/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/transplant/,

/clinical/cckm-tools/content/order-sets/inpatient/transplant/name-97909-en.cckm

20180105

page

100

UWHC,UWMF,

Tools,

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

IP - Liver Transplant - Adult - Evaluation [1983]

IP - Liver Transplant - Adult - Evaluation [1983] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Transplant


IP - Liver Transplant - Adult - Evaluation [1983]
for Adult Patients OnlyIntended
Laboratory
Laboratory [28270]
ABO AND RH TYPING [ABO] STAT, 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?
Two ABO's within 24 hours required for UNOS listing.
First ABO collection must be completed before second
draw is started, preferably 5 minutes apart [refer to
ABO and Rh Typing (2nd collection for UNOS)
request].
ABO AND RH TYPING (2ND COLLECTION FOR
UNOS) [TXPABO]
STAT, 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?
Second ABO collection cannot be at the same draw
time as the first.
PTT [PTT] STAT, 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?
AFP, TUMOR MARKER, SERUM [XAFPTM] STAT, 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?
ALPHA-1-ANTITRYPSIN PHENOTYPE
[HCAATPH]
STAT, 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?
AMMONIA [GM2200] STAT, 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?
ANA SCREEN WITH TITER IF POSITIVE [ANAT] STAT, 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?
O2 SATURATION [HCOSAT] STAT For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITH DIFFERENTIAL [CBC] STAT, 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?
CERULOPLASMIN [XCERU] STAT, 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?
ELECTROLYTES [LYTE] STAT, 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 1 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

BUN [BUN] STAT, 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?
CREATININE [CRET] STAT, 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?
GLUCOSE [GLU] STAT, 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?
CALCIUM [CA] STAT, 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] STAT, 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?
PROTEIN, TOTAL [TP] STAT, 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] STAT, 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] STAT, 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] STAT, 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?
ALT/SGPT [ALT] STAT, 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?
COPPER [XCOP] STAT, 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?
FERRITIN [FER] STAT, 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?
GGT [GGT] STAT, 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?
IRON AND TRANSFERRIN W/ TIBC,
SATURATION [FETRANS]
STAT, 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 2 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

LD, TOTAL [LDH] STAT, 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?
LIPID PANEL [LIPID] STAT, Starting today For 1 Occurrences, Routine,
Test includes Cholesterol, Total; HDL Cholesterol;
Triglyceride; LDL cholesterol, calculated; and non-
HDL cholesterol.
Patient must fast for a minimum of 10 hours and be
heparin free for 48 hours prior to specimen collection.
The patient can only have water during the fasting
period.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
E-GFR [HCEGFR] STAT, Starting today For 1 Occurrences, Routine,
Test is only available as an Add-On to a previously
ordered creatinine.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MITOCHONDRIAL AB [HCAMIA] STAT, 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?
PROTHROMBIN TIME/INR [PT] STAT, 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?
RHEUMATOID FACTOR [RF] STAT, 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?
SMOOTH MUSCLE AB, IGG [XSMOO] STAT, 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 WITH MICROSCOPY [UA] 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?
Laboratory HCG (female only) [122574]
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?
Laboratory PSA (male only) [122575]
PSA TOTAL, DIAGNOSTIC [PSA] STAT, Starting today For 1 Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Infectious Disease Serology [28271]
HEPATITIS C AB [HCV] STAT, 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 3 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

HEPATITIS C RNA, QUANT, PCR [XHCVRQ] STAT, 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?
HIV AB/AG COMBO [HIVABAG] STAT, Starting today For 1 Occurrences, Routine, I,
the ordering provider, have verified that the
patient/patient's authorized representative was:
1. Notified that the patient will be subjected to an HIV
test unless the patient/rep declines the test;
2. Given educational materials on HIV and HIV testing;
3. Notified that they may decline the test and health
care providers may not use the fact that the
patient/rep declined an HIV test as a basis for denying
other services; and
4. Provided an opportunity to ask questions and to
decline the HIV test.
The ordering provider verifies:
5. The patient/patient's authorized representative
understands that an HIV test will be performed; and
6. The decision of the patient/rep regarding whether to
have an HIV test performed was not coerced or
involuntary.
Pt/Pt's Rep did not opt out. Steps listed in instructions
taken. If test is declined, type ".HIVTESTDECLINE" in
progress note.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
VARICELLA ZOSTER AB, IGG [VZIGG] STAT, 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?
HEPATITIS A AB, IGG [HAVIGG] STAT, 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?
HEPATITIS A AB, IGM [XHAVM] STAT, 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?
HEPATITIS B CORE AB, TOTAL [HBCAB] STAT, 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?
HEPATITIS B CORE AB, IGM [XHBCM] STAT, 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?
HEPATITIS B SURFACE AB (IMMUNE STATUS)
[HBSABI]
STAT, 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 4 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

HEPATITIS B SURFACE AG [HBSAG] STAT, 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?
HEPATITIS E AB, IGG [HCHEVIGG] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS E AB, IGM [HCHEVIGM] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
For Patients with Positive Hepatitis B Surface Antigen Status [28272]
Hepatitis B Virus DNA Ultra Quantitative [RMISC] STAT, Starting today For 1 Occurrences, Routine
What lab test would you like to have performed?
For questions I can be reached at:
Indicate specimen source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS BE AG [HCHBEAG] STAT, 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?
HEPATITIS BE AB [HCHBEAB] STAT, 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?
CRYOGLOBULINS [CRYO] STAT, 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?
For Patients with Known Positive Hepatitis C+ Virus Status [28273]
CRYOGLOBULINS [CRYO] STAT, 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?
HEPATITIS C GENOTYPING [XHCVG] STAT, Starting today For 1 Occurrences, Routine,
Hepatitis C RNA, Quant, PCR should be requested
concurrently to verify the presence and level of
Hepatitis C Virus. If Hepatitis C, Quant, PCR is not
detected or less than 22,000 IU/mL, HCV Genotyping
will be canceled. HCV Genotyping can be ordered as
an "Add-on" to hepatitis C RNA, Quant, PCR within 3
weeks of collection of the specimen. Please contact
UWHC lab at (608)263-7060 to see if adequate
sample is available.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Metabolic Studies [28275]
MAGNESIUM [MAG] STAT, 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 5 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

PHOSPHATE [PHOS] STAT, 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?
URIC ACID [URIC] STAT, 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?
For Patients with Transferring Sat > 45, and/or Increase Ferritin [28276]
HEMOCHROMATOSIS MUTATION DETECTION
[HCHHPCR]
STAT, Starting today For 1 Occurrences, Routine, For
UWMF- Ordering source must fill out the UWMF
Genetic Lab Request prior to specimen collection.
Click on the link an open up "UWMF Genetic lab
Request" document.
For UWHC- Ordering source must fill out the UWHC
Referral Screening Flow Sheet prior to specimen
collection. Click on the link and open up "Referral
Screening Flow Sheet" document.
This test includes a billable professional interpretation.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
For Patients with Primary Sclerosing Cholangitis Diagnosis [28277]
CA 19-9 [XCA199] STAT, 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?
HLA DR/DQ, PRE-TX [126794]
DRB1 LOCUS, PRE-TX [HCDRB1S] NEXT AM For 1 Occurrences, Routine
Indicate organ for transplant:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
DRB345 LOCUS, PRE-TX [HCDRB345S] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
DQ LOCUS, PRE-TX [HCDQB1S] NEXT AM For 1 Occurrences, Routine
Indicate organ for transplant:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA DP/DQ, PRE-TX [148947]
HLA DPB LOCUS, PRE-TX [HCDPB1S] NEXT AM For 1 Occurrences, Routine
Indicate organ for transplant:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA DQ LOCUS, PRE-TX [HCDQB1S] NEXT AM For 1 Occurrences, Routine
Indicate organ for transplant:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA CLASS I TYPING (A,B,C), PRE-TX [126798]
Page 6 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

HLA A LOCUS, PRE-TX [HCALOCS] NEXT AM For 1 Occurrences, Routine
Indicate organ for transplant:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA B LOCUS, PRE-TX [HCBLOCS] NEXT AM For 1 Occurrences, Routine
Indicate organ for transplant:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA C LOCUS, PRE-TX [HCCLOCS] NEXT AM For 1 Occurrences, Routine
Indicate organ for transplant:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
For Antibody Screening [28279]
HLA CLASS I AB BY LUMINEX, PRE TX
[HCLUC1S]
STAT, Starting today For 1 Occurrences, Routine
Indicate organ for transplant:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA CLASS II AB BY LUMINEX, PRE TX
[HCLUC2S]
STAT, Starting today For 1 Occurrences, Routine
Indicate organ for transplant:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Diagnostic Tests and Imaging
Radiology [28282]
X-RAY CHEST 2 VIEWS [R71046] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Evaluate for infectious source of disease
pre-transplant
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Page 7 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

MAMMOGRAM DIGITAL SCREENING
BILATERAL [R77057B]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Why are you ordering this exam? Order diagnostic
mammogram for new clinical finding or abnormal
breast imaging.
Is patient pregnant?
Also perform diagnostic mammogram and/or breast
ultrasound as needed per radiologist determination.
No
Current signs and symptoms? Evaluation for liver
transplant
Is patient breastfeeding?
Does patient have breast implants?
Does this patient have previous breast imaging
studies at another facility? If yes, place facility and
date of study in comments box at bottom.
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):
Transport Method: Floor Determined/Entered
For female patients greater than or equal to 40 years
old or positive family history.
US CAROTID DOPPLER [R93880] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
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.
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Other Tests [28283]
Pulmonary Lab Testing [999992] ONCE, Starting today For 1 Occurrences, Routine
Reason for Exam: Evaluation for hepatopulmonary
syndrom
Specify Test: Pre-Op Non-Thoracic Surgery
(Spirometry, Bronchdilators if indicated)
Page 8 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

BONE MINERAL DENSITY ONLY AXIAL (BMD)
[R77080]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Evaluation for osteoporosis
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?
Is patient taking TUMS or calcium supplements or
antacids?
Perform the Appendicular exam per protocol?
Perform the VFA exam per protocol?
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
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: Other (enter comments),Pre-
operative
Comment:
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
Transthoracic Resting Echocardiogram
[ECH0003]
ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: OTHER (COMMENT)
Other (Comment): see comments
Do you want Agitated Bubble Study? YES (ORDER
THE MEDICATION AND SALINE)
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Indication: Evaluation for valvular disease, pulmonary
hypertension, ejection fraction, extra-
cardiac/interpulmonary shunts/hepatopulmonary
syndrome
Dobutamine Stress Echocardiogram [116807]
Page 9 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Dobutamine Stress Echocardiogram (Echo)
(Order 1 of 2) [ECH0031]
ONCE, Routine
Reason for exam:
Is this test being ordered to look for
ischemia/coronary artery disease?
Is this test being ordered to evaluate a specific
structural lesion?
Please provide any additional comments:
Indicate any medication holds:
Name and contact number of physician to contact on
the day of the procedure:
Relevant recent/ past history:
Bring comfortable shoes and wear pants.
NPO 4 hours; no caffeine or tobacco 12 hours
Dobutamine Stress Echocardiogram (Stress)
(Order 2 of 2) [ECH0002]
ONCE, Routine
Reason for exam:
Is this test being ordered to look for
ischemia/coronary artery disease?
Is this test being ordered to evaluate a specific
structural lesion?
Please provide any additional comments:
Indicate any medication holds:
Name and contact number of physician to contact on
the day of the procedure:
Relevant recent/ past history:
Bring comfortable shoes and wear pants.
NPO 4 hours; no caffeine or tobacco 12 hours
Exercise Stress Echocardiogram [116809]
Exercise Stress Echocardiogram (Echo) (Order 1
of 2) [ECH0033]
ONCE, Routine
Reason for exam:
Is this test being ordered to look for
ischemia/coronary artery disease?
Is this test being ordered to evaluate a specific
structural lesion?
Which specific lesion would you like to evaluate for
stress-related changes? (Select one or more
options):
Please provide any additional comments:
Can patient exercise? (If no, order Dobutamine
Stress Echocardiogram):
Type of equipment:
Indicate any medication holds:
Name and contact number of physician to contact on
the day of the procedure:
Relevant recent/ past history:
NPO for 4 hours and no caffeine for 12 hours.
Page 10 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

Exercise Stress Echocardiogram (Stress) (Order
2 of 2) [ECH0007]
ONCE, Routine
Reason for exam:
Is this test being ordered to look for
ischemia/coronary artery disease?
Is this test being ordered to evaluate a specific
structural lesion?
Which specific lesion would you like to evaluate for
stress-related changes? (Select one or more
options):
Please provide any additional comments:
Can patient exercise? (If no, order Dobutamine
Stress Echocardiogram):
Type of equipment:
Indicate any medication holds:
Name and contact number of physician to contact on
the day of the procedure:
Relevant recent/ past history:
NPO for 4 hours and no caffeine for 12 hours.
Esophagogastroduodenoscopy (EGD) [GI0003] ONCE, Starting today For 1 Occurrences, Routine
Reason for Exam: Document portal hypertension/need
for variceal banding
Colonoscopy [GI0002] ONCE, Starting today For 1 Occurrences, Routine
Reason for Exam: Evaluation for liver transplant
For patients greater than or equal to 50 years old, or
positive family history, or history of inflammatory bowel
disease.
PAP SMEAR [HCPATHP] ONCE, Starting today For 1 Occurrences, Routine,
Diagnostic: Previous Abnormal Pap, History of GYN
Cancer, Abnormal Complaints or Findings;
Screening, HIGH RISK: DES Daughter, History of
STD, Multiple Partners, Early Onset of Sexual Activity
Screening, LOW RISK: Routine Exam
If an HPV reflex option is not ordered at the time of the
Pap test it can be ordered as an "add on" test within 3
weeks of collection of the Pap test specimen.
HPV requests on conventional Paps require additional
sample collection in a ThinPrep PreservCyt Solution
vial.
Specimen Site:
HPV Reflex:
Clinical History- Select all that apply:
Menstrual Status:
Previous Procedures:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Indication: Evaluation for liver transplant.
Abdominal Imaging [148300]
Page 11 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

CT ANGIO ABDOMEN [R74175] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history.
Last creatinine value? (will auto pull in date and value
in comment):
Last patient weight? (will auto pull in value and date in
comment):
Transport Method:
CT ABDOMEN W IV CONTRAST [R74160] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Can pt be given oral contrast?
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history.
Last creatinine value? (will auto pull in date and value
in comment):
Last patient weight? (will auto pull in value and date in
comment):
Transport Method:
CT ABDOMEN PELVIS W & W/ O IV CONTRAST
[R07033]
ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Can pt be given oral contrast?
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history.
Last creatinine value? (will auto pull in date and value
in comment):
Last patient weight? (will auto pull in value and date in
comment):
Transport Method:
US ABDOMEN LIMITED W/ DOPPLER [R07694] ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
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.
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Page 12 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

MRI ABDOMEN PELVIS W & W/ O CONTRAST
[R07020]
ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Study Needed Within:
Is patient pregnant?
Does patient have a pacemaker or defibrillator?
Allergy to Gadolinium (MRI) contrast?
For Scheduling purposes, is the patient claustrophobic
or require any form of sedation? Note: ordering
provider is responsible for prescribing oral anxiolytic or
ordering sedation services.
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.
Relevant Surgical History (Select all applicable or
None):
Implanted Devices? (Select all applicable or None):
History of Metal in Body? (Select all applicable or
None):
Has patient had a colonoscopy/endoscopy in the last 8
weeks?
Last creatinine value? (will auto pull in date and value
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
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:
Page 13 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

MRA ABDOMEN PELVIS W OR W/ O
CONTRAST [R07022]
ONCE-RAD NEXT AVAILABLE For 1 Occurrences,
Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Study Needed Within:
Is patient pregnant?
Does patient have a pacemaker or defibrillator?
Allergy to Gadolinium (MRI) contrast?
For Scheduling purposes, is the patient claustrophobic
or require any form of sedation? Note: ordering
provider is responsible for prescribing oral anxiolytic or
ordering sedation services.
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.
Relevant Surgical History (Select all applicable or
None):
Implanted Devices? (Select all applicable or None):
History of Metal in Body? (Select all applicable or
None):
Has patient had a colonoscopy/endoscopy in the last 8
weeks?
Last creatinine value? (will auto pull in date and value
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
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:
Consults
Consults [28284]
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?
Indication: Evaluate and treat.
Consult Infectious Disease (Inpatient) [CON0037] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Nodular findings on
chest x-ray, follow-up for fungal serology studies.
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: OTHER
Indication: Evaluate psychosocial history.
Behavioral Health Consults (select below)
[132899]
Page 14 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

amp, transplant), - adjustment, protocol (eg. burn, trauma, rehab, pre-Psychology Health
noncompliance, grief, pain
Addictive Disorders - alcohol or drug related problems (eg. treatment recommendations,
withdrawal mgmt)
Psychiatry - safety, agitation, capacity, med mgmt, psychotropic SE
ACE - 60 and older - delirium, dementia, depression, decisional capacity, sleep (also for non-
behavioral geriatric syndromes; overall geriatric evaluation, mobility/falls, functional decline,
social/caregiver issues, disposition, medication management)
Consult Health Psychology (Inpatient)
[CON0033]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-Friday)
or if special assessment needs.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Addictive Disorders (Inpatient)
[CON0003]
ONCE, Routine, This order is for ADULT patients.
Please use the Consult Adolescent/Pediatric AODA
Counselor order for adolescent/pediatric patients
instead.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Psychiatry (Inpatient) [CON0064] ONCE
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Consult Ace/Geriatric (Inpatient) [CON0001] ONCE, Routine
Reason for Consult:
Can this consult be done via video?
Consult Transplant Coordinator [CON0156] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Evaluate for liver transplant
Consult Transplant Financial Coordinator
[CON0157]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Financial matters related to
transplant
Consult Dental (Inpatient) [CON0019] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Consult Women's Health Evaluation [CON0158] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Evaluate for transplant, pap
smear and pelvic exam
Consult Hepatology (Inpatient) [CON0035] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Evaluate need for liver
transplant.
For Patients with AODA History [28285]
Behavioral Health Consults [230635]
Page 15 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

amp, transplant), - adjustment, protocol (eg. burn, trauma, rehab, pre-Psychology Health
noncompliance, grief, pain
Addictive Disorders - alcohol or drug related problems (eg. treatment recommendations,
withdrawal mgmt)
Psychiatry - safety, agitation, capacity, med mgmt, psychotropic SE
ACE - 60 and older - delirium, dementia, depression, decisional capacity, sleep (also for non-
behavioral geriatric syndromes; overall geriatric evaluation, mobility/falls, functional decline,
social/caregiver issues, disposition, medication management)
Consult Health Psychology (Inpatient)
[CON0033]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-Friday)
or if special assessment needs.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Addictive Disorders (Inpatient)
[CON0003]
ONCE, Routine, This order is for ADULT patients.
Please use the Consult Adolescent/Pediatric AODA
Counselor order for adolescent/pediatric patients
instead.
Intent for Consult: Other
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Indication: Evaluate for ETOH and other concerns.
Consult Psychiatry (Inpatient) [CON0064] ONCE
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Consult Ace/Geriatric (Inpatient) [CON0001] ONCE, Routine
Reason for Consult:
Can this consult be done via video?
Page 16 of 16
Printed by STRAKA, KEVIN F [KFS1] at 1/4/2018 2:00:25 PM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org