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/clinical/cckm-tools/content/order-sets/inpatient/pulmonary/name-113251-en.cckm

201709263

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UWHC,UWMF,

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

IP - Asthma - Pediatric - Discharge [5801]

IP - Asthma - Pediatric - Discharge [5801] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Pulmonary


IP - Asthma - Pediatric - Discharge [5801]
Patient Care Orders
Confirmed Discharge Date/Time [151653]
Confirmed Discharge Date/Time [ADT0013] Confirmed Discharge Date:
Confirmed Discharge Time:
Conditions for Discharge:
Provider to be Present at Discharge?
Reason For Hospitalization [195219]
patient admitted to ICU select life threatening If
Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, @FNAME@ was hospitalized for a
{UWIP ASTHMA REASON FOR
HOSPITALIZATION:3000200} asthma attack.
@CAPHIS@ care included albuterol, steroids, and
teaching about asthma.
Activity [195221]
Activity - Up As Tolerated [NURACT0008] Routine
Discharge Activity: Up As Tolerated
Nutrition [195222]
Diet - General (No Modifications) [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
Other Patient Care Instructions [195220]
Other Discharge Patient Care Instructions
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, Please continue albuterol every 4
hours for the next 48 hours. Please remain in the
yellow zone for the next *** days.
Smoking Cessation [195223]
Provide Patient Education - Quit Smoking
[NURCOM0025]
ONCE, Starting today For 1 Occurrences, Routine,
Provide patient with the following patient education:
3096
When to Call Your Doctor [195224]
patient is followed by allergy or pulmonary was consulted during the hospitalization OR if the If
questons should be directed to the allergist or allergy or pulmonary, then any asthma related
pulmonologist.
Page 1 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/19/2017 2:22:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

When to Call Your Doctor - PCP Managing
Asthma [NURCOM0079]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Please refer to your Asthma Action
Plan.
If @FNAME@ has any of the following or you have
general pediatric questions or concerns please call
your Primary Care Provider, @PCP@, at @PCPPH@.
- In yellow zone for longer than 5-7 days or per your
Asthma Action Plan
- If back in your green zone BUT using your albuterol
more than 2 times per week, please call your PCP.
- ***
If you cannot reach a provider and you have a serious
medical concern, call 911 or bring your child to the
nearest emergency department.
When to Call Your Doctor - Allergy/Pulmonary
Managing Asthma [NURCOM0079]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, If @FNAME@ has any of the
following please call the {UWIP PEDS
ALLERGY/PULMONARY CONTACT INFO:3003799}.
- In yellow zone for longer than *** days
- Back in green zone and using albuterol more than 2
times per week
- ***
For urgent asthma related concerns after 4:30 PM,
before 8 AM, or on weekends call 608-263-6400 and
ask for the pediatric {UWIP
ALLERGY/PULMONARY:300398} provider on call. If
you cannot reach a provider and you have a serious
medical concern, call 911 or bring your child to the
nearest emergency department.
For non-asthma related general pediatric concerns
please call @FNAME@'s Primary Care Provider,
@PCP@, at @PCPPH@.
Page 2 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/19/2017 2:22:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

When to Call Your Doctor - Subspecialties
[NURCOM0079]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Your child received care from a
pediatric subspecialist during their hospitalization. To
Contact a provider from the pediatric specialty team
Monday-Friday 8:00 a.m. to 4:30 p.m., use the phone
numbers listed below:
{subspecialty phone numbers:3022232}
For urgent subspecialist medica needs during
evenings and weekends, call 608-263-6400 and ask
for the Pediatric *** Provider on-call.
If you cannot reach a provider, and you have a serious
medical concern, call 911 or bring your child to the
nearest emergency department.
If when you are in your green zone and you require
your albuterol for more than 2 times per week, please
call your pulmonologist or allergist.
Medications
Systemic Steroids (Single Response) [195230]
burst is a total of 5 days, but may need a prolonged taper up to Recommended
Attending/Consultant
prednisolone (PRELONE) 15 MG/5ML syrup -
NOTE: Suggested dose 1-2mg/kg/day given 1-2
times per day (Maximum 30 mg/dose) [46299]
starting 9/19/17, Normal
prednisone (DELTASONE) 10 MG tab -
Suggested dose 1-2mg/kg/day given 1-2 times
per day (Maximum 30 mg/dose) [41278]
starting 9/19/17, Normal
prednisone (DELTASONE) 20 MG tab -
Suggested dose 1-2mg/kg/day given 1-2 times
per day (Maximum 30 mg/dose) [41280]
starting 9/19/17, Normal
prednisolone (ORAPRED ODT) 10 MG
disintegrating tab - NOTE: Order only if unable to
tolerate syrup. Suggested dose 1-2mg/kg/day
given 1-2 times per day (Maximum 30 mg/dose)
[115119]
starting 9/19/17, Normal
prednisolone (ORAPRED ODT) 15 MG
disintegrating tab - NOTE: Order only if unable to
tolerate syrup. Suggested dose 1-2mg/kg/day
given 1-2 times per day (Maximum 30 mg/dose)
[113825]
starting 9/19/17, Normal
prednisolone (ORAPRED ODT) 30 MG
disintegrating tab - NOTE: Order only if unable to
tolerate syrup. Suggested dose 1-2mg/kg/day
given 1-2 times per day (Maximum 30 mg/dose)
[115120]
starting 9/19/17, Normal
Corticosteroid Reason Not Ordered [COR0006] Normal, Routine, Qty-1
Corticosteroid Already Ordered [COR0082] Normal, Routine, Qty-1
Page 3 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/19/2017 2:22:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Rescue Medications [196238]
albuterol HFA 108 (90 BASE) MCG/ACT inhaler
[53730]
1 Inhaler, , starting 9/19/17, Normal
albuterol HFA (PROAIR HFA) 108 (90 BASE)
MCG/ACT inhaler [113635]
1 Inhaler, , starting 9/19/17, Normal
albuterol 1.25 MG/3ML neb soln [68326] starting 9/19/17, Normal
albuterol 2.5 mg/0.5 mL neb soln [34315] starting 9/19/17, Normal
albuterol (2.5 MG/3ML) 0.083% neb soln [34314] starting 9/19/17, Normal
ipratropium (ATROVENT HFA) 17 MCG/ACT
inhaler [107267]
1 Inhaler, , starting 9/19/17, Normal
ipratropium (ATROVENT) 0.02 % neb soln
[47883]
starting 9/19/17, Normal
Ipratropium-Albuterol (COMBIVENT RESPIMAT)
Inhaler [152615]
1 Inhaler, , starting 9/19/17, Normal
ipratropium-albuterol (DUO-NEB) 0.5-2.5 (3)
MG/3ML neb soln [67220]
starting 9/19/17, Normal
Inhaled Corticosteroids (ICS) [196239]
fluticasone HFA (FLOVENT HFA) 44 MCG/ACT
Inhaler [106425]
starting 9/19/17, Normal
fluticasone HFA (FLOVENT HFA) 110 MCG/ACT
Inhaler [106426]
starting 9/19/17, Normal
fluticasone HFA (FLOVENT HFA) 220 MCG/ACT
Inhaler [106427]
starting 9/19/17, Normal
budesonide (PULMICORT) 0.25 MG/2ML neb
susp [65363]
starting 9/19/17, Normal
budesonide (PULMICORT) 0.5 MG/2ML neb susp
[65364]
starting 9/19/17, Normal
beclomethasone (QVAR) 40 MCG/ACT inhaler
[65596]
starting 9/19/17, Normal
beclomethasone (QVAR) 80 MCG/ACT inhaler
[65597]
starting 9/19/17, Normal
Inhaled Corticosteroids (ICS) / Long Acting Muscarinic Antagonists (LAMA) [196240]
Mometasone Furo-Formoterol Fum 100-5
MCG/ACT inhaler [141893]
1 Inhaler, , starting 9/19/17, Normal
Mometasone Furo-Formoterol Fum 200-5
MCG/ACT inhaler [141894]
1 Inhaler, , starting 9/19/17, Normal
budesonide-formoterol (SYMBICORT) 80-4.5
MCG/ACT inhaler [117728]
1 Inhaler, , starting 9/19/17, Normal
budesonide-formoterol (SYMBICORT) 160-4.5
MCG/ACT inhaler [117729]
1 Inhaler, , starting 9/19/17, Normal
fluticasone-salmeterol (ADVAIR HFA) 45-21
MCG/ACT Inhaler [113962]
1 Inhaler, , starting 9/19/17, Normal
fluticasone-salmeterol (ADVAIR HFA) 115-21
MCG/ACT Inhaler [113963]
1 Inhaler, , starting 9/19/17, Normal
fluticasone-salmeterol (ADVAIR HFA) 230-21
MCG/ACT Inhaler [113964]
1 Inhaler, , starting 9/19/17, Normal
Long Acting Muscarinic Antagonists [196242]
tiotropium (SPIRIVA) 18 MCG inhalant cap
[75472]
30 cap, , starting 9/19/17, Normal
Tiotropium Bromide Monohydrate 2.5 MCG/ACT
AERS [165878]
1 Inhaler, , starting 9/19/17, Normal
Leukotriene Modifier [196241]
montelukast (SINGULAIR) 10 MG tab - NOTE:
Order for adolescents greater than or equal to 15
years [58729]
30 tab, , starting 9/19/17, Normal
Page 4 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/19/2017 2:22:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

montelukast (SINGULAIR) 4 MG chew tab -
NOTE: Order for children >= 2 to < 6 years
[63727]
30 tab, , starting 9/19/17, Normal
montelukast (SINGULAIR) 5 MG chew tab -
NOTE: Order for children >= 6 to < 15 years
[58730]
30 tab, , starting 9/19/17, Normal
montelukast (SINGULAIR) 4 MG oral packet -
NOTE: Order for children >= 1 to < 2 years
[73012]
30 each, , starting 9/19/17, Normal
Follow-Up Care
Follow-Up Appointments [195225]
days. 5 -patient should have a follow up appointment with their PCP in 2Every
followed by allergy or patient received an an allergy or pulmonary consult, or is already If
the respective subspecialty clinic. pulmonary, then also schedule an appointment with
and/or life threatening patient has had GREATER than 2 ED visits in the last year for asthma If
schedule an appointment to the Pediatric asthma exacerbation (e.g. PICU stay), then also
Clinic.Advanced Asthma
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Asthma/Hospitalization follow-up
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty:
Schedule Appointment with Allergy Clinic
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Asthma/Hospitalization Follow Up
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty: Allergy Clinic
Schedule Appointment with Pulmonary Clinic
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Asthma/Hospitalization Follow Up
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty: Pulmonary Clinic
Schedule Appointment with Pediatric Advanced
Asthma Clinic [NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty: Pediatric Advanced Asthma
Clinic
Follow Up Appointments - Diabetes (Single Response) [192678]
*** RESPONSE REQUIRED *** This order facilitates documentation (only) about follow-up
appointments for patients with diabetes. Scheduling an appointment before discharge with a
provider who will manage a patient’s diabetes care (e.g., primary care physician, endocrinologist,
etc.) is a Joint Commission requirement. Exclusions are allowed based upon patient situation
(e.g., discharge to a skilled nursing facility, patient refusal, etc.). Only select “Appointment
Scheduled” if an appointment has already been scheduled, and use the Schedule Appointment
order as needed to request assistance in scheduling
Page 5 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/19/2017 2:22:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

No appointment: Patient does not have diabetes
[COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
does not have diabetes
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Appointment scheduled (with provider who can
manage diabetes) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment scheduled
(with provider who can manage diabetes)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Appointment scheduled per patient report
(ENTER DATE IN COMMENTS) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment scheduled per
patient report (ENTER DATE IN COMMENTS)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 6 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/19/2017 2:22:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Appointment pending: patient discharged on
weekend; follow-up information provided
[COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment pending:
patient discharged on weekend; follow-up information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Free clinic information provided [COR0064] ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Free clinic information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
No appointment: Patient discharging to a facility
(e.g., skilled nursing facility, correctional facility,
etc.) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
discharging to a facility (e.g., skilled nursing facility,
correctional facility, etc.)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 7 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/19/2017 2:22:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

No appointment: Patient refusal [COR0064] ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
refusal
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is a
Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Discharge Labs [195226]
Page 8 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/19/2017 2:22:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Please use the table below to determine what type of order to use to place discharge lab
orders.
Discharge Labs Workflow URL: https://uconnect.wisc.edu/growth/training--
education/health-link/10-minutes/inpatient-
discharge-consult/resources/name-82993-en.file
Who is Responsible for the
Result?
Where Will Labs be
Completed?
What Order Should You
Use?
Current Attending Provider UW Health Lab Specific lab orders (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
(B)
Current Consulting Provider
UW Health Lab
Specific lab orders with
AUTHORIZING PROVIDER
CHANGED TO
CONSULTANT (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
and AUTHORIZING
PROVIDER CHANGED TO
CONSULTANT (B)
Another Provider
UW Health Lab
Recommended Discharge
Labs (C)
Non-UW Health Lab
Recommended Discharge
Labs (C)
(A) SPECIFIC LAB ORDERS:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have the labs completed at a
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient's care will be responsible for the
result, you must change the AUTHORIZING PROVIDER on the order to the CONSULTING
PROVIDER before signing the order. To do this, click the Providers button near the top of the
Review, Sign & Hold tab of the discharge navigator. Update the authorizing provider to the
consulting provider.
(B) SPECIFIC LAB ORDER WITH ORDER CLASS CHANGED TO OUTSIDE:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have labs completed at a NON-
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient’s care will be responsible for the
result, you must change the AUTHORIZING PROVIDER on the order to the CONSULTING
PROVIDER before signing the order. To do this, click the Providers button near the top of the
Review, Sign & Hold tab of the discharge navigator. Update the authorizing provider to the
consulting provider.
The patient will receive a paper order to take to the lab.
(C) RECOMMENDED DISCHARGE LABS:
This order should be used to recommend to another provider labs that a patient should have
completed after discharge. The provider designated in the 'Send Recommendations To' field is
responsible for PLACING the lab orders AND will be responsible for the RESULTS of any
ordered labs.
Page 9 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/19/2017 2:22:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org

Recommended Discharge Labs [NURCOM0075] Details
Page 10 of 10
Printed by WILLIAMS, HEATHER R [HRS0] at 9/19/2017 2:22:29 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2017CCKM@uwhealth.org