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IP - Neurosurgery - Subarachnoid Hemorrhage - Adult - Intensive Care - Admission [3412]

IP - Neurosurgery - Subarachnoid Hemorrhage - Adult - Intensive Care - Admission [3412] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Neurosciences


IP - Neurosurgery - Subarachnoid Hemorrhage - Adult - Intensive Care -
Admission [3412]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [187518]
*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 [137172]
Page 1 of 28
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:12:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor: F8/4
Service: NEUROSURGERY
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: Subarachnoid Hemorrhage
E - EVALUATIONS PLANNED: Evaluation of
Subarachnoid Hemorrhage
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED: Those pertaining to
treatment of Subarachnoid Hemorrhage
Admission Status [142667]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor: F8/4
Service: NEUROSURGERY
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: Subarachnoid Hemorrhage
E - EVALUATIONS PLANNED: Evaluation of
Subarachnoid Hemorrhage
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED: Those pertaining to
treatment of Subarachnoid Hemorrhage
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [136416]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Moderate VTE Risk with Low Bleed Risk
[209996]
enoxaparin (LOVENOX) injection [800040] 30 mg, Subcutaneous, EVERY 12 HOURS
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
Sequential Compression Device (SCD)
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? 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
High VTE Risk with Low Bleed Risk [241260]
enoxaparin (LOVENOX) injection [800040] 30 mg, Subcutaneous, EVERY 12 HOURS
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS
Page 2 of 28
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:12:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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
High Bleed Risk [237204]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis (Single Response) [150230]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Moderate VTE Risk with Low Bleed Risk
[209996]
enoxaparin (LOVENOX) injection [800040] 30 mg, Subcutaneous, EVERY 12 HOURS
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
Sequential Compression Device (SCD)
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? 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
High VTE Risk with Low Bleed Risk [241263]
enoxaparin (LOVENOX) injection [800040] 30 mg, Subcutaneous, EVERY 12 HOURS
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
High Bleed Risk [237206]
Page 3 of 28
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:12:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs [20551]
Vital Signs [NURMON0013] EVERY 1 HOUR, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Intracranial Pressure (ICP) and Neuro Assessment
also
Assess Neurologic Status [NURMON0006] EVERY 1 HOUR, Starting today For Until specified,
Routine
Intracranial Pressure Monitoring [102023]
Intracranial Pressure Monitor [143423]
Transduce Intracranial Pressure [NURMON0060] CONTINUOUS, Transduce intracranial pressure -
Continuous
Measure Cerebral Perfusion Pressure Every
Hour [NURMON0060]
SEE COMMENTS, Measure cerebral perfusion
pressure every hour.
Ventriculostomy [145872]
lidocaine 1%-epINEPHrine 0.01 mg/mL
(1:100000) injection [45570]
3-5 mL, Subcutaneous, PRN, For procedure. Can
ONLY be administered by physician.
Can ONLY be administered by physician.
Transduce Intracranial Pressure [NURMON0060] CONTINUOUS, Transduce intracranial pressure -
Continuous
Maintain Ventriculostomy Catheter
[NURTAD0039]
CONTINUOUS, Routine
Ventriculostomy Details: Other (Comment)
Height Change: 10 mmHg
Measure Cerebral Perfusion Pressure Every
Hour [NURMON0060]
SEE COMMENTS, Measure cerebral perfusion
pressure every hour.
GLUCOSE, CSF [GM2740] 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? Drawn by
Neurosurgery Service
PROTEIN, CSF [GM2745] 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? Drawn by
Neurosurgery Service
Page 4 of 28
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:12:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CELL COUNT, CSF [HCCFCC] CONDITIONAL, Starting today For 7 Days, Routine,
Please indicate if specimen source is CSF, lumbar
puncture, or ventricular shunt fluid.
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Drawn by
Neurosurgery Service
CULTURE, CSF, AER WITH GRAM STAIN
[HCSFC]
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? Drawn by
Neurosurgery Service
GLUCOSE, CSF [GM2740] CONDITIONAL, Starting 12/22/17 For 7 Days,
Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Drawn by
Neurosurgery Service
PROTEIN, CSF [GM2745] CONDITIONAL, Starting 12/22/17 For 7 Days,
Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Drawn by
Neurosurgery Service
CELL COUNT, CSF [HCCFCC] CONDITIONAL, Starting 12/22/17 For 7 Days,
Routine, Please indicate if specimen source is CSF,
lumbar puncture, or ventricular shunt fluid.
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Drawn by
Neurosurgery Service
CULTURE, CSF, AER WITH GRAM STAIN
[HCSFC]
CONDITIONAL, Starting 12/22/17 For 7 Days,
Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Drawn by
Neurosurgery Service
GLUCOSE, CSF [GM2740] CONDITIONAL, Starting 12/29/17 For 7 Days,
Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Drawn by
Neurosurgery Service
PROTEIN, CSF [GM2745] CONDITIONAL, Starting 12/29/17 For 7 Days,
Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Drawn by
Neurosurgery Service
CELL COUNT, CSF [HCCFCC] CONDITIONAL, Starting 12/29/17 For 7 Days,
Routine, Please indicate if specimen source is CSF,
lumbar puncture, or ventricular shunt fluid.
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Drawn by
Neurosurgery Service
Page 5 of 28
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:12:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CULTURE, CSF, AER WITH GRAM STAIN
[HCSFC]
CONDITIONAL, Starting 12/29/17 For 7 Days,
Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Drawn by
Neurosurgery Service
LACTATE, CSF [HCCFLACT] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Drawn by
Neurosurgery Service
LACTATE, CSF [HCCFLACT] CONDITIONAL, Starting 12/22/17 For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Drawn by
Neurosurgery Service
LACTATE, CSF [HCCFLACT] CONDITIONAL, Starting 12/29/17 For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Drawn by
Neurosurgery Service
Activity [102025]
Bed Rest [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: other (comment)
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Activity progression as needed. Turn patient every 2
hours
Elevate Head Of Bed [NURACT0002] Equal to (degrees): 30
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today
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:
Nutrition [20556]
Page 6 of 28
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:12:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Strict NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Hypoglycemia Management [193415]
Glucose, POC [IPGLUCOSE] EVERY 6 HOURS For 3 Days, 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?
Hypoglycemia Management (Adult) [191576]
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today For Until specified,
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?
Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA
TREATMENT, Starting today For Until specified,
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?
Per hypoglycemia treatment algorithm Recheck
glucose 15 minutes after providing treatment until
glucose is greater than or equal to 70 mg/dL. If
patient has been critically low (i.e., glucose less than
40 mg/dL), recheck glucose after 1 hour to ensure
glucose remains greater than or equal to 70mg/dL.
After resolution of mild hypoglycemia (i.e., glucose
40-69 mg/dL), consider rechecking after 1 hour if
patient has signs/symptoms of hypoglycemia or is at
risk for a subsequent hypoglycemic event (e.g.,
previously administered insulin still active, altered
renal status, altered mental status, NPO or
interrupted nutrition, or any other condition that
increases hypoglycemia risk)
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Glucose,Other
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
Other: Nutritional status changes
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If blood glucose less
than 40mg/dL and patient able to eat/swallow safely.
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater.
Page 7 of 28
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:12:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If glucose is 40-69
mg/dL and patient able to eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater.
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose 40-
69 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
less than 40 mg/dL
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, For blood glucose less
than 69 mg/dL and patient unable to eat/swallow
safely AND has NO IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
dextrose injection [800233] 12.5 g, Intravenous, PRN, For blood glucose 40-69
mg/dL and patient unable to eat/swallow safely AND
has IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
dextrose injection [800233] 25 g, Intravenous, PRN, For blood glucose less than
40 mg/dL and patient unable to eat/swallow safely
AND has IV access.
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia Algorithm
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL, Starting 12/23/17 For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Respiratory [20564]
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine
Provide Manual Resuscitator and Mask at
Bedside [RT0039]
CONTINUOUS, Starting today, Routine
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Ventilation (Single Response) [138980]
For Patients on Ventilator [242397]
Page 8 of 28
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:12:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Mechanical Ventilation [RT0028] Routine, For ADULT patients order chlorihexidene
gluconate (PERIDEX) 0.12% soln 15 mL to swab
oral cavity 2x daily while on ventilation.
Is this a modification to a current vent order?
Ventilator Management: Adult Vent Management
Protocol
Mode:
Set Rate/Min:
Tidal Volume Multiplier: 8
PEEP (cmH2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Pressure Support:
Pressure Control:
Wean: As Tolerated per RT
P High (cmH20):
P Low (PEEP) (cmH20):
T High (sec):
T Low (T PEEP) (sec):
PS above P High (cmH2O):
PS above PEEP (cmH2O):
NAVA Level (µV):
Provide Manual Resuscitator at Bedside
[RT0039]
CONTINUOUS, Routine
chlorhexidine (PERIDEX) 0.12 % soln
MULTIDOSE [792004]
15 mL, Mouth/Throat, 2 X DAILY
Use to swab oral cavity. Discontinue when patient no
longer on ventilation
Insert and Maintain Orogastric Tube
[NURTAD0015]
CONTINUOUS, Routine
Options:
Flush with:
Flush Frequency:
Check Residual:
Does this need to be inserted/placed?
Device Status: Not Ready For Use
Refer to Policy 2.20 Enteral Tubes Used for
Instillation of Fluids, Medications, or Feeding
X-RAY ABDOMEN AP VIEW (KUB) [R74000] CONDITIONAL, Starting today For 3 Occurrences,
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?
Is patient pregnant? Unknown
If being performed remotely, where?
Last patient weight? (will auto pull in value and date
in comment):
Transport Method: Floor Determined/Entered
If Conditional, What Condition? Evaluate orogastric
tube placement. The location of orogastric tube
should be confirmed prior to the instillation of fluids,
medications, or feedings. Refer to Policy 2.20
Enteral Tubes Used for Instillation of Fluids,
Medications, or Feeding
Respiratory Therapy Communication (Order
Sets) [RT0073]
CONTINUOUS, Routine, Contact Physician for peak
airway pressure greater than 34 cm H20; pCO2 less
than 32 or greater than 37 mmHg; pO2 less than 80
mmHg
Page 9 of 28
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:12:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

No Swallow Consult Needed - Reason Not
Ordered [COR0065]
ONCE For 1 Occurrences, Routine
Reason Not Ordered: Patient is intubated
Consult NeuroCritical Care (Inpatient) [CON0136] ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Respiratory failure and management of cardiac
function
Can this consult be done via video?
midazolam (VERSED) injection RANGE [750056] 2-4 mg, Intravenous, EVERY 15 MINUTES PRN,
sedation, Sedation/Seizure
First line for active seizure. Second line to keep
RASS sedation score -3 if propofol infusion is at
maximum dose
propofol (DIPRIVAN) 10 mg/mL infusion [800260] 5-50 mcg/kg/min, Intravenous, CONTINUOUS
Initiate at 30 mcg/kg/min. Titrate by 10 mcg/kg/min
every 10 minutes as needed to achieve a RASS
sedation score of -3
For Patients NOT on Ventilator [216987]
Incentive Spirometry [NURTRT0018] EVERY 1 HOUR, Routine, WHILE AWAKE
Cough And Deep Breathe [NURTRT0019] EVERY 1 HOUR, Routine, While awake
Oxygen Therapy [RT0032] CONTINUOUS, 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?
Consult Speech Therapy (Inpatient) Eval and
Treat [CON0077]
ONCE For 1 Occurrences, Routine
Patient Type:
Consult Swallow Therapy (Inpatient) [CON0079] ONCE For 1 Occurrences, Routine
Reason for Consult: Evaluate and Treat Patient
May the Speech Pathologist and Registered
Dietician place diet orders on your behalf? Yes
Is this a potential new stroke patient?
Continuous Positive Airway Pressure (CPAP)
Treatment [RT0010]
SEE COMMENTS, Starting today, Routine
PEEP (cmH2O): 10
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Self Administered (Only RT may document in this
box after patient assessment): RT Approval
Required
Every 4 hours while patient is awake - Discontinue if
patient is able to do incentive spirometry.
CPAP Overnight and Nap [RT0063] OVERNIGHT AND NAP, Starting today, Routine
Therapy Settings: Per RT
CPAP Level (cm H2O):
Oxygen (LPM or %):
Self Administered (Only RT may document in this
box after patient assessment): RT Approval
Required
Complete the UWH Bedside Dysphagia screen
prior to ANY oral intake including medication or
diet orders [NURCOM0022]
ONCE For 1 Occurrences, The RN must be trained
in the use of the UWH Dysphagia Screen.
Page 10 of 28
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12/2017CCKM@uwhealth.org

Biphasic Positive Airway Pressure (BIPAP)
[RT0004]
Routine
Mode:
IPAP (cm H2O):
EPAP (cm H2O):
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Set Rate/Min:
Titrate oxygen to maintain O2 sat at (%):
Self Administered (Only RT may document in this
box after patient assessment): RT Approval
Required
Intake and Output [20576]
Measure Intake And Output [NURMON0005] EVERY 2 HOURS, Starting today, Routine
Non-Categorized Patient Care Orders [20577]
Supplemental" Order Set-Feeding Tube Placement, Refer to "Feeding Tube Placement Request For
Supplemental" -Request Adult PICC Placement -PICC Placement, Refer to "Venous Access Team For
Order Set
Measure Central Venous Pressure
[NURMON0002]
EVERY 6 HOURS, Starting today, Routine
Maintain Arterial Line [NURVAD0001] CONTINUOUS, Starting today, Routine
Flush Solution:
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today, Routine, To
discontinue this order, enter a new order for
"Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes in
the new order.
Type: Indwelling Single Lumen
Indication for Placement: Other (Comment Required)
(Hemorrhagic Stroke)
Initiate Urinary Catheter Removal Protocol? Yes
Details: To Dependent Drainage
Does this need to be inserted/placed?
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
CONTINUOUS, Routine
Indication: ICU/PACU patient
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Apply Cooling Blankets Above and Below Patient
[NURTRT0048]
SEE COMMENTS, Starting today, As needed for
when patient has temperature greater than 37 degrees
Celsius with diminished level of consciousness
Apply Ice Packs [NURTRT0008] PRN, Starting today, Routine
Site: Affected Area
As needed for when patient has temperature greater
than 37 degrees Celsius with diminished level of
consciousness
Keep Lights on in Patient Room During the
Daytime [NURMON0060]
CONTINUOUS, Starting today
Apply IPOC Template -- Brain
Aneurysm/AVM/SAH IPOC [NURCOM0074]
Name of IPOC template to apply? Brain
Aneurysm/AVM/SAH IPOC
Contingency Parameters [20578]
Page 11 of 28
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Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 140
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 90
If diastolic blood pressure < (mmHg): 40
If temperature > (C): 37.2
If temperature < (C): 35
If heart rate > (bpm): 110
If heart rate < (bpm): 50
If respiratory rate >: 30
If respiratory rate <: 8
If blood glucose > (mg/dL): 180
If blood glucose < (mg/dL): 70
If pain score >:
Pulse Oximetry < (%): Less than 92% on 2 liters or
greater per nasal cannula
If urine output < (mL): Less than 0.5 mL/kg per hour
for 3 hours or greater than 250 mL/hr for 2 hours or
greater than 350 mL/hr for 1 hour
Other:
Intracranial pressure greater than 20 mmHg for 5
minutes; Any deterioration in neurological status;
Serum osmolality greater than 320 mOsm/L; Specific
gravity less than 1.005; pCO2 less than 32 or greater
than 37 mmHg; pO2 less than 80 mmHg
Intravenous Therapy
Premedications for Needle Insertion [106310]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is immediate.
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, peripheral line
insertion - see Admin Instructions
Do NOT apply to area greater than 200 square
centimeters (maximum 2.5 g/site; maximum 4 sites
per hour, 6 times per day). Do NOT leave on longer
than 2 hours. Use for stable patient, no allergies to
lidocaine, with at least 30 minutes time prior to IV use
sodium chloride (bacteriostatic) 0.9 % injection
[50585]
0.05-0.1 mL, Intradermal, PRN, peripheral line
insertion - see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
IV Fluids (Single Response) [103227]
dextrose 5%- NaCl 0.9% with KCl 20 mEq/L
infusion [44904]
at 75 mL/hr, Intravenous, CONTINUOUS
sodium chloride 0.9% with KCl 20 mEq/L infusion
[46261]
at 75 mL/hr, Intravenous, CONTINUOUS
sodium chloride 0.9% infusion [64367] at 75 mL/hr, Intravenous, CONTINUOUS
Medications
Please refer to IP - Dexmedetomidine Infusion - Adult ICU Supplemental Order Set
Non-Categorized [223238]
Page 12 of 28
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NOTE: No medication via ORAL route to be
ordered/verified/administered prior to
documentation of passing dysphagia screen.
[950018]
2 X DAILY
NOTE: No medication via ORAL route to be
ordered/verified/administered prior to documentation
of passing dysphagia screen.
Analgesics - Acetaminophen - PRN [20548]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Nasogastric Tube, EVERY 4 HOURS PRN,
pain/fever
Temperature greater than 37 degrees Celsius or See
Pain Management Algorithm for the Selection of As-
Needed Analgesics
Analgesics - NSAIDS - PRN [242261]
ibuprofen (MOTRIN) susp [45376] 400 mg, Nasogastric Tube, EVERY 4 HOURS PRN,
pain
Alternative every 2 hours with acetaminophen. See
Pain Management Algorithm for the Selection of As-
Needed Analgesics
Analgesics - Opioids - Oral - PRN [242262]
oxycodone 5 MG/5ML soln [45975] 5 mg, Nasogastric Tube, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
Analgesics - Opioids - Intravenous - PRN [242263]
FENTanyl PF injection RANGE [750047] 12.5-50 mcg, Intravenous, EVERY 15 MINUTES PRN,
pain
See Pain Management Algorithm for the Selection of
As-Needed Analgesics
Do NOT give while on continuous opioid infusion
unless pain is uncontrolled and provider is notified
for 1 Minutes
Analgesics - Opioids - Intravenous - Scheduled [242264]
FENTanyl (50 mcg/mL) infusion [800264] 25 mcg/hr, Intravenous, CONTINUOUS
Anticonvulsants [193449]
levetiracetam (KEPPRA) soln [73616] 500 mg, Nasogastric Tube, 2 X DAILY For 14 Days
Anti-emetics [242265]
Adult - Standard - Anti-emetics [242267]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line if unable to take medications by mouth
or enteral tube OR if immediate effect is needed.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line if there is inadequate response to
first line anti-emetic within 30 minutes. If there is no
response to second line therapy within 30 minutes,
notify provider
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line. Use if there is inadequate
response to first line anti-emetic within 30 minutes
and if unable to take medications by mouth or
enteral tube OR if immediate effect is needed. If
there is no response to second line therapy within 30
minutes, notify provider
For Hypoactive Bowel Sounds [242268]
Page 13 of 28
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metoclopramide (REGLAN) injection [800059] 10 mg, Intravenous, EVERY 8 HOURS PRN, For
hypoactive bowel sounds
If ordered IV: Administer over 2 minutes.
Antihypertensives - As Needed [242294]
labetalol (NORMODYNE;TRANDATE) injection
RANGE [750053]
10-20 mg, Intravenous, EVERY 1 HOUR PRN,
hypertension - See Admin Instructions
Administer to keep blood pressure below the upper
limits identified in notify provider section of orders.
Give first line for blood pressure control if heart rate
greater than or equal to 60 beats per minute. Do not
give if heart rate is < 60 beats per minute. Wait at
least 15 minutes after any administration of bolus as
needed antihypertensives, including hydralazine,
before giving labetalol. Do NOT give while on a
continuous infusion of an antihypertensive, unless the
continuous infusion is at maximum dose and provider
is notified.
for 2 Minutes
hydrALAZINE (APRESOLINE) injection RANGE
[750049]
10-20 mg, Intravenous, EVERY 1 HOUR PRN,
hypertension
Administer to keep blood pressure below the upper
limits identified in notify provider section of orders.
Give first line for blood pressure control if heart rate is
< 60 beats per minute or give second line if heart rate
is greater than or equal to 60 beats per minute and
labetalol is ordered. Wait at least 15 minutes after any
administration of bolus as needed antihypertensives,
including labetalol, before giving hydralazine. Do NOT
give while on a continuous infusion of an
antihypertensive unless the continuous infusion is at
maximum dose and provider is notified.
Antihypertensives - Continuous Infusion [242295]
labetalol (NORMODYNE,TRANDATE) 500
mg/100mL infusion [785151]
5-180 mg/hr, Intravenous, CONTINUOUS
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult Protocol.
Initiate at 10 mg/hr or current rate and titrate to
maintain systolic blood pressure referred to in the
notify provider section of orders.
Hold if heart rate < 60 beats per minute.
Do NOT discontinue Health Link order per protocol.
nicardipine (CARDENE) 50 mg in sodium chloride
0.9 % 250 mL infusion [700960]
5-15 mg/hr, Intravenous, CONTINUOUS
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult Protocol.
Initiate at 5mg/hr or current rate and titrate to maintain
systolic blood pressure referred to in notify provider
section of the orders.
Do NOT discontinue Health Link order per protocol.
Anti-shivering [20536]
meperidine (DEMEROL) injection RANGE
[750055]
25-50 mg, Intravenous, EVERY 3 HOURS PRN,
rigors, shivering AND temperature greater than 37
degrees Celsius
Use with caution in elderly patients and patients with
renal dysfunction.
for 4 Minutes
buspirone (BUSPAR) tab [720025] 30 mg, Nasogastric Tube, EVERY 8 HOURS
Page 14 of 28
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magnesium sulfate intraVENOUS [800111] 2 g, Intravenous, EVERY 3 HOURS For 5 Doses
Pharmacist to contact provider for dosage adjustment
if renal dysfunction present.
Bowel Management - Scheduled [242296]
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
2 tab, Nasogastric Tube, 2 X DAILY
Hold for loose stools
lactobacillus rhamnosus GG (CULTURELLE) cap
[152674]
1 cap, Nasogastric Tube, 2 X DAILY
Open capsule and put down nasogastric tube
Bowel Management - As Needed [242297]
Adult - Bowel Management - As Needed
[242371]
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY PRN, constipation
First Line Therapy
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Oral, 1 X DAILY PRN, constipation
Second line therapy, if no response to first line
therapy within 12 hours
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation
If unable to take medications by mouth or enteral
tube OR if need immediate laxation OR if failure of
second line agent after 6 hours
Diuretics [104301]
furosemide (LASIX) intraVENOUS [800046] 40 mg, Intravenous, EVERY 6 HOURS PRN, other,
CVP greater than 14 mmHg
Intracranial Pressure Management [20540]
sodium chloride (HYPERTONIC) 3% IV BOLUS
[730019]
250 mL, Intravenous, ONCE For 1 Doses
sodium chloride (HYPERTONIC) 3% infusion
[42190]
Intravenous, CONTINUOUS
sodium chloride 1.8% infusion [700397] at 60 mL/hr, Intravenous, CONTINUOUS
Minerals and Vitamins [20541]
multivitamin with mineral tab [800240] 1 tab, Nasogastric Tube, 1 X DAILY
folic acid (FOLVITE) tab [37644] 1 mg, Nasogastric Tube, 1 X DAILY
thiamine (VITAMIN B-1) intraVENOUS [800261] 100 mg, Intravenous, ONCE For 1 Doses
ferrous sulfate syrup [37463] 300 mg, Nasogastric Tube, 3 X DAILY (AT
MEALTIME)
ascorbic acid (VITAMIN C) tab - Hold for patient
with active kidney stone problems or renal
disease on admission. [43693]
1,000 mg, Nasogastric Tube, 3 X DAILY (AT
MEALTIME)
Hold for patient with active kidney stone problems or
renal disease on admission.
Discontinue when indwelling catheter is discontinued.
Nimodipine (Single Response) [102667]
nimodipine soln [780223] 30 mg, Nasogastric Tube, EVERY 2 HOURS For 21
Days
Nimodipine - Reason Not Ordered [COR0044] ONCE, Routine
Reason Not Ordered: Hypotension/hemodynamic
instability
Stress Ulcer Prophylaxis (Single Response) [187452]
famotidine (PEPCID) intraVENOUS [800279] 20 mg, Intravenous, EVERY 12 HOURS
Administer if unable to take orally
famotidine (PEPCID) tab [45134] 20 mg, Nasogastric Tube, 2 X DAILY
pantoprazole (PROTONIX) susp [780113] 40 mg, Nasogastric Tube, 1 X DAILY
Vasopressors [20544]
Page 15 of 28
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DOPamine (INTROPIN) 800 mg in dextrose 5%
250 mL infusion [50506]
2-20 mcg/kg/min, Intravenous, CONTINUOUS
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult Protocol.
Initiate at 2 mcg/kg/min or current rate and titrate to
maintain SBP greater than goal referred to in the notify
provider order. Must keep heart rate less than 100
bpm unless physician approved. Do NOT discontinue
Health Link order per protocol.
norepinephrine (LEVOPHED) infusion [700247] 0.01-2 mcg/kg/min, Intravenous, CONTINUOUS
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult Protocol.
Initiate at 0.01 mcg/kg/min or current rate and titrate to
maintain SBP greater than goal referred to in the notify
provider order. Do NOT discontinue Health Link order
per protocol.
phenylEPHRINE(NEO-SYNEPHRINE) infusion
[700258]
0.1-5 mcg/kg/min, Intravenous, CONTINUOUS
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult Protocol.
Initiate at 0.25 mcg/kg/min or current rate and titrate to
maintain SBP greater than goal referred to in the notify
provider order. Do NOT discontinue Health Link order
per protocol.
Electrolyte Supplementation
Potassium Chloride (Single Response) [146649]
potassium chloride 10 mEq/100 mL bag [46253] 10 mEq, Intravenous, PRN - NOTIFY PHARMACY
WHEN NEEDED, potassium supplementation - See
Admin Instruction
For serum K between 3.6 - 3.9 mmol/L give 10 mEq
every 1 hour for 2 doses
For serum K between 3.1 - 3.5 mmol/L give 10 mEq
every 1 hour for 4 doses
For serum K less than or equal to 3.0 mmol/L give 10
mEq every 1 hour for 6 doses
Use only if patient is unable to tolerate enteral
administration
Do NOT give IV and oral formulation at the same time.
for 60 Minutes
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
potassium chloride 20 mEq/ 50 mL bag
CENTRAL LINE ONLY [46256]
20 mEq, Intravenous, PRN, Reminder: Pharmacist to
adjust per UWHC Renal Dosing Protocol if applicable
For central line use ONLY For serum K between 3.6 -
3.9 mmol/L give 20 mEq ONCE For serum K between
3.1 - 3.5 mmol/L give 20 mEq every 1 hour for 2 doses
For serum K less than or equal to 3.0 mmol/L give 20
mEq every 1 hour for 3 doses for 60 Minutes Use only
if patient is unable to tolerate enteral administration Do
NOT give IV and oral formulation at the same time.,
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
for 60 Minutes
Page 16 of 28
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potassium chloride 20 mEq oral packet [41217] 20 mEq, Oral, PRN, potassium supplementation - See
Admin Instructions
For serum K between 3.6 - 3.9 mmol/L give 1 packet
(20 mEq) ONCE;
For serum K between 3.1 - 3.5 mmol/L give 2 packets
(40 mEq) ONCE;
For serum K less than or equal to 3.0 mmol/L give 2
packets (40 mEq) ONCE followed by 1 packet
(20mEq) ONCE 1 hour later
Do NOT give IV and oral formulation at the same time.
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
potassium chloride ER tab [73470] 20 mEq, Oral, PRN, potassium supplementation - See
Admin Instructions
For serum K between 3.6 - 3.9 mmol/L give 1 tab (20
mEq) ONCE
For serum K between 3.1 - 3.5 mmol/L give 2 tabs (40
mEq) ONCE
For serum K less than or equal to 3.0 mmol/L give 2
tabs (40 mEq) ONCE followed by 1 tab (20mEq)
ONCE 1 hour later
Do NOT give IV and oral formulation at the same time.
Swallow whole; do not break, chew, or crush tablet
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
potassium chloride ER cap [49087] 10 mEq, Oral, PRN, potassium supplementation - See
Admin Instruction
For serum K between 3.6 - 3.9 mmol/L give 2 caps (20
mEq) ONCE;
For serum K between 3.1 - 3.5 mmol/L give 4 caps (40
mEq) ONCE;
For serum K less than or equal to 3.0 mmol/L give 4
caps (40 mEq) ONCE followed by 2 caps (20mEq)
ONCE 1 hour later
Do NOT give IV and oral formulation at the same time.
Swallow whole; do not break, chew, or crush tablet
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
Magnesium Sulfate [142608]
Magnesium Supplemental Scale [950039] PRN - NOTIFY PHARMACY WHEN NEEDED,
magnesium supplementation - see Admin Instructions
Non-cardiac patients: For serum magnesium 1.6-1.8
mg/dL - do not replace
Cardiac patients: For serum magnesium 1.6-1.8
mg/dL give 0.05 g/kg IV x1
For serum magnesium 1.0-1.5 mg/dL give 0.1 g/kg IV
x1
For serum magnesium less than 1 mg/dL give 0.15
g/kg IV x1
Administer each 2 gram bag over 3 hours at a
frequency of one bag every 4 hours.
Maximum 6 grams per replacement dose
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
Page 17 of 28
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Phosphate Sodium (Single Response) [141815]
phosphate-potassium & sodium (PHOS-NAK) oral
packet - For normal renal function [112317]
2 packet, Nasogastric Tube, PRN, phosphate
supplementation - See Admin Instructions
For serum phosphate 1.6 - 2.4 mg/dL, give 2 packets
every 4 hours while awake x 3 doses;
For serum phosphate 1.0 - 1.5 mg/dL, give 2 packets
every 4 hours while awake x 4 doses
For serum phosphate less than 1.0 mg/dL, call
provider for IV dosing.
phosphorus (K-PHOS NEUTRAL) tab [45503] 1 tab, Nasogastric Tube, PRN, phosphate
supplementation - See Admin Instructions
For serum phosphate 1.6 - 2.3 mg/dL give 1 tablet
every 4 h while awake x 3 dose
For serum phosphate 1.0 - 1.5 mg/dL give 1 tablet
every 4 h while awake x 4 doses
For serum phosphate less than 1.0 mg/dL, call
provider
Post Supplementation [145454]
POTASSIUM [K] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw 1 hour after IV
replacement or 4 hours after oral
replacement.,Arrhythmias
MAGNESIUM [MAG] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw AM following
completion of infusion,Arrhythmias
PHOSPHATE [PHOS] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw 4 hours after
enteral replacement.
Laboratory
Draw Now [104183]
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?
Page 18 of 28
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BLOOD GASES AND O2 SATURATION
[HCBGASOS]
CONDITIONAL, Starting today For 7 Days, STAT
If source is OTHER, indicate here:
Indicate FIO2: Per Nursing
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Vent changes and as
needed
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?
HEMATOCRIT [HCT] 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?
WHITE CELL COUNT [WBC] 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?
PLATELET COUNT [PLT] 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?
CULTURE, URINE [URC] 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?
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 19 of 28
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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?
URINALYSIS WITH MICROSCOPY [UA] ONCE, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
DRUG SCREEN, URINE [HCUPNL] STAT, Starting today For 1 Occurrences, Routine,
Test includes: Amphetamines/Methamphetamines,
Barbiturates, Benzodiazepine, Cocaine, and Opiates
(primarily targets morphine, codeine, and heroin).
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
TYPE AND SCREEN [HCTS] STAT 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.
Draw Daily Starting Tomorrow for 7 days [103229]
ELECTROLYTES [LYTE] NEXT AM For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] NEXT AM For 7 Days, 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 7 Days, 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 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEMATOCRIT [HCT] NEXT AM For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
WHITE CELL COUNT [WBC] NEXT AM For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PLATELET COUNT [PLT] NEXT AM For 7 Days, 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 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
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12/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL [TBIL] NEXT AM For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTEIN, TOTAL [TP] NEXT AM For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALBUMIN [ALB] NEXT AM For 7 Days, 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 7 Days, 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 7 Days, 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 7 Days, 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] NEXT AM For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
SODIUM [NA] EVERY 4 HOURS For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
OSMOLALITY [GM2215] EVERY 4 HOURS For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Endocrine [101780]
CORTISOL [CORT] 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?
TSH [TSH] 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?
T4, FREE [FT4] 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?
Laboratory - Pregnancy Test [112034]
surgery is pelvic, renal, pregnancy test if female between menarche & menopause and any of: (1) Obtain
intercourse, (3) patient missed menses, (4) patient says abdominal, (2) patient had unprotected -or intra
pregnant. she "could" be
Urine, Pregnancy Test [UPREG] 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 21 of 28
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [102033]
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, ASAP
Current signs and symptoms? Limited gas exchange
What specific question(s) would you like answered by
this exam? Evaluate for Parenchymal Lung Disease or
effusion
Relevant recent/past history? Subarachnoid
Hemorrhage
Is patient pregnant? Unknown
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
X-RAY CHEST AP VIEW [R71010] ONCE-ON SPECIFIC DATE, Starting tomorrow For 1
Occurrences, Routine
Current signs and symptoms? Limited gas exchange
What specific question(s) would you like answered by
this exam? Evaluate for Parenchymal Lung Disease or
effusion
Relevant recent/past history? Subarachnoid
Hemorrhage
Is patient pregnant? Unknown
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
CT ANGIO HEAD, NECK W PERFUSION
[R07001]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms? Subarachnoid
Hemorrhage related symptoms
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history. Evaluate cause of Subarachnoid Hemorrhage
Last creatinine value? (will auto pull in date and value
in comment):
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
CT HEAD W/ O IV CONTRAST [R70450] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms? Subarachnoid
Hemorrhage related symptoms
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history. Evaluate Subarachnoid hemorrhage / infarct
Last creatinine value? (will auto pull in date and value
in comment):
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Page 22 of 28
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12/2017CCKM@uwhealth.org

MRI & MRA HEAD W & W/ O CONTRAST
[R07010]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms? Subarachnoid
Hemorrhage related symptoms
What specific question(s) would you like answered by
this exam? Evaluate Subarachnoid hemorrhage /
infarct
Relevant recent/past history? Subarachnoid
hemorrhage / infarct
Is patient pregnant? Unknown
Does patient have a pacemaker or defibrillator?
Allergy to Gadolinium (MRI) contrast?
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.
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.
Relevant Surgical History (Select all applicable or
None):
Implanted Devices? (Select all applicable or None):
History of Metal in Body? (Select all applicable or
None):
Has patient had a colonoscopy/endoscopy in the last 8
weeks?
Study Needed Within:
Last creatinine value? (will auto pull in date and value
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
Last patient height? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Transesophageal Echocardiogram [ECH0008] ONCE, Starting today For 1 Occurrences, Routine
Indication: Stroke/TIA
Name and pager number of the physician to contact
the day of the procedure:
Can the patient provide consent?
If not is the POA aware of the procedure and available
to provide consent the day of the procedure?
List the name and the primary telephone number of
the POA (indicate N/A if not needed):
Does the patient have positive blood cultures?
Does the patient have a history of esophageal varices,
strictures or dysphagia?
Does the patient have a history of cervical spine
deformity or cervical collar that can not be removed?
Has the patient been NPO for at least 8 hours prior to
the procedure?
Is patient mechanically ventilated? Yes
Is patient ICU status? Yes
Does patient need continuous monitoring? Yes
Page 23 of 28
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Transcranial Duplex (UW Hospital) [VASC0005] ONCE, Routine
Reason for exam: SUBARACHNOID HEMORRHAGE
Is patient mechanically ventilated? Yes
Is patient ICU status? Yes
Does patient need continuous monitoring? Yes
Performed in Heart Vascular Care Echo/Vasc Lab
ANGIOGRAM CERVICAL CAROTID [R36222] ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms? Subarachnoid
Hemorrhage
What specific question(s) would you like answered by
this exam? Evaluate cause of Subarachnoid
Hemorrhage
Relevant recent/past history? Subarachnoid
Hemorrhage
Is patient pregnant?
Allergies to IV contrast or iodine? Pt non responsive-
ED/IP Only
Is patient on anticoagulation therapy? If yes, specify
coagulation disorder and current medications in
comments box at bottom.
Last creatinine value? (will auto pull in date and value
in comment):
Last patient weight? (will auto pull in value and date in
comment):
Last e-GFR value? (will auto pull in value and date in
comment):
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.
Transport Method: Floor Determined/Entered
Cardiac Workup [138593]
ECG - 12 Lead [EKG0008] ONCE For 1 Occurrences, Routine
Reason for exam: Stroke/TIA
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.
TROPONIN [GM2447] EVERY 6 HOURS For 3 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Notify Physician if Troponin level has not peaked and
is still increasing after 3 occurances.
Transthoracic Resting Echocardiogram
[ECH0003]
ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: STROKE/TIA
Do you want Agitated Bubble Study?
Is patient mechanically ventilated? Yes
Is patient ICU status? Yes
Does patient need continuous monitoring? Yes
Consults
Consults [20590]
Page 24 of 28
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12/2017CCKM@uwhealth.org

Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: OTHER
Health Care Power of Attorney / Guardianship
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: Other
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Formulate Treatment Plan
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?
Diabetes Consult Order Panel (Adult) [188497]
Page 25 of 28
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12/2017CCKM@uwhealth.org

Diabetes Management Service : Will provide management or treatment recommendations for
patients with hyperglycemia and/or those who report outpatient use of insulin or other diabetes
medications. Patients should be expected to remain inpatient > 24 hrs from time of consult.
Consult is required for patients with insulin pumps or who use U-500 insulin. Consult Endocrine
for any non-diabetes-related endocrine questions.
Learning Center - Diabetes Education (Adult): Diabetes Education (Adult): Diabetes education
(meter/insulin skills/other diabetes survival skills) for patients/families with knowledge deficits
and/or need for diabetes knowledge assessment. Recommended for all new diagnoses or
patients with A1C > 9.
Diabetes Education – Nutrition : Diabetes nutrition therapy including nutrition assessment,
carbohydrate education (consistent carbohydrate meals, use of insulin-to-carbohydrate ratio),
and/or individualized, nutritious meal planning for carbohydrates, portions, or considering other
comorbidities. Recommended for all new diagnoses or patients with A1C > 9
Consult Diabetes Management Service (DMS)
(Inpatient) [CON0022]
ONCE
Can this consult be done via video?
Call back number:
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Consult Learning Center - Diabetes Education
(Adult) [CON0021]
ONCE, Routine, - If patient is newly diagnosed or is
new to insulin, provide 24 hours notice to allow
adequate time for education,
- Indicate diabetes medication/treatment plan if
known.
- Consults requested after 1600 on Fridays may not
be seen until following Monday. Learning Center
available Mon-Sat 0800-1630 (only 1 RN available
on Saturday for CSC and AFCH).
- Staff may be contacted by Pager 7927 on
weekdays and Pager 3276 on weekends.
- Learning Center staff are not available on holidays.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Page 26 of 28
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Consult Diabetes Education - Nutrition (Inpatient)
[CON0126]
ONCE, Routine, · If your patient is newly diagnosed
and/or is new to insulin therapy, provide 24 hours
notice to allow adequate time for nutrition education.
· Indicate diabetes medication/treatment plan if
known.
· Consults requested after 1300 on Friday may not
be completed until the following Monday.
· If you are placing a consult on a weekend day for a
patient who will be discharging that weekend, please
have the Paging Center contact the on-call dietitian
to help you facilitate the diabetes nutrition education
session prior to the patient's discharge.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Nutrition Assessment w/
Recommendations
Delegate to Initiate and Manage Tube Feeding: Yes
Delegate to Initiate Feeding Tube Placement Order
Set: Yes
Delegate to Manage Diet Order/Supplement Order:
Yes
Delegate to Dysphagia Diet Order Progression: Yes
Protein/Calorie Malnutrition
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting 12/17/17 For 1 Occurrences, Routine
Reason for Occupational Therapy Consult: ADL
Training
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting 12/17/17 For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
Consult Orthotics / Prosthetics (Inpatient)
[CON0051]
ONCE, Starting today For 1 Occurrences, Routine
Do you need Orthotics or Prosthetics? Orthotics
Reason for Consult: Brace Fitting
Type of Pad/Equipment:
Consult Stroke - Non-Acute (Inpatient)
[CON0133]
ONCE
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Stroke
Consult Wound And Skin Care Service (Inpatient)
[CON0086]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: OTHER (COMMENT) (Skin
Problems)
Can this consult be done via video?
Consult Cardiology (Inpatient) [CON0012] ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Heart Problems
Consult Hematology (Inpatient) [CON0034] ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Hematologic Problems
CONSULT TO NEPHROLOGY [1009059] ONCE, Starting today For 1 Occurrences
Page 27 of 28
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:12:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Consult Spiritual Care (Inpatient) [CON0056] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Existential Crisis
Consult Rehab Medicine (Inpatient) [CON0068] ONCE
Purpose of Consult: Medical Management
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Recommendations for
Subarachnoid Hemorrhage
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 28 of 28
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:12:13 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org