfused (mL):
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): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
ONCE, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
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 [214408]
Page 13 of 34
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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11/2017CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
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:
Consent Status:
Total Volume to be transfused (mL):
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): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
ONCE, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
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
[214421]
Page 14 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
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:
Consent Status:
Total Volume to be transfused (mL):
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): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
ONCE, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
PR5-Acute blood loss or anticipated surgical
blood loss [214425]
Page 15 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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11/2017CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
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:
Consent Status:
Total Volume to be transfused (mL):
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): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
ONCE, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
PR6-Target Hemoglobin > 7 g/dL or Hematocrit >
21% [214426]
Page 16 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
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:
Consent Status:
Total Volume to be transfused (mL):
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): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
ONCE, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
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
[214427]
Page 17 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
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:
Consent Status:
Total Volume to be transfused (mL):
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): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
ONCE, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
PR8-Chronic transfusions in selected patients
with Sickle Cell or thalassemia syndromes OR
partial exchange or exchange transfusion
[214428]
Page 18 of 34
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
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:
Consent Status:
Total Volume to be transfused (mL):
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): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
ONCE, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
PR9-Massive Transfusion Procedure [214429]
Page 19 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
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:
Consent Status:
Total Volume to be transfused (mL):
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): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
ONCE, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
PR10-Other [214430]
Page 20 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Red Blood Cells (Neonatal) [BLB0023] < 1 UNIT For 1 Occurrences, Routine
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:
Consent Status:
Total Volume to be transfused (mL):
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): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
Transfuse Red Blood Cells (Neonatal)
[NURTRT0070]
ONCE, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL.
Run Over:
Total Volume to be transfused (mL):
Plasma (Single Response) [214461]
indication below.Select
PF1-Elevated INR with active bleeding or
anticipated major surgery/invasive procedure
[214434]
Plasma (Neonatal) [BLB0024] < 1 UNIT For 1 Occurrences, Routine
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:
Total Volume to be transfused (mL):
Transfuse Plasma (Neonatal) [NURTRT0071] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
Page 21 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

PF2-Pump prime in pediatric open heart surgery
as appropriate for neonates and lower weight
pediatric patients [214437]
Plasma (Neonatal) [BLB0024] < 1 UNIT For 1 Occurrences, Routine
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:
Total Volume to be transfused (mL):
Transfuse Plasma (Neonatal) [NURTRT0071] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PF3-Replacement therapy for hemostatic factor
deficiencies if concentrate not available [214441]
Plasma (Neonatal) [BLB0024] < 1 UNIT For 1 Occurrences, Routine
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:
Total Volume to be transfused (mL):
Transfuse Plasma (Neonatal) [NURTRT0071] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PF4-Disseminated intravascular coagulation with
active bleeding [214442]
Plasma (Neonatal) [BLB0024] < 1 UNIT For 1 Occurrences, Routine
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:
Total Volume to be transfused (mL):
Page 22 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Transfuse Plasma (Neonatal) [NURTRT0071] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PF5-Immediate reversal of warfarin effect for
emergency surgery or active bleeding (in
combination with vitamin K) [214443]
Plasma (Neonatal) [BLB0024] < 1 UNIT For 1 Occurrences, Routine
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:
Total Volume to be transfused (mL):
Transfuse Plasma (Neonatal) [NURTRT0071] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PF6-Massive Transfusion Procedure [214444]
Plasma (Neonatal) [BLB0024] < 1 UNIT For 1 Occurrences, Routine
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:
Total Volume to be transfused (mL):
Transfuse Plasma (Neonatal) [NURTRT0071] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PF7-Other [214445]
Page 23 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Plasma (Neonatal) [BLB0024] < 1 UNIT For 1 Occurrences, Routine
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:
Total Volume to be transfused (mL):
Transfuse Plasma (Neonatal) [NURTRT0071] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
Platelets (Single Response) [214462]
indication below.Select
PP1-Target Platelets > 20 K/µL in a stable
premature infant (GA < 37 weeks) [214446]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
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:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
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 [214447]
Page 24 of 34
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
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:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
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 [214448]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
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:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Page 25 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Transfuse Platelets (Neonatal) [NURTRT0072] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP4-Target Platelets > 10 K/µL in a non-bleeding
patient with failure of platelet production [214449]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
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:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
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.)
[214450]
Page 26 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
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:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP6-Target Platelets > 50 K/µL with failure of
platelet production AND active bleeding OR need
for an invasive procedure [214451]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
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:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Page 27 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Transfuse Platelets (Neonatal) [NURTRT0072] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP7-Significant bleeding in a patient with a
qualitative platelet defect, regardless of platelet
count [214452]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
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:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP8-Target Platelets > 75 K/µL in a non-bleeding
patient on ECMO [214453]
Page 28 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
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:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
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) [214454]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
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:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Page 29 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Transfuse Platelets (Neonatal) [NURTRT0072] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP10-Massive Transfusion Procedure [214455]
Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
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:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PP11-Other [214456]
Page 30 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Platelets (Neonatal) [BLB0025] < 1 SINGLE DONOR UNIT For 1 Occurrences,
Routine
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:
Consent Status:
Total Volume to be transfused (mL):
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history): Yes
Indication for Irradiated Blood: S1 Patients during the
first four months of life
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history): Yes
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Transfuse Platelets (Neonatal) [NURTRT0072] ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
Cryoprecipitate (Single Response) [214463]
indication below.Select
PC1-Active bleeding OR anticipated major
surgery/invasive procedure (e.g., ECMO) with
fibrinogen < 100 mg/dL or dysfibrinogenemia
[214457]
Cryoprecipitate (Neonatal) [BLB0026] 1 UNIT For 1 Occurrences, 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:
Total Volume to be transfused (mL):
Transfuse Cryoprecipitate (Neonatal)
[NURTRT0073]
ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
Page 31 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

PC2-Factor XIII deficiency [214458]
Cryoprecipitate (Neonatal) [BLB0026] 1 UNIT For 1 Occurrences, 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:
Total Volume to be transfused (mL):
Transfuse Cryoprecipitate (Neonatal)
[NURTRT0073]
ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PC3-Massive Transfusion Procedure [214459]
Cryoprecipitate (Neonatal) [BLB0026] 1 UNIT For 1 Occurrences, 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:
Total Volume to be transfused (mL):
Transfuse Cryoprecipitate (Neonatal)
[NURTRT0073]
ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
PC4-Other [214460]
Cryoprecipitate (Neonatal) [BLB0026] 1 UNIT For 1 Occurrences, 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:
Total Volume to be transfused (mL):
Transfuse Cryoprecipitate (Neonatal)
[NURTRT0073]
ONCE, Routine, Patient Weight
No data found for Wt
REMINDER: Complete request to disepnse 30-60
minutes before transfusion to prepare products.
1 Plasma Unit ~ 200 mL
Run Over:
Total Volume to be transfused (mL):
Page 32 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Diagnostic Tests and Imaging
Diagnositc Tests and Imaging [142923]
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
X-RAY ABDOMEN AP VIEW (KUB) [R74000] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
X-RAY BABYGRAM (PEDS CHEST/ABD
COMBINED-LESS THAN 2 YEARS) [R07709]
ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Consults
Consults [144586]
Consult Social Work (Inpatient) [CON0076] ONCE For 1 Occurrences, Routine
Reason for Consult: OTHER (Evaluate and treat)
Consult Lactation Consultant [CON0177] ONCE For 1 Occurrences, Routine, Patient's assigned
RN is to arrange for the Lactation Consultant or
designee to complete the consult.
Reason for Consult: Other (Evaluate and treat)
Consult Speech Therapy [CON0077] ONCE For 1 Occurrences, Routine
Patient Type: Pediatric
Reason for Speech Therapy Consult: Developmental
Assessment
Consult Physical Therapy [CON0061] ONCE For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Developmental
Assessment
Consult Occupational Therapy [CON0046] ONCE For 1 Occurrences, Routine
Reason for Occupational Therapy Consult:
Developmental Assessment
Page 33 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Consult Case Management (Inpatient) [CON0013] ONCE For 1 Occurrences, Routine
Reason for Consult: OTHER (Evaluate and treat)
Consult Pediatric Health Psychology (Inpatient)
[CON0202]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-Friday)
or if special assessment needs.
Reason for Consult: Evaluate and treat
Consult Spiritual Care (Inpatient) [CON0056] ONCE For 1 Occurrences, Routine
Reason for Consult: Evaluate and treat
Consult Neonatal Ophthalmology (Inpatient)
[CON0179]
ONCE
Reason for Consult:
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Call back number:
Consult Infectious Disease (Inpatient) [CON0037] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): For HIV exposed
infants or mothers who receive no antepartum
antiretroviral prophylaxis
Consult Angle Tolerance Test (Inpatient)
[CON0164]
ONCE For 1 Occurrences, Routine
Reasons / indications for test: Physiologic immaturity
(i.e., hypotonia, cardio-respiratory complications,
Down's syndrome, congenital neuromuscular
disorders, craniofacial anomalies, or congenital heart
defects)
Provider to Notify: Provider
If heart rate < (bpm): 80
Pulse Oximetry < (%): 90
If bradycardia >= (sec): 10
If desaturation >= (sec): 10
If apnea >= (sec): 20
Consult Pediatric Nutrition Support (Inpatient)
[CON0176]
ONCE
Intent: Consult and Recommend (Write Orders)
Reason for Consult: Initiate Parenteral Nutrition
Consult Pediatric Neurology (Inpatient)
[CON0097]
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:
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 34 of 34
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:30:17 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org