/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-98028-en.cckm

201712341

page

100

UWHC,UWMF,

Tools,

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

IP - Cystic Fibrosis - Adult - Admission [1616]

IP - Cystic Fibrosis - Adult - Admission [1616] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Pulmonary


IP - Cystic Fibrosis - Adult - Admission [1616]
for Adult Patients OnlyIntended
Admission Status
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 (Single Response) [82665]
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:
Page 1 of 15
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12/2017CCKM@uwhealth.org

Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [211005]
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: Acute Pulmonary
Exacerbation of Cystic Fibrosis
E - EVALUATIONS PLANNED: Cultures, Chest
X-Ray, Labs
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED: IV Antibiotics
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Discharge Status [209458]
Anticipated Discharge Date [ADT0016] Anticipated Discharge Date:
Isolation Status
If patient requires isolation, please search for isolation in the additional orders section below.
Isolation [198364]
Isolation - Contact - Cystic Fibrosis Patients
Without Pulmonary Exacerbation - Panel
[196683]
Contact/Droplet Isolation - Cystic Fibrosis with
MDRO or Exacerbation [ISO0339]
Details
Isolation - Contact And Droplet - Cystic Fibrosis
Pulmonary Exacerbation - Panel [116334]
Contact/Droplet Isolation - Cystic Fibrosis with
MDRO or Exacerbation [ISO0339]
Details
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
Page 2 of 15
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12/2017CCKM@uwhealth.org

High VTE Risk with Low Bleed Risk (Single
Response) [129777]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 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 subcutaneous injection [800290] 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:
Patient Care Orders
Vital Signs [22442]
Vital Signs [NURMON0013] DAILY, Starting today with First Occurrence Include
Now, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Activity [22443]
Page 3 of 15
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Ad Lib [NURACT0008] CONTINUOUS For Until specified, Routine
AD LIB: ad lib
AMBULATE:
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 [22444]
Patient Approved for Additional Menu Items
[NURDIE0013]
CONTINUOUS
Patient may order food items from UWHC café or
Mendota Market? Yes
Patient may order regular soda or other sugar-
sweetened beverages? Yes
High Calorie & High Protein Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Miscellaneous
Miscellaneous: High Protein/High Calorie
Bedside Meal Instructions:
Room Service Class:
Procedure Site Care [22445]
Maintain Central Implanted Port [NURVAD0005] CONTINUOUS, Starting today, Routine
Device Status:
Type:
Site:
Change needle every 7 days.
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:
heparin 100 UNIT/ML lock flush injection [64978] 500 units, Flush, ONCE PRN For 1 Doses, flush/line
care
Deaccessing port prior to discharge.
Respiratory [22446]
Pulse Oximetry [NURMON0009] DAILY, Starting today with First Occurrence Include
Now, Routine
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?
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Respiratory Therapy to Assess for Self-
Administration of Metered Dose Inhalers
[RT0073]
ONCE, Starting today For 1 Occurrences, Routine
Page 4 of 15
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12/2017CCKM@uwhealth.org

Pulmonary Lab Testing - Spirometry [999992] ONCE, Starting today For 1 Occurrences, Routine
Reason for Exam: Spirometry in PF Lab on admission
for CF Exacerbation
Specify Test: Spirometry
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
Non-Categorized Patient Care Orders [22448]
Measure Weight [NURMON0015] EVERY 2 DAYS, Starting today, Routine
Weigh With? Portable Scale
Weigh when?
Starting on admission. Weigh patient standing.
Maintain Gastrostomy Tube [NURTAD0007] CONTINUOUS, Routine
Tube Indications: Medication Administration
Flush With: Water
Flush Volume (mL):
Flush Frequency:
Site Assessment Frequency:
Care Frequency:
Wash With:
Primary Dressing:
Secondary Dressing:
Contingency Parameters [22449]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 170
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 100
If diastolic blood pressure < (mmHg): 45
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): 130
If heart rate < (bpm): 50
If respiratory rate >: 30
If respiratory rate <: 8
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Hemoptysis
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.
Page 5 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

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.
Anti-infectives - Antipseudomonal
2 antibiotics from different classesSelect
Beta-lactams (prolonged infusion) - must select this option if using tobramyicn Q24hr dosing regardless
of previous MIC [120512]
Adult Cystic Fibrosis - Cefepime Prolonged
Infusion [235328]
cefepime (MAXIPIME) in dextrose 5 % 50 mL
bag [700167]
2 g, Intravenous, EVERY 8 HOURS
Administer over 4 hours
Note: Run cefepime (MAXIPIME) over 4 hours
[950056]
EVERY 8 HOURS
Adult Cystic Fibrosis - Meropenem Prolonged
Infusion [235330]
meropenem 10 mg/mL in sodium chloride 0.9%
(MERREM) injection [755108]
2,000 mg, Intravenous, EVERY 8 HOURS For 96
Hours, for 3 Hours
Note: Run meropenem (MERREM) over 3 hours
[950049]
EVERY 8 HOURS
Adult Cystic Fibrosis - Piperacillin/Tazobactam
Prolonged Infusion [235332]
piperacillin-tazobactam (ZOSYN) 4.5 g vial +
minibag [54251]
4.5 g, Intravenous, EVERY 6 HOURS, for 3 Hours
Note: Run piperacillin-tazobactam (ZOSYN) over
3 hours [950018]
EVERY 6 HOURS
Fluoroquinolones [23053]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, EVERY 12 HOURS
Aminoglycosides [23054]
tobramycin (NEBCIN) intraVENOUS - NOTE: Per
previous admission, contact D6/5 pharmacist
[800081]
10 mg/kg, Intravenous, EVERY 24 HOURS
Adult Cystic Fibrosis dosing only. Pharmacist to adjust
initial order based on dose (mg) and interval (hours)
used during prior admission. If no history of
tobramycin use, initiate with 10 mg/kg IV every 24
hours (infused over 60 minutes) based on Ideal Body
Weight (or actual body weight if less than ideal). Do
not exceed an initial dose of 700mg.
Probiotic [200227]
-therapeutic broadconsider the use of probiotics in immunocompetent patients receiving Please
-4th generation cephalosporins, betaspectrum antibiotics, such as fluoroquinolones, 3rd and
diarrhea clindamycin to prevent antibiotic associated lactamase inhibitors, and -lactam/beta
lactobacillus rhamnosus GG (CULTURELLE) cap
[152674]
1 cap, Oral, 1 X DAILY
Anti-infectives - Methicillin-resistant Staphylococcus Aureus (MRSA)
Methicillin-resistant Staphylococcus Aureus (MRSA) Coverage [23064]
Page 6 of 15
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vancomycin (VANCOCIN) in dextrose 5 % 250
mL bag [700516]
15 mg/kg, Intravenous, EVERY 12 HOURS
linezolid (ZYVOX) tab [64770] 600 mg, Oral, EVERY 12 HOURS For 96 Hours
Medications
Corticosteroids, Inhaled [23057]
Patient May Keep Metered Dose Inhalers At
Bedside [NURCOM0022]
CONTINUOUS, Starting today
fluticasone (FLONASE) 50 mcg/act nasal spray
[112183]
2 spray, Nostril (Each), 1 X DAILY
Mucolytics [23059]
sodium chloride (HYPERSAL) 7% neb soln
[118873]
4 mL, Nebulization, RT 2 X DAILY
Pancreatic Enzyme Note Orders [215157]
Note: RPh Patient may self-administer pancreatic
enzymes [950018]
ONCE For 1 Doses
RPh: Patient may self-administer pancreatic enzymes
Note: RPh Patient may use home supply of
pancreatic enzymes if available [950018]
ONCE For 1 Doses
RPh: Patient may use home supply of pancreatic
enzymes if available
Administer Pancrelipase PRN meal dosing with all
MEALS (recommended 3x/day). Administer
Pancrelipase PRN snack dosing with all
SNACKS. [NURCOM0022]
CONTINUOUS
Pancreatic Enzymes (Single Response) [215052]
pancrelipase (CREON 6000) EC cap [218188]
pancrelipase (CREON) 6000 units delayed
release cap [136487]
Oral, 3 X DAILY PRN, meals
pancrelipase (CREON) 6000 units delayed
release cap [136487]
Oral, PRN, snacks
pancrelipase (CREON 12000) EC cap [218189]
pancrelipase (CREON) 12000 units delayed
release cap [136488]
Oral, 3 X DAILY PRN, meals
pancrelipase (CREON) 12000 units delayed
release cap [136488]
Oral, PRN, snacks
pancrelipase (CREON 240000) EC cap [218190]
pancrelipase (CREON) 24000 units delayed
release cap [136489]
Oral, 3 X DAILY PRN, meals
pancrelipase (CREON) 24000 units delayed
release cap [136489]
Oral, PRN, meals
pancrelipase (ZENPEP) 5000 UNITS EC cap
[218191]
pancrelipase (ZENPEP) 5000 units delayed
release cap [138296]
Oral, 3 X DAILY PRN, meals
pancrelipase (ZENPEP) 5000 units delayed
release cap [138296]
Oral, PRN, snacks
pancrelipase (ZENPEP) 10000 UNITS EC cap
[218192]
pancrelipase (ZENPEP) 10000 units delayed
release cap [138297]
Oral, 3 X DAILY PRN, meals
pancrelipase (ZENPEP) 10000 units delayed
release cap [138297]
Oral, PRN
pancrelipase (ZENPEP) 15000 UNITS EC cap
[218193]
pancrelipase (ZENPEP) 15000 units delayed
release cap [138298]
Oral, 3 X DAILY PRN, meals
pancrelipase (ZENPEP) 15000 units delayed
release cap [138298]
Oral, PRN, snacks
Page 7 of 15
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12/2017CCKM@uwhealth.org

pancrelipase (ZENPEP) 20000 UNITS EC cap
[218194]
pancrelipase (ZENPEP) 20000 units delayed
release cap [138299]
Oral, 3 X DAILY PRN, meals
pancrelipase (ZENPEP) 20000 units delayed
release cap [138299]
Oral, PRN, snacks
Vitamins [23060]
multivitamin cystic fibrosis cap [800234] 2 cap, Oral, 1 X DAILY
multivitamin with mineral tab [800240] 2 tab, Oral, 1 X DAILY
tocopherol (VITAMIN E) cap [43715] Oral, 1 X DAILY
phytonadione (VITAMIN K1) soln [800250] 5 mg, Oral, 1 X DAILY
phytonadione (VITAMIN K1) soln [800250] Oral
ergocalciferol (VITAMIN D) 50000 units cap
[139104]
50,000 units, Oral, 1 X DAILY
ergocalciferol (VITAMIN D) 50000 units cap
[139104]
50,000 units, Oral, EVERY MON, WED, FRI
cholecalciferol (VITAMIN D-3) tab [720036] Oral, 1 X DAILY
vitamin A tab [141915] 15,000 units, Oral, 1 X DAILY
Gastric [23061]
pantoprazole (PROTONIX) delayed release tab
[62661]
40 mg, Oral, 1 X DAILY
famotidine (PEPCID) tab [45134] 20 mg, Oral, 1 X DAILY (HS)
Bowel Management [23062]
Adult - Bowel Management - Scheduled
[240446]
senna-docusate (SENOKOT S) 8.6-50 MG per
tab [60530]
2 tab, Oral, 2 X DAILY
Adult - Bowel Management - As Needed
[240448]
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
Analgesics [23063]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain, pain or
temperature greater than 38 degrees Celsius
See Pain Management Algorithm for the Selection of
As-Needed Analgesic
Laboratory
Labs [22450]
CBC WITH DIFFERENTIAL [CBC] NEXT DRAW, 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?
SODIUM [NA] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 8 of 15
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

POTASSIUM [K] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CHLORIDE [CL] NEXT DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CARBON DIOXIDE [CO2] NEXT DRAW 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 DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] NEXT DRAW 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 DRAW For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BLOOD GASES [HCBGAS] NEXT DRAW For 1 Occurrences, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GLUCOSE [GLU] NEXT DRAW, 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?
MAGNESIUM [MAG] NEXT DRAW, 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 DRAW, 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 DRAW, 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 DRAW, 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 9 of 15
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

GGT [GGT] NEXT DRAW, 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 DRAW, 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, NO MICROSCOPY [UACHEM] 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?
Page 10 of 15
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:47:27 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

VITAMIN D, 25-HYDROXY BY HPLC (Vitamin D
Status) [HCLCD25]
NEXT DRAW, Starting today For 1 Occurrences,
Routine, Screening for Vitamin D deficiency is not
covered by Medicare. If this is the reason for the test,
please advise the patient of non-coverage via the ABN
process. Coverage is allowed in some other
circumstances. If one of these diagnoses is
appropriate for your patient, please associate the
corresponding code with this order.
252.00 (ICD-9); E21.3 (ICD-10) Hyperparathyroidism,
unspecified
252.01 (ICD-9); E21.0 (ICD-10) Primary
Hyperparathyroidism
252.02 (ICD-9); E21.1 (ICD-10) Secondary
Hyperparathyroidism, Non-Renal
252.08 (ICD-9); E21.2 (ICD-10) Other
Hyperparathyroidism
252.1 (ICD-9); E20.9 (ICD-10) Hypoparathyroidism
268.0 (ICD-9); E55.0 (ICD-10) Rickets Active
268.2 (ICD-9); M83.9 (ICD-10) Osteomalacia
Unspecified
268.9 (ICD-9); E55.9 (ICD-10) Established Vitamin D
Deficiency (monitoring efficacy of replacement
therapy)
275.3 (ICD-9); E83.30 (ICD-10) Disorders of
Phosphorus Metabolism
275.41 (ICD-9); E83.51 (ICD-10) Hypocalcemia
275.42 (ICD-9); E83.52 (ICD-10) Hypercalcemia
585.3 (ICD-9); N18.3 (ICD-10) Chronic Kidney
Disease, Stage III (Moderate)
585.4 (ICD-9); N18.4 (ICD-10) Chronic Kidney
Disease, Stage IV (Severe)
585.5 (ICD-9); N18.5 (ICD-10) Chronic Kidney
Disease, Stage V
585.6 (ICD-9); N18.6 (ICD-10) End Stage Renal
Disease
588.81 (ICD-9); N25.81 (ICD-10) Secondary
Hyperparathyroidism (of Renal Origin)
733.00 (ICD-9); M81.0 (ICD-10) Osteoporosis
Unspecified
Page 11 of 15
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:47:27 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

733.01 (ICD-9); M81.0 (ICD-10) Senile Osteoporosis
733.02 (ICD-9); M81.8 (ICD-10) Idiopathic
Osteoporosis
733.03 (ICD-9); M81.8 (ICD-10) Disuse Osteoporosis
733.09 (ICD-9); M81.8 (ICD-10) Other Osteoporosis
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
IMMUNOGLOBULIN E [IGE] NEXT DRAW, 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?
VITAMIN A [HCVITA] NEXT DRAW, Starting today For 1 Occurrences,
Routine, Please advise patient to fast overnight for 12
hours, avoid alcohol for 12 hours, and refrain from
taking daily vitamins prior to blood draw.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
VITAMIN E [HCVITE] NEXT DRAW, Starting today For 1 Occurrences,
Routine, Please advise patient to fast overnight for 12
hours, avoid alcohol for 12 hours, and refrain from
taking daily vitamins prior to blood draw.
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 DRAW, 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?
HCG, QUALITATIVE, URINE [UPREG] 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?
Note: Tobramycin Level Per Pharmacy [950025] ONCE
Every 5 days if patient on Tobramycin [22452]
CREATININE [CRET] CONDITIONAL, Starting today For 4 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? If patient on
Tobramycin
Microbiology [22454]
CULTURE, SPUTUM, CF PATIENT, WITH
GRAM STAIN [HCCFCS]
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?
Cystic Fibrosis Patient.
Diagnostic Tests
Studies [22455]
Page 12 of 15
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:47:27 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

X-RAY CHEST PA & LAT VIEWS [R71020] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history? Cystic Fibrosis
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
BONE MINERAL DENSITY AXIAL (W
APPENDICULAR & VERTEBRAL FRACTURE
ASSESSMENT (VFA) (PRN) (BMD) [R07029]
ONCE-RAD NEXT AVAILABLE, Routine
Perform the Appendicular exam per protocol?
Perform the VFA exam per protocol?
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
Has the patient had a PET or Nuclear Medicine
procedure in last 48 hours or Radiology procedures
with contrast (oral and/or IV) within the last two
weeks?
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.
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
Consults
Consults [22456]
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, 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 Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: OTHER (Yearly evaluation (if
more than 1 year since last evaluation))
Consult Occupational Therapy (Inpatient) Eval
and Treat [CON0046]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Occupational Therapy Consult:
Diabetes Consult Order Panel (Adult) [188497]
Page 13 of 15
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:47:27 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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 14 of 15
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:47:27 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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?
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 15 of 15
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:47:27 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org