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/clinical/cckm-tools/content/order-sets/inpatient/transplant/name-97898-en.cckm

20170241

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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,Transplant

IP - Abdominal Transplant - Medical - Adult - Discharge [4913]

IP - Abdominal Transplant - Medical - Adult - Discharge [4913] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Transplant


IP - Abdominal Transplant - Medical - Adult - Discharge [4913]
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 15
Printed by STRAKA, KEVIN F [KFS1] at 2/6/2017 4:56:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@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 15
Printed by STRAKA, KEVIN F [KFS1] at 2/6/2017 4:56:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@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 2/6/17, No Print
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, 1 suppository, 1, starting 2/6/17, No Print
Blood Glucose Management [111710]
glucagon 1 mg injection kit [107799] 1 mg, 1 each, 1, starting 2/6/17, No Print
Glucose 40 % oral gel [118089] 10 g, 1 Tube, 1, starting 2/6/17, 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 2/6/17, No Print
Senna-Docusate Sodium 8.6-50 MG per tab
[70181]
1-2 tab, 1 tab, 1, starting 2/6/17, No Print
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, 1 Bottle, 1, starting 2/6/17, No Print
polyethylene glycol (MIRALAX) oral powder
[61353]
17 g, 1 Bottle, 1, starting 2/6/17, No Print
Non-categorized Medications [111711]
guaifenesin-dextroMETHORPHAN
(ROBITUSSIN DM) syrup [51568]
10 mL, 1 Bottle, 1, starting 2/6/17, No Print
carbamide peroxide (DEBROX) 6.5% otic soln
[35545]
3 drop, 1 Bottle, 1, starting 2/6/17 until 2/11/17, No
Print
Page 3 of 15
Printed by STRAKA, KEVIN F [KFS1] at 2/6/2017 4:56:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

alum-mag-simeth (MYLANTA ES) susp [44073] 30 mL, 1 Bottle, 1, starting 2/6/17, No Print
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 [129829]
Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Vital Signs [119672]
Measure Weight [NURMON0015] Routine
Frequency: Daily
Call your Transplant Coordinator if your weight
increases by 3 pounds in one day or 5 pounds (total)
in one week.
Measure Blood Pressure and Pulse
[NURMON0019]
Routine, Measure and record blood pressure and
pulse two times each day and alert Transplant
Coordinator if systolic blood pressure (top number) is
greater than 180, and diastolic blood pressure
(bottom number) is greater than 90.
Measure Temperature [NURMON0015] Routine
Frequency: Daily
Measure temperature daily. Call your Transplant
Coordinator if your temperature is greater than 100.5
degrees F
Monitor Blood Glucose (for Diabetic Patients)
[NURMON0060]
Routine, 4 times daily. Call Diabetes Management
Service at (608) 263-2416 if blood sugar is greater
than 400 mg/dL.
Monitor Blood Glucose (for Pancreas Transplant
Patients) [NURMON0060]
Routine, Monitor before all meals and at bedtime.
Record values. Alert your Transplant Coordinator if
any blood sugars are greater than 200 mg/dL.
Measure Blood Pressure and Pulse [219227]
For Pancreas and Liver Transplant Patients
(Single Response) [219226]
Measure Blood Pressure and Pulse
[NURMON0019]
Routine
For Kidney Transplant Patients (Single
Response) [219228]
Measure Blood Pressure and Pulse
[NURMON0019]
Routine, Measure and record blood pressure and
pulse two times each day and alert Transplant
Coordinator if systolic blood pressure (top number)
is greater than 180, and diastolic blood pressure
(bottom number) is greater than 90.
Activity [105675]
Activity No New Restrictions [NURACT0008] Routine
Discharge Activity:
Return to Work - [DC0014] Routine
Return to Work:
Other Restrictions [NURACT0011] Routine
Nutrition [119657]
Page 4 of 15
Printed by STRAKA, KEVIN F [KFS1] at 2/6/2017 4:56:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

General Diet [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
For patients taking tacrolimus, cyclosporine, sirolimus
or everolimus avoid grapefruit and grapefruit juice.
Heart Healthy Diet [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:
Tube Feeding:
Low Cholesterol
For patients taking tacrolimus, cyclosporine, sirolimus
or everolimus avoid grapefruit and grapefruit juice.
Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications:
For patients taking tacrolimus, cyclosporine, sirolimus
or everolimus avoid grapefruit and grapefruit juice.
Diet - Low Sodium [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid:
Esophagectomy:
Fat Controlled:
Fiber:
Fluid Restriction:
Heart Healthy:
Metabolic:
Renal:
Sodium Controlled: NAS
NPO:
Tube Feeding:
For patients taking tacrolimus, cyclosporine, sirolimus
or everolimus avoid grapefruit and grapefruit juice.
Page 5 of 15
Printed by STRAKA, KEVIN F [KFS1] at 2/6/2017 4:56:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Diabetes Diet [NUT8888] Routine
General:
Diet Modifications: Diabetes
Other Diet Modifications:
For patients taking tacrolimus, cyclosporine, sirolimus
or everolimus avoid grapefruit and grapefruit juice.
Renal with Hemodialysis Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid:
Esophagectomy:
Fat Controlled:
Fiber:
Fluid Restriction:
Heart Healthy:
Metabolic:
Renal: Renal Low Sodium, Low Potassium, Low
Phosphorus
Sodium Controlled:
NPO:
Tube Feeding:
For patients taking tacrolimus, cyclosporine, sirolimus
or everolimus avoid grapefruit and grapefruit juice.
Renal without Dialysis Diet [NUT8888] Routine
General:
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid:
Esophagectomy:
Fat Controlled:
Fiber:
Fluid Restriction:
Heart Healthy:
Metabolic:
Renal: Renal Low Protein, Low Sodium, Low
Potassium, Low Phosphorus
Sodium Controlled:
NPO:
Tube Feeding:
For patients taking tacrolimus, cyclosporine, sirolimus
or everolimus avoid grapefruit and grapefruit juice.
Page 6 of 15
Printed by STRAKA, KEVIN F [KFS1] at 2/6/2017 4:56:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Low Sodium with 2 Liter Fluid Restriction, Low
Potassium Diet [NUT8888]
Routine
General:
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid:
Esophagectomy:
Fat Controlled:
Fiber:
Fluid Restriction: Fluid Restriction (mLs/24 Hr)
Fluid Restriction Amount: 2 Liter
Heart Healthy:
Metabolic:
Renal:
Sodium Controlled: NAS
NPO:
Tube Feeding:
Low Potassium
For patients taking tacrolimus, cyclosporine, sirolimus
or everolimus avoid grapefruit and grapefruit juice.
Wound Care [105679]
Wound Care [NURWND0018] Routine, ***
Line and Drain Care [119660]
Line and Drain Care [NURTAD0046] Routine, For Lines: Your dressing needs to be
changed every 7 days. Your line should be flushed
daily with ***. This will be done by {staff
options:30021404}. Your line should be removed ***,
by ***.
For Drains: Dressing change ***. You will need to
flush your drain with 10mL of Normal Saline *** times
per day. Your drain should be removed ***, by ***. If
you have questions about your line or drain, contact
your Transplant Coordinator.
Bowel Care [123361]
Bowel Care [NURELM0068] Routine
Bladder Care [123379]
Bladder Care [NURELM0067] Routine
Other Discharge Patient Care Instructions [131974]
Discharge Medication Monitoring
[NURCOM0072]
Details
Page 7 of 15
Printed by STRAKA, KEVIN F [KFS1] at 2/6/2017 4:56:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Diabetes Care [NURCOM0071] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, Check your blood sugar 4 times a day.
If your blood sugar is out of your goal range you may
need your insulin dose changed.
When to Call
- Blood sugar is greater than 150 mg/dL more than
half of the time
- Blood sugar is greater than 400 mg/dL
- Blood sugar is less than 70 mg/dL
Call your primary provider / diabetes specialist /
inpatient diabetes team if seen by the Diabetes
Management Service (DMS).
Inpatient Diabetes Management Service (608) 263-
2416
The best time to reach the DMS is Monday - Friday
8:30 a.m. - 10:00 a.m. Please leave a message with
your name and phone number and someone will
return your call. If after hours, call the paging
operator at (608) 262-2122 and ask for the Diabetes
Team (pager #0218).
Home Health [105685]
Home Health Information [NURCOM0022] Routine, Home Health Agency:
@FLOWREFRESH[330601@
@FLOWREFRESH[330607@
When to Call Your Doctor [132305]
Page 8 of 15
Printed by STRAKA, KEVIN F [KFS1] at 2/6/2017 4:56:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

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 911 FOR EMERGENCIES
Contact Information:
Transplant office at: (608) 263-1384
Transplant Coordinator: @TXPCOORD@
Transplant Clinic at: (608) 262-5420
For URGENT issues on weekends, evenings, and
holidays call (608) 263-6400 and ask for the
Abdominal Transplant Coordinator on call.
Call Your Transplant Coordinator if you have any of
the following symptoms:
* Increased Pain
* Fever over 100.5 degrees F
* Weight gain of 3 pounds in one day or 5 pounds in
one week
* Systolic blood pressure (top number) above 180 or
diastolic blood pressure (bottom number) above 90.
* ***
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
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
Page 9 of 15
Printed by STRAKA, KEVIN F [KFS1] at 2/6/2017 4:56:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

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)
Follow Up Care
Follow Up Appointments [131975]
Discharge Appointment Instructions
[NURCOM0083]
This order should be used by providers to
communicate appointment instructions directly to the
patient. This order will appear on the After Hospital
Care Plan. This orders does NOT go to the HUC for
follow-up. If you would like the HUC to schedule an
appointment, you should use the Schedule
Appointment order., Routine, Always go to Lab at
least 90 minutes prior to your Transplant Clinic
appointments to have labs obtained so results are
known at the time of your clinic visit. See Health
Facts for You in your binder for clinic instructions.
Bring your medication box and medications with you
to be reviewed by the Transplant Clinic Pharmacist.
Schedule Follow Up Appointment with Primary
Care Provider [NURCOM0026]
Reason for Hospital Follow Up Appointment: Resume
Care Following Transplant Admission
When do you want appointment: Within 4 Weeks of
Discharge
Which Clinic or Specialty: Primary Care Provider
Which Provider (Optional):
Schedule Follow Up Appointment with Transplant
Clinic [NURCOM0026]
Reason for Hospital Follow Up Appointment: Hospital
Follow-up
When do you want appointment:
Which Clinic or Specialty: Transplant Clinic
Which Provider (Optional):
Page 10 of 15
Printed by STRAKA, KEVIN F [KFS1] at 2/6/2017 4:56:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Schedule Follow Up Appointment with Transplant
Clinic for Biopsy [NURCOM0026]
Reason for Hospital Follow Up Appointment: Biopsy
Follow-Up
When do you want appointment:
Which Clinic or Specialty: Transplant Clinic
Which Provider (Optional):
Schedule Follow Up Appointment with Urology
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
When do you want appointment:
Which Clinic or Specialty: Urology
Which Provider (Optional):
Schedule Follow Up Appointment with Transplant
Clinic for Desensitization Patients
[NURCOM0026]
Reason for Hospital Follow Up Appointment: IVIG
(intravenous immunoglobulin) Infusions and To Be
Seen in Clinic
When do you want appointment: Weekly for 4 Weeks
Which Clinic or Specialty: Transplant Clinic
Which Provider (Optional):
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
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
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.
Page 11 of 15
Printed by STRAKA, KEVIN F [KFS1] at 2/6/2017 4:56:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

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.
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.
Page 12 of 15
Printed by STRAKA, KEVIN F [KFS1] at 2/6/2017 4:56:37 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

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.
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.
Recommended Labs [135971]
The Transplant Service will use the
RECOMMENDED DISCHARGE LABS orders
option below. Please indicate the Transplant
URL:
Page 13 of 15
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Coordinator in the "Send Recommendations" field.
The coordinator's name will be found in the order
comments section.
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]
With the exception of HLA and other Desensitization labs, all lab
results should be FAXED to the UW Hospital transplant office at
608-262-5624. HLA and other Desensitization lab samples will
have special processing instructions provided by the transplant
coordinator.
This patient's transplant coordinator is @TXPCOORD@.
{Abdominal Transplant Monitoring Labs -
Kidney/Panc/Liver/Immuno/Desensitization/Anticoag/Misc:21293}
Anticoagulation Follow Up [119675]
PROTHROMBIN TIME/INR [PT] Status: Future, Expires: 3/23/17, Normal, Routine, To
be drawn on ***
Labs [132088]
BUN [BUN] Normal, Routine
CREATININE [CRET] Normal, Routine
GLUCOSE [GLU] Normal, Routine
HEMATOCRIT [HCT] Normal, Routine
POTASSIUM [K] Normal, Routine
WHITE CELL COUNT [WBC] Normal, Routine
Labs - Immunosuppression Drug Levels [130345]
CYCLOSPORINE [XCYCA] Status: Future, Expected:2/8/17, Expires: 3/8/17,
Normal, Routine, *** time weekly. This lab has to be
drawn prior to taking your morning dose of
cyclosporine. Do not take your morning dose of
cyclosporine until after your lab draw. Take your
evening dose the night before (12 hours before) your
lab will be drawn.
SIROLIMUS [HCSIRO] Status: Future, Expected:2/8/17, Expires: 3/8/17,
Normal, Routine, *** time weekly. This lab has to
be drawn prior to taking your morning dose of
sirolimus. Do not take your morning dose of sirolimus
until after your lab draw. Take your evening dose the
night before (12 hours before) your lab will be drawn.
TACROLIMUS LEVEL [HCTAC] Status: Future, Expected:2/8/17, Expires: 3/8/17,
Normal, Routine, 1 time weekly. This lab has to be
drawn prior to taking your morning dose of tacrolimus.
Do not take your morning dose of tacrolimus until
after your lab draw. Take your evening dose the night
before (12 hours before) your lab will be drawn.
Labs - Additional for Liver Transplant Monitoring [132089]
GGT [GGT] Status: Future, Expected:2/8/17, Expires: 3/10/17,
Normal, Routine
AST/SGOT [AST] Status: Future, Expected:2/8/17, Expires: 3/10/17,
Normal, Routine
ALT/SGPT [ALT] Status: Future, Expected:2/8/17, Expires: 3/10/17,
Normal, Routine
BILIRUBIN, TOTAL [TBIL] Status: Future, Expected:2/8/17, Expires: 3/10/17,
Normal, Routine
Page 14 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

ALKALINE PHOSPHATASE [ALKP] Status: Future, Expected:2/8/17, Expires: 3/10/17,
Normal, Routine
Labs - Additional for Pancreas Transplant Monitoring [132090]
AMYLASE [AMYL] Status: Future, Expected:2/8/17, Expires: 3/8/17,
Normal, Routine
LIPASE [LIPS] Status: Future, Expected:2/8/17, Expires: 3/8/17,
Normal, Routine
Labs - Additional [119677]
BK VIRUS, QUANTITATIVE BY PCR
[HCBKVPCR]
Status: Future, Expected:2/8/17, Expires: 3/10/17,
Normal, Routine
C REACTIVE PROTEIN [CRPN] Status: Future, Expected:2/8/17, Expires: 3/10/17,
Normal, Routine
CBC WITH DIFFERENTIAL [CBC] Status: Future, Expected:2/8/17, Expires: 3/10/17,
Normal, Routine
CMV QUANTITATIVE BY PCR [HCCMVDNA] Status: Future, Expected:2/8/17, Expires: 3/10/17,
Normal, Routine
EBV QUANTITATIVE BY PCR [HCEBVPCR] Status: Future, Expected:2/8/17, Expires: 3/10/17,
Normal, Routine
ESR [ESR] Status: Future, Expected:2/8/17, Expires: 3/10/17,
Normal, Routine
Labs - Desensitization [119673]
HLA CLASS I DONOR SPECIFIC AB BY
LUMINEX [HCDSA1B]
Status: Future, Expected:2/20/17, Expires: 2/6/18,
Normal, Routine, On weeks 2, 4, and 6 post
transplant surgery and then once monthly.
PROCESS INSTRUCTIONS: Donor-specific HLA
Class I Ab: 5 mL red top tube; ship to UW Hospitals
and Clinics, 600 Highland Ave., HLA Lab D4/231,
Madison, WI 53792-2472 with patient provided label,
or at minimum, label with 2 patient identifiers (i.e.,
name & DOB)
HLA CLASS II DONOR SPECIFIC AB BY
LUMINEX [HCDSA2B]
Status: Future, Expected:2/20/17, Expires: 2/6/18,
Normal, Routine, On weeks 2, 4, and 6 post
transplant surgery and then once monthly.
PROCESS INSTRUCTIONS: Donor-specific HLA
Class II Ab: 5 mL red top tube; ship to UW Hospitals
and Clinics, 600 Highland Ave., HLA Lab D4/231,
Madison, WI 53792-2472 with patient provided label,
or at minimum, label with 2 patient identifiers (i.e.,
name & DOB)
CMV QUANTITATIVE BY PCR [HCCMVDNA] Status: Future, Expected:5/7/17, Expires: 2/6/18,
Normal, Routine, Months 3, 6, 9 and 12 post
transplant surgery
BK VIRUS, QUANTITATIVE BY PCR
[HCBKVPCR]
Status: Future, Expected:2/20/17, Expires: 2/6/18,
Normal, Routine, Every 2 weeks for 3 months post
transplant surgery and then monthly for 3 months,
then every 3 months up to one year post transplant
surgery.
Page 15 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org