/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/orthopedicsrehab/,

/clinical/cckm-tools/content/order-sets/inpatient/orthopedicsrehab/name-98116-en.cckm

201705138

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Orthopedics/Rehab

IP - Rehabilitation - Adult - Admission [5192]

IP - Rehabilitation - Adult - Admission [5192] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Orthopedics/Rehab


IP - Rehabilitation - Adult - Admission [5192]
for Adult Patients OnlyIntended
Rehabilitation Procedure Type
Procedure Type Specific Orders (Single Response) [149996]
Amputation [151984]
Knee Immobilizer [NURTRT0009] CONTINUOUS, Routine, If ordering a Bledsoe Boot
or Hip Abduction Brace, please contact the cast
room technician at 265-0746.
Type: Knee Immobilizer
Left/Right/Bilateral?
Wearing schedule:
Apply Brace/Splint, Lower Body [NURTRT0009] CONTINUOUS, Routine, If ordering a Bledsoe Boot
or Hip Abduction Brace, please contact the cast
room technician at 265-0746.
Type: Rigid Removable Dressing
Left/Right/Bilateral?
Wearing schedule:
Stroke [150049]
aspirin chew tab [720164] 81 mg, Oral, 1 X DAILY
aspirin tab [34787] 325 mg, Oral, 1 X DAILY
clopidogrel (PLAVIX) tab [58345] 75 mg, Oral, 1 X DAILY
Platelet Inhibitors Reason Not Ordered
[COR0040]
ONCE, Routine
Reason Not Ordered:
Platelet Inhibitors Already Ordered. This does
NOT generate a medication order. Please be
sure you have ordered the Platelet Inhibitor in
Med Rec. [COR0063]
ONCE, Routine
Traumatic Brain Injury [149997]
SODIUM [NA] 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?
Cognitive Recovery Program [NURCOM0051] Details
quetiapine (SEROQUEL) tab [720129] 25 mg, Oral, 1 X DAILY (HS)
quetiapine (SEROQUEL) tab [720129] 25-50 mg, Oral, EVERY 8 HOURS PRN, delirium,
agitation
propranolol (INDERAL) tab [41454] 10 mg, Oral, 3 X DAILY
traZODONE (DESYREL) tab [720150] 25 mg, Oral, 1 X DAILY (HS)
Spinal Cord Injury [208188]
Initiate Spinal Cord Injury Daily Bowel Program
Algorithm [NURELM0062]
CONTINUOUS, Routine
Abdominal Binder [NURTRT0014] CONTINUOUS, Routine
Type: Abdominal Binder
Wearing schedule:
nitroglycerin (NITRO-BID) 2 % ointment [40285] 1 inch, Transdermal, PRN For 2 Doses, for
Autonomic dysreflexia
Administer 1 inch every 15 minutes for 2 doses for
increase SBP>30 or DBP >20 above baseline for
autonomic dysreflexia. Notify prescriber if
hypertension and/or signs and symptoms are not
resolved after second dose. Remove paste after
resolution of symptoms.
Admission Status
Page 1 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org

Level of Care (Single Response) [186484]
*An admit patient order has already been written, but the level of care at which the patient
should be placed still needs to be identified.
Place Patient on General Care [ADT0018] General Care, has already been signed. This order
will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intermediate Care (IMC)
[ADT0018]
Intermediate Care, has already been signed. This
order will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intensive Care (ICU) [ADT0018] Intensive Care, has already been signed. This order
will ensure that the patient is placed at the
appropriate level of care.
Admit to Inpatient (Single Response) [188296]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically
necessary because of either an anticipated LOS >2
midnights, complexity and/or severity of illness, an
inpatient-only surgery, or a previously-authorized
inpatient stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [150021]
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:
Admission Status [150022]
Page 2 of 15
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05/2017CCKM@uwhealth.org

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:
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [130119]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis (Single Response) [150156]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [129757]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Page 3 of 15
Printed by O'BRIEN, RYLEY P [RPO249] at 5/15/2017 8:51:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

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 [150023]
Vital Signs [NURMON0013] 2X DAILY, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital Signs [NURMON0013] DAILY, Starting today with First Occurrence As
Scheduled, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital Signs [NURMON0013] EVERY 8 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Activity [150024]
Chair Twice Daily With Assistance
[NURACT0008]
CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR: 2x daily,other (comment)
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Page 4 of 15
Printed by O'BRIEN, RYLEY P [RPO249] at 5/15/2017 8:51:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Ambulate Per Physical Therapy
Recommendations [NURACT0008]
CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: other (comment)
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Reposition [NURCOM0022] SEE COMMENTS, Starting today with First
Occurrence As Scheduled, Every 2 hours while in
bed.
Weight Bearing Status [NURACT0008] CONTINUOUS, Starting today, Routine
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Apply Brace, Spine [NURTRT0014] CONTINUOUS, Starting today, Routine
Type:
Wearing schedule:
Apply Brace/Splint, Lower Body [NURTRT0009] CONTINUOUS, Starting today, Routine, If ordering a
Bledsoe Boot or Hip Abduction Brace, please contact
the cast room technician at 265-0746.
Type:
Left/Right/Bilateral?
Wearing schedule:
Apply Brace/Splint, Upper Body [NURTRT0015] CONTINUOUS, Starting today, Routine, If ordering a
Sarmiento Humeral Fracture Orthosis, please contact
the cast room technician at 265-0746.
Type:
Left/Right/Bilateral?
Wearing schedule:
Cervical Spine Precautions [PRECAU0005] CONTINUOUS, Starting today, Routine, Cervical
Spine Precautions:
Cervical collar at all times.
No pillow behind head.
No lifting anything greater than 10 pounds.
No lifting of arms over head.
Sternal Precautions [PRECAU0010] CONTINUOUS, Starting today, Routine, Sternal
Precautions:
No lifting greater than 8 pounds.
No pushing/pulling with arms during transfers.
No shoulder elevation past 90 degrees.
Total Hip Precautions [PRECAU0006] CONTINUOUS, Starting today, Routine
Nutrition [195340]
Page 5 of 15
Printed by O'BRIEN, RYLEY P [RPO249] at 5/15/2017 8:51:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

General Diet [NUT0030] EFFECTIVE NOW, Starting today, Routine
Diet Type: General
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Diabetes Meal Plan [NUT0030] EFFECTIVE NOW, Starting today, Routine
Diet Type: Diabetes Meal Plan
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
NPO [NUT0030] EFFECTIVE NOW, Starting today, Routine
Diet Type: NPO
NPO: Strict NPO
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Clear Liquid Diet [NUT0030] EFFECTIVE NOW, Starting today, Routine
Diet Type: Clear Liquid
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Full Liquid Diet [NUT0030] EFFECTIVE NOW, Starting today, Routine
Diet Type: Full Liquid
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Pureed Dysphagia Diet & Thin Liquids
[NUT0030]
EFFECTIVE NOW, Starting today, Routine
Diet Type: Consistency
Liquid Thickness: Thin
Solid Consistency: Pureed
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Page 6 of 15
Printed by O'BRIEN, RYLEY P [RPO249] at 5/15/2017 8:51:49 AM
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05/2017CCKM@uwhealth.org

Pureed Dysphagia Diet & Thick Liquids (Nectar)
[NUT0030]
EFFECTIVE NOW, Starting today, Routine
Diet Type: Consistency
Liquid Thickness: Nectar
Solid Consistency: Pureed
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Pureed Dysphagia Pureed & Thick Liquids
(Honey) [NUT0030]
EFFECTIVE NOW, Starting today, Routine
Diet Type: Consistency
Liquid Thickness: Honey
Solid Consistency: Pureed
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Pureed Dysphagia Diet - Diabetic & Thin Liquids
[NUT0030]
EFFECTIVE NOW, Starting today, Routine
Diet Type: Consistency,Diabetes Meal Plan
Liquid Thickness: Thin
Solid Consistency: Pureed
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Pureed Dysphagia Diet - Diabetic & Thick Liquids
(Nectar) [NUT0030]
EFFECTIVE NOW, Starting today, Routine
Diet Type: Diabetes Meal Plan,Consistency
Liquid Thickness: Nectar
Solid Consistency: Pureed
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Pureed Dysphagia Diet - Diabetic & Thick Liquids
(Honey) [NUT0030]
EFFECTIVE NOW, Starting today, Routine
Diet Type: Consistency,Diabetes Meal Plan
Liquid Thickness: Honey
Solid Consistency: Pureed
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Page 7 of 15
Printed by O'BRIEN, RYLEY P [RPO249] at 5/15/2017 8:51:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Mechanical Soft Dysphagia Diet & Thin Liquids
[NUT0030]
EFFECTIVE NOW, Starting today, Routine
Diet Type: Consistency
Liquid Thickness:
Solid Consistency: Mechanical Soft
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Mechanical Soft Dysphagia Diet & Thick Liquds
(Nectar) [NUT0030]
EFFECTIVE NOW, Starting today, Routine
Diet Type: Consistency
Liquid Thickness: Nectar
Solid Consistency: Mechanical Soft
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Mechanical Soft Dysphagia & Thick Liquids
(Honey) [NUT0030]
EFFECTIVE NOW, Starting today, Routine
Diet Type: Consistency
Liquid Thickness: Honey
Solid Consistency: Mechanical Soft
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Mechanical Soft Dysphagia Diet - Diabetic & Thin
Liquids [NUT0030]
EFFECTIVE NOW, Starting today, Routine
Diet Type: Consistency,Diabetes Meal Plan
Liquid Thickness:
Solid Consistency: Mechanical Soft
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Mechanical Soft Dysphagia DIet - Diabetic &
Thick Liquids (Nectar) [NUT0030]
EFFECTIVE NOW, Starting today, Routine
Diet Type: Consistency
Liquid Thickness: Nectar
Solid Consistency: Mechanical Soft
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Page 8 of 15
Printed by O'BRIEN, RYLEY P [RPO249] at 5/15/2017 8:51:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Mechanical Soft Dysphagia Diet - Diabetic &
Thick Liquids (Honey) [NUT0030]
EFFECTIVE NOW, Starting today, Routine
Diet Type: Consistency,Diabetes Meal Plan
Liquid Thickness: Honey
Solid Consistency: Mechanical Soft
Food Allergies:
Feeding Tube (Dietary Consult Needed within 48
Hours):
Medical Food / Oral Supplement(s):
Schedule:
Nourishment / Snack Item(s):
Respiratory [150025]
Respiratory Therapy per Protocol [RT0035] ONCE, Starting today For 1 Occurrences, Routine
Protocol Type:
Suction Airway [NURTAD0017] PRN, Routine
Location:
Provide Trach Care [NURTAD0019] 2X DAILY PRN, Routine
Bladder Management [150043]
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?
Check Bladder Volume with Bladder Scan
[NURELM0001]
EVERY 8 HOURS, Routine
Straight Cath for Residual > (mL):
Initiate Neurogenic Bladder Voiding Trial
Algorithm [NURELM0046]
CONTINUOUS, Routine
Initiate Acute Spinal Cord Injury Cathing
Algorithm [NURELM0044]
CONTINUOUS, Routine
Wound Care [150026]
Wound Care [NURWND0015] CONTINUOUS, Routine
Wound Type:
Wound Site:
Wound Location:
Assess Frequency:
Care Frequency:
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing:
Secondary Dressing:
Intake and Output [146671]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today For Until specified,
Routine
Non-Categorized Patient Care Orders [150027]
Measure Weight [NURMON0015] ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
On admission.
Measure Weight [NURMON0015] EVERY 7 DAYS, Starting today, Routine
Weigh With?
Weigh when?
Page 9 of 15
Printed by O'BRIEN, RYLEY P [RPO249] at 5/15/2017 8:51:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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05/2017CCKM@uwhealth.org

Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral?
Type:
Sequential Compression Device (SCD) Panel
(TREATMENT AND SUPPLY) [206111]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral?
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type:
Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Maintain PICC [NURVAD0050] CONTINUOUS, Routine
Device Status:
Site:
PICC Secured With:
Flush With(Must also enter separate medication order
to obtain drug):
Site Assessment Frequency:
Glucose, POC [IPGLUCOSE] ONCE For 1 Occurrences, 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?
Non-Categorized Patient Care Orders [195339]
Measure Weight [NURMON0015] ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
On admission.
Measure Weight [NURMON0015] EVERY 7 DAYS, Starting today, Routine
Weigh With?
Weigh when?
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral?
Type:
Sequential Compression Device (SCD) Panel
(TREATMENT AND SUPPLY) [206111]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral?
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type:
Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Maintain PICC [NURVAD0050] CONTINUOUS, Routine
Device Status:
Site:
PICC Secured With:
Flush With(Must also enter separate medication order
to obtain drug):
Site Assessment Frequency:
Page 10 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

GLUCOSE, POC [GLUCPOC] ONCE For 1 Occurrences, Routine
If Conditional, What Condition?
Contingency Parameters [150044]
Notify [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 110
If diastolic blood pressure < (mmHg): 50
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%): 88
If urine output < (mL):
Other:
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 within 1 minute. Choice of medication should be based on patient’s previous
experience/preference, history of lidocaine allergy and ease of access.
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
lidocaine (XYLOCAINE) 1% injection [39034] 0.1-0.4 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. Choice of medication should be based on
patient’s previous experience/preference, history of
lidocaine allergy and ease of access
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. Choice of medication should be based on
patient’s previous experience/preference, history of
lidocaine allergy and ease of access
Page 11 of 15
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Medications
Analgesics - Acetaminophen - PRN [221197]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain,
temperature greater than 38.5 degrees C or pain
For mild to moderate pain.
No more than 3 grams acetaminophen per 24 hours.
Analgesics - Opioids - Oral - PRN (Single Response) [151998]
oxycodone-acetaminophen (PERCOCET) 5-325
MG per tab [750033]
1-2 tab, Oral, EVERY 4 HOURS PRN, pain
For severe pain.
No more than 3 grams acetaminophen per 24 hours.
oxycodone tab [750032] 5-10 mg, Oral, EVERY 4 HOURS PRN, pain
For severe pain
Analgesics - Opioids - Oral - Scheduled (Single Response) [150045]
MORPHine (MS CONTIN, ORAMORPH) ER tab
[156572]
15 mg, Oral, 2 X DAILY, Post-Op/Phase II
MORPHine (MS CONTIN, ORAMORPH) ER tab
[156572]
30 mg, Oral, 2 X DAILY, Post-Op/Phase II
Analgesics - Other [219668]
gabapentin (NEURONTIN) cap [54258] Oral, 3 X DAILY
Bowel Management [150046]
senna-docusate (SENOKOT-S) 8.6-50 mg per
tab [60530]
2 tab, Oral, 2 X DAILY
Hold for loose stool or suspected obstruction.
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY PRN, constipation
Hold for loose stool or suspected obstruction. Use as
first line rescue therapy if inadequate response to
scheduled bowel management.
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation
Hold for loose stool. Use as second line rescue
therapy if no response to first line rescue therapy
within 24 hours and notify Primary Team.
Hypnotics [219357]
traZODONE (DESYREL) tab [720150] 25 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see IPOC supplemental Sleep/Rest
Disturbance Adult)
Laboratory
Draw Next AM [150029]
CBC WITH DIFFERENTIAL [CBC] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR [PT] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] NEXT AM, 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] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 12 of 15
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CREATININE [CRET] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GLUCOSE [GLU] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM [CA] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALBUMIN [ALB] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALKALINE PHOSPHATASE [ALKP] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
AST/SGOT [AST] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] NEXT AM, 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?
PREALBUMIN [XPRALB] NEXT AM, 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?
Conditional Labs [151079]
GLUCOSE [GLU] CONDITIONAL - RN COLLECT, Starting today,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw STAT as
needed for blood glucose (bedside) less than 40 or
greater than 400 mg/dL
Consults
Consults [150030]
Consult Physical Therapy (Inpatient) Eval and
Treat [CON0061]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Physical Therapy Consult: Mobility
Training
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult: ADL
Training
Page 13 of 15
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05/2017CCKM@uwhealth.org

Consult Speech Therapy (Inpatient) Eval and
Treat [CON0077]
ONCE, Starting today For 1 Occurrences, Routine
Patient Type: Adult
Reason for Speech Therapy Consult: Other (Please
provide evaluation and treatment for communication,
cognition and dysphagia as indicated)
Consult Therapeutic Recreation (Inpatient)
[CON0080]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Evaluate and Treat
Behavioral Health Consults (select below)
[132899]
amp, transplant), - adjustment, protocol (eg. burn, trauma, rehab, pre-Psychology Health
noncompliance, grief, pain
Addictive Disorders - alcohol or drug related problems (eg. treatment recommendations,
withdrawal mgmt)
Psychiatry - safety, agitation, capacity, med mgmt, psychotropic SE
ACE - 60 and older - delirium, dementia, depression, decisional capacity, sleep (also for non-
behavioral geriatric syndromes; overall geriatric evaluation, mobility/falls, functional decline,
social/caregiver issues, disposition, medication management)
Consult Health Psychology (Inpatient)
[CON0033]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-
Friday) or if special assessment needs.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Addictive Disorders (Inpatient)
[CON0003]
ONCE, Routine, This order is for ADULT patients.
Please use the Consult Adolescent/Pediatric AODA
Counselor order for adolescent/pediatric patients
instead.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
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?
Consult Vocational Services (Inpatient)
[CON0085]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Other (Comment)
Evaluate and treat.
Consult Nutrition (Inpatient) [CON0043] ONCE, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Can this consult be done via video?
Consult Wound And Skin Care Service
(Inpatient) [CON0086]
ONCE, Routine
Reason for Consult:
Can this consult be done via video?
BestPractice
Page 14 of 15
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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 15 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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05/2017CCKM@uwhealth.org