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IP - Abdominal Transplant - Surgical - Adult - Discharge [4464]

IP - Abdominal Transplant - Surgical - Adult - Discharge [4464] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Transplant


SmartSet: IP - ABDOMINAL TRANSPLANT - SURGICAL- ADULT -
DISCHARGE (ID:4464)
General Information
Display name: IP - Abdominal Transplant - Surgical - Adult - Discharge
Type: General
Merge priority: 0
Version comment:
Content source:
Synonyms: 1. Abdominal
2. Transplant
3. Discharge
4. .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
Skilled Nursing Facility Patient Care Orders
Page 1 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/31/2017 11:15:26 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

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 17
Printed by STRAKA, KEVIN F [KFS1] at 1/31/2017 11:15:26 AM
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 17
Printed by STRAKA, KEVIN F [KFS1] at 1/31/2017 11:15:26 AM
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
Vital Signs
Measure Weight 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 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.
Page 4 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/31/2017 11:15:26 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Measure Temperature 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) 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)
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
For Pancreas and Liver Transplant Patients
(Single Response)
Measure Blood Pressure and Pulse Routine
For Kidney Transplant Patients (Single
Response)
Measure Blood Pressure and Pulse 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
Lifting Restriction: Do not lift greater than 10
pounds for 8 weeks
Routine
Bathing Restrictions Routine, You may shower. No tub baths until cleared
by surgeon. Do not immerse incisions until fully
healed, about 4-6 weeks.
Activity: Daily, low impact aerobic exercise such
as walking.
Routine
Discharge Activity: See Instructions
Daily, low impact aerobic exercise such as walking.
Do Not Drive Until Given Permission by Surgeon Routine
Other Restrictions Routine
Return to Work - Routine
Return to Work:
Nutrition
General Diet Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
For patients taking tacrolimus, cyclosporine, sirolimus
or everolimus avoid grapefruit and grapefruit juice.
Page 5 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/31/2017 11:15:26 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Heart Healthy Diet 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 Routine
General:
Diet Modifications:
Other Diet Modifications:
For patients taking tacrolimus, cyclosporine, sirolimus
or everolimus avoid grapefruit and grapefruit juice.
Diet - Low Sodium 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.
Diabetes Diet Routine
General:
Diet Modifications: Diabetes
Other Diet Modifications:
For patients taking tacrolimus, cyclosporine, sirolimus
or everolimus avoid grapefruit and grapefruit juice.
Page 6 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/31/2017 11:15:26 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Renal with Hemodialysis Diet 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 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 7 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/31/2017 11:15:26 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Low Sodium with 2 Liter Fluid Restriction, Low
Potassium Diet
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
Wound Care Routine, Wash incision daily with soap and water. Do
not rub the site. Do not use lotions and/or ointments
on the incision. Monitor wounds for signs and
symptoms of infection (redness, swelling, drainage,
or odor). Call your Transplant Coordinator if you
notice these symptoms.
Line and Drain Care
Line and Drain Care 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
Bowel Care Routine
Bladder Care
Bladder Care Routine
Other Patient Care Instructions
Discharge Medication Monitoring Details
Page 8 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/31/2017 11:15:26 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Diabetes Care 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).
Stent Removal Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, You will have another appointment in
transplant clinic in about 2-3 weeks for routine follow
up and also in urology clinic for transplant stent
removal. Take (Cipro, ***) 1 hour prior to Urology
appointment for stent removal.
Delayed Graft Function Clinic Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, You will return to UWHC {Daily or
Every Other Day:21291} for labs and clinic
appointments with the Transplant Nephrologist.
You need to restrict your fluid intake to *** liters/day.
You need to limit your potassium intake to ***
mEq/day.
You need to limit your phosphorus intake.
If you have a fistula or graft, check it daily to assure it
is working.
You will need to weigh yourself daily, each morning,
after urination with minimal clothing on.
You will need to collect all urine output and record
this daily. Bring your records to your Transplant Clinic
appointments.
You will need to arrive early on the day of clinic visits
to get your blood tested prior to your clinic visit.
Following your clinic visit, if you need dialysis, this
can be done at the UWHC dialysis unit.
Home Health
Home Health Information Routine, Home Health Agency:
@FLOWREFRESH[330601@
@FLOWREFRESH[330607@
When To Call Your Doctor
Page 9 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/31/2017 11:15:26 AM
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 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
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
Page 10 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/31/2017 11:15:26 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

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)
For New Transplant Recipients Only
Good to Go Program
Good to Go Program Routine, Your Good to Go program includes:
• Your discharge instructions, recorded by your
healthcare team while in
your hospital room
• Easy access to the education materials your health
care team wants
you to study
To access your Good to Go program information:
Via the Internet: uwhealth.org/goodtogo
Via phone: Dial 877-266-1559
Having trouble accessing your information? Contact
the UW Hospitals and Clinics Transplant Unit: (608)
263-8737
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 Follow Up Appointment with
Transplant Surgeon
Reason for Hospital Follow Up Appointment: Hospital
Follow-up
When do you want appointment:
Which Clinic or Specialty: Transplant Surgeon
Which Provider (Optional):
Page 11 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/31/2017 11:15:26 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

Schedule Follow Up Appointment with Primary
Care Provider
Reason for Hospital Follow Up Appointment: Resume
Care Post Transplant
When do you want appointment: 4 Weeks From
Discharge After Surgery
Which Clinic or Specialty: Primary Care Provider
Which Provider (Optional):
Schedule Follow Up Appointment with
Transplant Clinic Pharmacist
Reason for Hospital Follow Up Appointment:
Transplant Follow Up
When do you want appointment: 2-3 Weeks
Which Clinic or Specialty: Transplant Pharmacist
Which Provider (Optional):
Schedule Follow Up Appointment With Delayed
Graft Function Clinic
Reason for Hospital Follow Up Appointment: Delayed
Graft Function
When do you want appointment:
Which Clinic or Specialty: Transplant Surgery
Which Provider (Optional):
Schedule Follow Up Appointment with
Transplant Clinic for Biopsy
Reason for Hospital Follow Up Appointment: Biopsy
Follow-Up
When do you want appointment: 4 Weeks Post
Transplant
Which Clinic or Specialty: Transplant Surgery
Which Provider (Optional):
Schedule Follow Up Appointment with Urology Reason for Hospital Follow Up Appointment: Stent
removal
When do you want appointment: 2-3 Weeks Post
Surgery
Which Clinic or Specialty: Urology
Which Provider (Optional):
Take your antibiotic 1 hour prior to Urology
appointment for stent removal
Schedule Follow Up Appointment with
Transplant Clinic for Desensitization Patients
Reason for Hospital Follow Up Appointment: IVIG
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 Reason for Hospital Follow Up Appointment:
Which Provider:
Which Clinic or Specialty:
Schedule Appointment Reason for Hospital Follow Up Appointment:
Which Provider:
Which Clinic or Specialty:
Follow Up Appointments - Diabetes
Page 12 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/31/2017 11:15:26 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

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.
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.
Page 13 of 17
Printed by STRAKA, KEVIN F [KFS1] at 1/31/2017 11:15:26 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2017CCKM@uwhealth.org

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.
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.
Page 14 of 17
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01/2017CCKM@uwhealth.org

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.
Recommended Labs
Recommended Discharge Labs 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
PROTHROMBIN TIME/INR Status: Future, Expires: S+45, Normal, Routine, To
be drawn on ***
Labs - Immunosuppression Drug Levels
CYCLOSPORINE Status: Future, Expected:S+2, Expires: S+30,
Normal, Routine, 1 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 Status: Future, Expected:S+2, Expires: S+30,
Normal, Routine, 1 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 Status: Future, Expected:S+2, Expires: S+30,
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
GGT Status: Future, Expected:S+2, Expires: S+32,
Normal, Routine, 2 times weekly
Page 15 of 17
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01/2017CCKM@uwhealth.org

AST/SGOT Status: Future, Expected:S+2, Expires: S+32,
Normal, Routine, 2 times weekly
ALT/SGPT Status: Future, Expected:S+2, Expires: S+32,
Normal, Routine, 2 times weekly
BILIRUBIN, TOTAL Status: Future, Expected:S+2, Expires: S+32,
Normal, Routine, 2 times weekly
ALKALINE PHOSPHATASE Status: Future, Expected:S+2, Expires: S+32,
Normal, Routine, 2 times weekly
Labs - Additional for Pancreas Trasplant Monitoring
AMYLASE Status: Future, Expected:S+2, Expires: S+30,
Normal, Routine, 2 times weekly
LIPASE Status: Future, Expected:S+2, Expires: S+30,
Normal, Routine, 2 times weekly
Labs - Additional
BK VIRUS, QUANTITATIVE BY PCR Status: Future, Expected:S+2, Expires: S+32,
Normal, Routine
C REACTIVE PROTEIN Status: Future, Expected:S+2, Expires: S+32,
Normal, Routine
CBC WITH DIFFERENTIAL Status: Future, Expected:S+2, Expires: S+32,
Normal, Routine
CMV QUANTITATIVE BY PCR Status: Future, Expected:S+2, Expires: S+32,
Normal, Routine
EBV QUANTITATIVE BY PCR Status: Future, Expected:S+2, Expires: S+32,
Normal, Routine
ESR Status: Future, Expected:S+2, Expires: S+32,
Normal, Routine
Labs - Desensitization
HLA CLASS I DONOR SPECIFIC AB BY
LUMINEX
Status: Future, Expected:S+14, Expires: S+365,
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
Status: Future, Expected:S+14, Expires: S+365,
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 Status: Future, Expected:S+90, Expires: S+365,
Normal, Routine, Months 3, 6, 9 and 12 post
transplant surgery
BK VIRUS, QUANTITATIVE BY PCR Status: Future, Expected:S+14, Expires: S+365,
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.
Criteria
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01/2017CCKM@uwhealth.org

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