/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/pulmonary/,

/clinical/cckm-tools/content/order-sets/inpatient/pulmonary/name-98025-en.cckm

201706167

page

100

UWHC,UWMF,

Tools,

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

IP - COPD - Adult - Discharge [4184]

IP - COPD - Adult - Discharge [4184] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Pulmonary


IP - COPD - Adult - Discharge [4184]
Global Initiative for Chronic Obstructive Lung
Disease (2010 COPD Gold Guidelines)
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/respiratory/name-97739-
en.cckm
Skilled Nursing Facility Orders
This Patient is going to a skilled nursing facilty, directly below is a group of orders commonly
associated with this patient population. Please review the orders below and select the
appropriate ones for this patient. If this patient is not going to a SNF, contact Case Management
to update the discharge plan. Updating the discharge plan will remove this set of SNF orders from
the order set.
Skilled Nursing Facility Certification Statement [114940]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Certification Statement [118260]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Admit Order [114941]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Admit Order [118261]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Patient Care Orders [111713]
For dyspnea, Oxygen at 2 L/minute per nasal
canula; If this is an acute change for the patient
call PCP with assessment ASAP after oxygen is
started. Suction PRN to clear airways.
[NURCOM0022]
Routine
DME - Home Oxygen [1009468] Patient's O2 Requirements Assessed and Meets
Criteria for Home O2:
Delivery Device:
Equipment Needed:
Continuous (liters/min):
Continuous (FiO2):
With Activity (liters/min):
With Activity (FiO2):
With Sleep (liters/min):
With Sleep (FiO2):
Length of Need:
Vendor:
DME - CPAP [1009443] Formal Sleep Study Completed:
Diagnosis:
CPAP Pressure (cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Page 1 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 6/14/2017 3:35:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DME - BiPAP (S) [1009441] Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S):
Diagnosis:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
DME - BiPAP (S/T) [1009442] Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S/T):
Diagnosis:
Respiratory Rate:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessd and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Patient may self administer medication per RN
assessment [NURCOM0022]
Routine
Patient medications (per Skilled Nursing Facility
policy) may be left at bedside [NURCOM0022]
Routine
Facility Therapy Needs [113391]
Physical Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Occupational Therapy to Evaluate and Treat at
Next Facility [NURCOM0022]
Routine
Speech Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Communicable Diseases [111717]
State Law requires at least one of the following statements be checked for your patient. May check both
if applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have
any other clinically apparent communicable
diseases. [NURCOM0022]
Routine
Page 2 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 6/14/2017 3:35:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Communicable Diseases [118262]
State Law requires at least one of the following statements be checked for your patient. May check both
if applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have
any other clinically apparent communicable
diseases. [NURCOM0022]
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Analgesics [111708]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, 1 tab, 1, starting 6/14/17, No Print
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, 1 suppository, 1, starting 6/14/17, No Print
Blood Glucose Management [111710]
glucagon 1 mg injection kit [107799] 1 mg, 1 each, 1, starting 6/14/17, No Print
Glucose 40 % oral gel [118089] 10 g, 1 Tube, 1, starting 6/14/17, No Print
Nursing Communication [NURCOM0022] Routine, Notify {Notify for Blood Glucose:3004146} if
blood glucose is greater than 400 mg/dL or less than
40 mg/dL
Diabetes Care Instructions [NURCOM0112] Routine, - Patient's blood glucose goal range before
meals is *** mg/dL.
- Monitor patient's blood glucose {Glucose Monitoring
Frequency:25242}.
- If your patient's blood glucoses are uncontrolled
contact provider.
- "Uncontrolled" blood glucoses mean:
* Blood glucose above 150 mg/dL more than half the
time during a week.
* Blood glucose over *** mg/dL.
* Blood glucose less than 70 mg/dL two or more times
per week (or if having signs/symptoms of low blood
glucose such as shaking, sweating, or light-
headedness).
Bowel Management [111709]
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, 1 suppository, 1, starting 6/14/17, No Print
Senna-Docusate Sodium 8.6-50 MG per tab
[70181]
1-2 tab, 1 tab, 1, starting 6/14/17, No Print
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, 1 Bottle, 1, starting 6/14/17, No Print
polyethylene glycol (MIRALAX) oral powder
[61353]
17 g, 1 Bottle, 1, starting 6/14/17, No Print
Non-categorized Medications [111711]
guaifenesin-dextroMETHORPHAN
(ROBITUSSIN DM) syrup [51568]
10 mL, 1 Bottle, 1, starting 6/14/17, No Print
carbamide peroxide (DEBROX) 6.5% otic soln
[35545]
3 drop, 1 Bottle, 1, starting 6/14/17 until 6/19/17, No
Print
Page 3 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 6/14/2017 3:35:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

alum-mag-simeth (MYLANTA ES) susp [44073] 30 mL, 1 Bottle, 1, starting 6/14/17, No Print
Discharge 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 Hospitlization [130085]
Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Activity [112339]
Activity [NURACT0008] Routine
Discharge Activity: Up As Tolerated
Nutrition [112340]
Low-fat, Low Sodium, Low Cholesterol
[NUT8888]
Routine
General:
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid:
Esophagectomy:
Fat Controlled: Low Fat
Fiber:
Fluid Restriction:
Heart Healthy:
Metabolic:
Renal:
Sodium Controlled: NAS
NPO:
Low Cholesterol
Diet - General (No Modifications) [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
Diabetes Diet [NUT8888] Routine
General:
Diet Modifications: Diabetes
Other Diet Modifications:
Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
Respiratory [112343]
If a patient is going home on O2, they need to have documentation of a SPO2 of 88% at rest, with activity,
or with sleep within 48 hours of discharge. If a patient is going to a SNF then this is not necessary.
DME - Home Oxygen [142943]
Page 4 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 6/14/2017 3:35:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Both of the following orders MUST be completed in order for this DME to be delivered to the
patient.
-CNS has a facereimbursement requirements in 2013 require that a physician, PA, NP, or New
durable medical equipment (DME). It face encounter with a patient prior to ordering certain -to
face -to-provided with the documentation of the facealso requires that the DME supplier be
order prior to delivery of the DME.encounter and a signed
National Coverage Determination for Home Use
of Oxygen (See section D for qualifying
diagnoses)
URL: http://www.cms.gov/medicare-coverage-
database/details/ncd-details.aspx?
NCDId=169&ncdver=1&bc=AgAAQAAAAAAAAA%
3d%3d&
DME - Home Oxygen [1009468] Patient's O2 Requirements Assessed and Meets
Criteria for Home O2:
Delivery Device:
Equipment Needed:
Continuous (liters/min):
Continuous (FiO2):
With Activity (liters/min):
With Activity (FiO2):
With Sleep (liters/min):
With Sleep (FiO2):
Length of Need:
Vendor:
DME - Home Oxygen Justification [1009463] Details
Pulmonary Lab Testing [PFT5068] Routine
Wound Care [112351]
Wound Care [NURWND0015] Routine
Bowel Care [123367]
Bowel Care [NURELM0068] Routine
Bladder Care [123366]
Bladder Care [NURELM0067] Routine
Other Patient Care Instructions [123384]
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
When to Call Your Doctor [130086]
When to Call Your Doctor [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, Reasons to call:***
Who to call:***
Heart Failure Recommended Care
These order groups are showing because either your patient has an EF < 40% documented or
has Heart Failure on their problem list.
UW Health HF guideline URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/cardiovascular/name-97485-
en.cckm
Page 5 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 6/14/2017 3:35:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Heart Failure Discharge Instructions [190359]
Weigh yourself daily or as directed
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
When to Call Your Doctor [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, Call your doctor if you have any of
these symptoms as they may indicate worsening
Heart Failure:
- Increased shortness of breath
- Cough or chest congestion
- Swelling in your abdomen or legs
- Any increase or decrease in weight of more than 3
pounds in a day or 5 pounds total
If you do not have a scheduled return
appointment, please schedule an appointment
with your primary physician [NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Core Measure Documentation - ACE Inhibitor/ARB (Single Response) [150651]
Core Measures - This Does NOT Generate A Medication Order (Use Med Reconciliation To
Prescribe Medications)
ACE Inhibitor/ARB Reason Not Ordered
[COR0001]
ONCE, Starting today For 1 Occurrences, Routine
Reason Not Ordered:
ACE Inhibitor/ARB Already Ordered [COR0001] ONCE, Starting today For 1 Occurrences, Routine
Reason Not Ordered: Other (Comments required for
not ordering BOTH an ACEI and an ARB)
Medications
monotherapy should not be used as monotherapy for treatment of COPD. Furthermore, ICS
preferred to LABA/ICS. ICS with LAMA or combination therapy with LABA/LAMA are generally
LAMA/LABA for those patients with persistent on therapy to -may be considered as add
exacerbations.symptoms and/or further
Inhaled Bronchodilators [112274]
albuterol HFA (VENTOLIN HFA) 90 mcg/act
inhaler [53730]
2 puff, 1 Inhaler, 6, starting 6/14/17, Normal
salmeterol (SEREVENT) 50 mcg/act inhaler
[64793]
1 puff, 1 each, 6, starting 6/14/17, Normal
Inhaled Combinations [112277]
fluticasone-salmeterol (ADVAIR DISKUS) 100-50
mcg/dose inhaler [62984]
1 puff, 1 each, 6, starting 6/14/17, Normal
fluticasone-salmeterol (ADVAIR DISKUS) 250-50
mcg/dose inhaler [62985]
1 puff, 1 each, 6, starting 6/14/17, Normal
fluticasone-salmeterol (ADVAIR DISKUS) 500-50
mcg/dose inhaler [62986]
1 puff, 1 each, 6, starting 6/14/17, Normal
fluticasone-salmeterol (ADVAIR HFA) 45-21
mcg/dose inhaler [113962]
2 puff, 1 Inhaler, 6, starting 6/14/17, Normal
fluticasone-salmeterol (ADVAIR HFA) 115-21
mcg/dose inhaler [113963]
2 puff, 1 Inhaler, 6, starting 6/14/17, Normal
fluticasone-salmeterol (ADVAIR HFA) 230-21
mcg/dose inhaler [113964]
2 puff, 1 Inhaler, 6, starting 6/14/17, Normal
Page 6 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 6/14/2017 3:35:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

budesonide-formoterol (SYMBICORT) 80-4.5
MCG/ACT inhaler [117728]
2 puff, 1 Inhaler, 6, starting 6/14/17, Normal
budesonide-formoterol (SYMBICORT) 160-4.5
MCG/ACT inhaler [117729]
2 puff, 1 Inhaler, 6, starting 6/14/17, Normal
Oral Steroids [112279]
prednisone (DELTASONE) 20 mg tab [41280] 20 mg, starting 6/14/17, Normal
Smoking Cessation [113146]
information:Prescribing
PatchesNicotine
followed by smoking >10 cigarettes/day: Begin with step 1 (21 mg/day) for 6 weeks, Patients
for 2 weeksstep 2 (14 mg/day) for 2 weeks; finish with step 3 (7 mg/day)
Patients smoking less than or equal to 10 cigarettes/day: Begin with step 2 (14 mg/day) for 6
weeks, followed by step 3 (7 mg/day) for 2 weeks. Therapy treatment is 8 weeks
Bupropion
Therapy duration 12 weeks. Dosing is 150mg qday for 3 days then 150mg BID thereafter.
Consider inpatient vs outpatient beginning of treatment date when choosing dosing.
Varenicline
is 12 weeks totalTherapy
nicotine (NICOTROL) 7 mg 24 hr patch - 1x/d
[64389]
7 mg, 30 patch, 1, starting 6/14/17, Normal
nicotine (NICOTROL) 14 mg 24hr patch - 1x/d
[64391]
14 mg, 30 patch, 1, starting 6/14/17, Normal
nicotine (NICOTROL) 21 mg 24 hr patch - 1x/d
[64392]
21 mg, 30 patch, 1, starting 6/14/17, Normal
nicotine polacrilex (NICORETTE) 2 mg gum -
PRN [45872]
1 each, 3, starting 6/14/17, Normal
nicotine polacrilex (NICORETTE) 4 MG chewing
gum - PRN [45873]
1 each, 3, starting 6/14/17, Normal
bupropion (ZYBAN) 150 mg 12hr ER tab - 2x/d
[74471]
150 mg, 60 tab, 2, starting 6/14/17, Normal
varenicline (CHANTIX STARTING PAK) 0.5 MG
X 11 & 1 MG X 42 oral kit [113264]
1 each, 0, starting 6/14/17, Normal
varenicline (CHANTIX) 1 mg tab - 2x/d [113263] 1 mg, 60 tab, 2, starting 6/14/17, Normal
Follow-Up Care
Follow-Up Appointments - Ambulatory [112346]
Schedule Appointment With UWH Pulmonary
Rehabilitation [NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: UWH Pulmonary
Rehabilitation
Page 7 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 6/14/2017 3:35:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Referral Cardiac Rehab (Outpatient) [CON0174] All patients being discharged from UWHC IP CVM
with the following diagnoses should receive a referral
to cardiac rehab: Acute Myocardial Infarction (i.e. all
STEMI or NSTEMI patients), Stable Angina, Coronary
Artery Bypass Surgery, Valve Surgery (repair or
replacement), Percutaneous Coronary Angioplasty or
Stenting, or Heart Transplant, or Stable Congestive
Heart Failure.
Typically, outpatient cardiac rehab follow-up
appointments occur 3-4 weeks post-hospitalization.
Inpatient Preventive Cardiology staff clinicians will
refer and make arrangements for the patient. If you
have further questions, you may call them at 263-
6630.
Routine
Has this patient been seen by inpatient Cardiac
Rehab/Preventive Cardiology during this encounter?
Schedule Appointment With Physicial Therapy
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Physical Therapy
Schedule Appointment with Occupational
Therapy [NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Occupational Therapy
Schedule Appointment With Speech Therapy
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Speech Therapy
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Patient to Schedule Appointment
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Which Provider:
Follow Up Appointments - Diabetes (Single Response) [148552]
*** 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 8 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 6/14/2017 3:35:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@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 9 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 6/14/2017 3:35:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@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 10 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 6/14/2017 3:35:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@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.
Facility Therapy Needs [112356]
Continue Respiratory Therapy at Next Facility
[NURCOM0022]
Routine
Continue Physical Therapy at Next Facility
[NURCOM0022]
Routine
Continue Occupational Therapy at Next Facility
[NURCOM0022]
Routine
Continue Speech Therapy at Next Facility
[NURCOM0022]
Routine
Discharge Labs [134929]
Page 11 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 6/14/2017 3:35:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@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
Recommended Discharge Labs [NURCOM0075] Details
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 12 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 6/14/2017 3:35:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Laboratory [112347]
Consulting Provider lab orders should only be used if the current Attending Provider or These
lab.will be responsible for the result of the
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:10/14/17 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:7/16/18 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:10/14/17 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:10/14/17 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:7/16/18 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:10/14/17 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:10/14/17 MANUAL,Count:1,
Normal, Routine
BILIRUBIN, TOTAL [TBIL] Status: Standing, Expires:10/14/17 MANUAL,Count:1,
Normal, Routine
PROTEIN, TOTAL [TP] Status: Standing, Expires:10/14/17 MANUAL,Count:1,
Normal, Routine
ALBUMIN [ALB] Status: Standing, Expires:10/14/17 MANUAL,Count:1,
Normal, Routine
ALKALINE PHOSPHATASE [ALKP] Status: Standing, Expires:10/14/17 MANUAL,Count:1,
Normal, Routine
AST/SGOT [AST] Status: Standing, Expires:7/16/18 MANUAL,Count:1,
Normal, Routine
ALT/SGPT [ALT] Status: Standing, Expires:7/16/18 MANUAL,Count:1,
Normal, Routine
Diagnostic Tests and Imaging [112544]
X-RAY CHEST PA & LAT VIEWS [R71020] Status: Future, Expires: 8/14/18, Normal, Routine
SNF/Home Care
Lines/Drains/Airway [112545]
PICC Line Maintenance [NURCOM0022] Routine
Communication Aids [112546]
Hearing Aid [DC0005] Routine
Type (Each Vendor Requires a Separate Order):
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Diagnosis:
Medical Equipment [112549]
DME - Nebulizer Unit [143701]
Both of the following orders MUST be completed in order for this DME to be delivered to the
patient.
-CNS has a facereimbursement requirements in 2013 require that a physician, PA, NP, or New
durable medical equipment (DME). It face encounter with a patient prior to ordering certain -to
face -to-provided with the documentation of the facealso requires that the DME supplier be
order prior to delivery of the DME.encounter and a signed
Page 13 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 6/14/2017 3:35:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

DME - Nebulizer Unit [1009444] Patient has met specific criteria for coverage:
Diagnosis:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Length of Need:
DME - Nebulizer Administration Set [1009497] Internal referral, Routine, Qty-1
DME - Nebulizer Unit Justification [1009456] Details
Contingency Parameters [112550]
Call PCP if O2 Saturation is Less Than 88%
[NURCOM0001]
Routine
Call PCP if SBP is Greater Than 150 or Less
than 90 [NURCOM0001]
Routine
Call PCP if DBP is Greater Than 95 or Less Than
50 [NURCOM0001]
Routine
Call PCP if Pulse is Greater Than 110 or Less
Than 50 [NURCOM0001]
Routine
Call PCP if Temp is Greater Than 38 Degrees
Celcius [NURCOM0001]
Routine
Page 14 of 14
Printed by WILLIAMS, HEATHER R [HRS0] at 6/14/2017 3:35:03 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org