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IP - Abdominal Transplant - Organ Not Available - Adult - Discharge [4937]

IP - Abdominal Transplant - Organ Not Available - Adult - Discharge [4937] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Transplant


SmartSet: IP - ABDOMINAL TRANSPLANT - ORGAN NOT AVAILABLE -
ADULT - DISCHARGE (ID:4937)
General Information
Display name: IP - Abdominal Transplant - Organ Not Available - Adult - Discharge
Type: General
Merge priority: 0
Version comment:
Content source:
Synonyms: 1. DC
2. D/C
3. Transplant
4. not available
5. discharge
6. .TRANSPLANT
SmartSet notes:
Description:
Web information: Title URL
1.
Questionnaire:
Configuration
Skilled Nursing Facility Orders
Skilled Nursing Facility Certification Statement
Facility Certification Statement Routine
Skilled Nursing Facility Certification Statement
Facility Certification Statement Routine
Skilled Nursing Facility Admit Order
Admit to Skilled Nursing Facility Routine
Skilled Nursing Facility Admit Order
Admit to Skilled Nursing Facility Routine
Page 1 of 10
Printed by STRAKA, KEVIN F [KFS1] at 1/17/2017 2:03:19 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

Skilled Nursing Facility Patient Care Orders
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.
Routine
DME - Home Oxygen 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 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:
DME - BiPAP (S) 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:
Page 2 of 10
Printed by STRAKA, KEVIN F [KFS1] at 1/17/2017 2:03:19 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

DME - BiPAP (S/T) 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
Routine
Patient medications (per Skilled Nursing Facility
policy) may be left at bedside
Routine
Facility Therapy Needs
Physical Therapy to Evaluate and Treat at Next
Facility
Routine
Occupational Therapy to Evaluate and Treat at
Next Facility
Routine
Speech Therapy to Evaluate and Treat at Next
Facility
Routine
Communicable Diseases
Patient has been screened for TB within the last
90 days prior to admission and does not have
any other clinically apparent communicable
diseases.
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
Routine
Communicable Diseases
Patient has been screened for TB within the last
90 days prior to admission and does not have
any other clinically apparent communicable
diseases.
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
Routine
Analgesics
acetaMINOPHEN (TYLENOL) tab 650 mg, 1 tab, 1, starting S, No Print
acetaMINOPHEN (TYLENOL) suppository 650 mg, 1 suppository, 1, starting S, No Print
Blood Glucose Management
glucagon 1 mg injection kit 1 mg, 1 each, 1, starting S, No Print
Glucose 40 % oral gel 10 g, 1 Tube, 1, starting S, No Print
Nursing Communication Routine, Notify {Notify for Blood Glucose:3004146} if
blood glucose is greater than 400 mg/dL or less than
40 mg/dL
Page 3 of 10
Printed by STRAKA, KEVIN F [KFS1] at 1/17/2017 2:03:19 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Diabetes Care Instructions 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
bisacodyl (DULCOLAX) rectal suppository 10 mg, 1 suppository, 1, starting S, No Print
Senna-Docusate Sodium 8.6-50 MG per tab 1-2 tab, 1 tab, 1, starting S, No Print
magnesium hydroxide (MILK OF MAGNESIA)
susp
30 mL, 1 Bottle, 1, starting S, No Print
polyethylene glycol (MIRALAX) oral powder 17 g, 1 Bottle, 1, starting S, No Print
Non-categorized Medications
guaifenesin-dextroMETHORPHAN
(ROBITUSSIN DM) syrup
10 mL, 1 Bottle, 1, starting S, No Print
carbamide peroxide (DEBROX) 6.5% otic soln 3 drop, 1 Bottle, 1, starting S until S+5, No Print
alum-mag-simeth (MYLANTA ES) susp 30 mL, 1 Bottle, 1, starting S, No Print
Patient Care Orders
Confirmed Discharge Date/Time
Confirmed Discharge Date/Time Confirmed Discharge Date:
Confirmed Discharge Time:
Conditions for Discharge:
Provider to be Present at Discharge?
Reason For Hospitalization
Why You Were Hospitalized Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Activity
Activity Routine
Discharge Activity:
Return to activity prior to admission
Nutrition
Page 4 of 10
Printed by STRAKA, KEVIN F [KFS1] at 1/17/2017 2:03:19 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Diet Routine
General:
Diet Modifications:
Other Diet Modifications: -
Solid Consistency:
Liquid Consistency:
Liquid:
Esophagectomy:
Fat Controlled:
Fiber:
Fluid Restriction:
Heart Healthy:
Metabolic:
Renal:
Sodium Controlled:
NPO:
Return to diet prior to admission
Wound Care
Wound Care Routine
Bladder Care
Bladder Care Routine
Bowel Care
Bowel Care Routine
Other Discharge Patient Care Instructions
Other Discharge Patient Care Instructions Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
When to Call Your Doctor
When to Call Your Doctor 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@
For URGENT issues on weekends, evenings, and
holidays call (608) 263-6400 and ask for the
Abdominal Transplant Coordinator on call.
Heart Failure Discharge Instructions
Weigh yourself daily or as directed Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Page 5 of 10
Printed by STRAKA, KEVIN F [KFS1] at 1/17/2017 2:03:19 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

When to Call Your Doctor 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
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
Heart Failure Recommended Care
Heart Failure Discharge Instructions
Weigh yourself daily or as directed Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine
When to Call Your Doctor 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
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
ACE Inhibitor/ARB Reason Not Ordered ONCE, Starting S For 1 Occurrences, Routine
Reason Not Ordered:
ACE Inhibitor/ARB Already Ordered ONCE, Starting S For 1 Occurrences, Routine
Reason Not Ordered: Other (Comments required for
not ordering BOTH an ACEI and an ARB)
Page 6 of 10
Printed by STRAKA, KEVIN F [KFS1] at 1/17/2017 2:03:19 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Follow-Up Care
Follow Up Appointments
Discharge Appointment Instructions 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 Appointment Reason for Hospital Follow Up Appointment:
Which Provider:
Which Clinic or Specialty:
Follow Up Appointments - Diabetes
No appointment: Patient does not have diabetes ONCE, Starting S 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)
ONCE, Starting S 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.
Page 7 of 10
Printed by STRAKA, KEVIN F [KFS1] at 1/17/2017 2:03:19 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Appointment scheduled per patient report
(ENTER DATE IN COMMENTS)
ONCE, Starting S 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
ONCE, Starting S 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 ONCE, Starting S 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.
Page 8 of 10
Printed by STRAKA, KEVIN F [KFS1] at 1/17/2017 2:03:19 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

No appointment: Patient discharging to a facility
(e.g., skilled nursing facility, correctional facility,
etc.)
ONCE, Starting S 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 ONCE, Starting S 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.
Criteria
Suggestions: UWIP C DISCHARGE ORDER SET SUGGESTION - NON-LOGIN
DEPARTMENT SPECIFIC[3901755]
Filter: UWIP ORDER SET RESTRICTION - IP ONLY DISCHARGE[1754]
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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Printed by STRAKA, KEVIN F [KFS1] at 1/17/2017 2:03:19 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org