/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-97917-en.cckm

201712341

page

100

UWHC,UWMF,

Tools,

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

IP - Lung Transplant - Adult - Re-Admission [2126]

IP - Lung Transplant - Adult - Re-Admission [2126] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Transplant


IP - Lung Transplant - Adult - Re-Admission [2126]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [186484]
*An admit patient order has already been written, but the level of care at which the patient should be placed
still needs to be identified.
Place Patient on General Care [ADT0018] General Care, has already been signed. This order will ensure
that the patient is placed at the appropriate level of care.
Place Patient on Intermediate Care (IMC) [ADT0018] Intermediate Care, has already been signed. This order will
ensure that the patient is placed at the appropriate level of
care.
Place Patient on Intensive Care (ICU) [ADT0018] Intensive Care, has already been signed. This order will
ensure that the patient is placed at the appropriate level of
care.
Admit to Inpatient (Single Response) [188296]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary because
of either an anticipated LOS >2 midnights, complexity and/or
severity of illness, an inpatient-only surgery, or a previously-
authorized inpatient stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit to Observation (Single Response) [188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single Response)
[188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [7248]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary because of
either an anticipated LOS >2 midnights, complexity and/or
severity of illness, an inpatient-only surgery, or a previously-
authorized inpatient stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [82665]
Page 1 of 15
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Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary because of
either an anticipated LOS >2 midnights, complexity and/or
severity of illness, an inpatient-only surgery, or a previously-
authorized inpatient stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [130119]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single Response)
[129777]
enoxaparin (LOVENOX) subcutaneous injection [800040] 40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [129757]
Sequential Compression Device (SCD) (TREATMENT)
[NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot Pump
(SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered:
VTE Prophylaxis (Single Response) [150156]
Padua VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97520-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered: Low Risk
High VTE Risk with Low Bleed Risk (Single Response)
[129777]
enoxaparin (LOVENOX) subcutaneous injection [800040] 40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
High Bleed Risk with High VTE Risk [129757]
Sequential Compression Device (SCD) (TREATMENT)
[NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Sequential Compression Device (SCD) / Foot Pump
(SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Page 2 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered:
Patient Care Orders
Vital Signs [29604]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Vital Signs [NURMON0013] EVERY 8 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Patient Monitoring [29605]
Cardiac Rhythm Monitoring - Adult [NURMON0010] ONCE, Routine
Notify Provider: Symptomatic Change in Rhythm,Serious
Arrhythmia
Functional Cardiac Defibrillator Present:
Activity [29606]
Ambulate 3 Times Daily [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: 3x daily
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Nutrition [29607]
NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
Diabetes Meal Plan [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Diabetes
Bedside Meal Instructions:
Room Service Class:
Respiratory [29608]
Pulse Oximetry [NURMON0009] EVERY 8 HOURS, Starting today, Routine
Page 3 of 15
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12/2017CCKM@uwhealth.org

Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 90
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Respiratory Therapy per Protocol [RT0035] Routine
Protocol Type:
Respiratory Therapy per Previous Lung Transplant Admit
Protocol.
Ambulating Oximetry Test [RT0036] ONCE, Starting today For 1 Occurrences, Routine, Ambulating
oximetry tests must be done within 48 hours of discharge due
to insurance issues.
Is this order for home O2?
Anticipated or Confirmed Discharge Date:
Confirmed Discharge Time:
Intake and Output [29609]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
Non-Categorized Patient Care Orders [29610]
Refer to "Diabetes Management - Adult - Supplemental" Order Set for diabetes management.
Strict Handwashing per Precautions for
Immunocompromised Patients Policy 13.06
[NURCOM0022]
CONTINUOUS, Starting today
Contingency Parameters [29611]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38.3
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 60
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%): 88
If urine output < (mL):
Other:
Intravenous Therapy
Premedications for Needle Insertion [106310]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30 minutes time prior to
needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV access; onset is
immediate.
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, peripheral line insertion - see
Admin Instructions
Do NOT apply to area greater than 200 square centimeters
(maximum 2.5 g/site; maximum 4 sites per hour, 6 times per
day). Do NOT leave on longer than 2 hours. Use for stable
patient, no allergies to lidocaine, with at least 30 minutes time
prior to IV use
sodium chloride (bacteriostatic) 0.9 % injection [50585] 0.05-0.1 mL, Intradermal, PRN, peripheral line insertion - see
Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge needle to
inject solution and create a wheal. Wait 30 seconds to 1 minute
then insert IV catheter into center of wheal. Use if IV is needed
within 30 minutes.
IV Fluids [31379]
Page 4 of 15
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12/2017CCKM@uwhealth.org

Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today For Until specified, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
sodium chloride 0.9% infusion [64367] Intravenous, CONTINUOUS
sodium chloride 0.9% BOLUS [730003] 500 mL, Intravenous, ONCE For 1 Doses
Maintain Central Implanted Port [NURVAD0005] CONTINUOUS, Routine
Device Status: Ready For Use
Type:
Site:
Flushes [27208]
sodium chloride 0.9% flush 10 mL injection [785055] Flush, PRN, flush/line care, administer every 8 hours and after
each use as needed to flush peripheral line
See VAD Guidelines
Anti-infectives - Cystic Fibrosis
Beta-lactams (prolonged infusion) - must select this option if using tobramycin Q24hr dosing regardless of previous MIC
[120512]
Adult Cystic Fibrosis - Cefepime Prolonged Infusion
[235328]
cefepime (MAXIPIME) in dextrose 5 % 50 mL bag
[700167]
2 g, Intravenous, EVERY 8 HOURS
Administer over 4 hours
Note: Run cefepime (MAXIPIME) over 4 hours [950056] EVERY 8 HOURS
Adult Cystic Fibrosis - Meropenem Prolonged Infusion
[235330]
meropenem 10 mg/mL in sodium chloride 0.9%
(MERREM) injection [755108]
2,000 mg, Intravenous, EVERY 8 HOURS For 96 Hours, for 3
Hours
Note: Run meropenem (MERREM) over 3 hours [950049] EVERY 8 HOURS
Adult Cystic Fibrosis - Piperacillin/Tazobactam Prolonged
Infusion [235332]
piperacillin-tazobactam (ZOSYN) 4.5 g vial + minibag
[54251]
4.5 g, Intravenous, EVERY 6 HOURS, for 3 Hours
Note: Run piperacillin-tazobactam (ZOSYN) over 3 hours
[950018]
EVERY 6 HOURS
Fluoroquinolones [23053]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, EVERY 12 HOURS
Aminoglycosides [23054]
tobramycin (NEBCIN) intraVENOUS - NOTE: Per
previous admission, contact D6/5 pharmacist [800081]
10 mg/kg, Intravenous, EVERY 24 HOURS
Adult Cystic Fibrosis dosing only. Pharmacist to adjust initial
order based on dose (mg) and interval (hours) used during prior
admission. If no history of tobramycin use, initiate with 10
mg/kg IV every 24 hours (infused over 60 minutes) based on
Ideal Body Weight (or actual body weight if less than ideal). Do
not exceed an initial dose of 700mg.
Methicillin-resistant Staphylococcus Aureus (MRSA) Coverage [23064]
vancomycin (VANCOCIN) in dextrose 5 % 250 mL bag
[700516]
15 mg/kg, Intravenous, EVERY 12 HOURS
linezolid (ZYVOX) tab [64770] 600 mg, Oral, EVERY 12 HOURS For 96 Hours
Anti-infectives - Non-Cystic Fibrosis
American
Thoracic
Society
Guidelines:
Am J Respir
Crit Care Med
2005;171:858-
873
URL: http://workspaces.uconnect.wisc.edu/download/attachments/10327345/HAP+Guidelines+-+IDSA+and+ATS%
2C+2005.pdf?version=1&modificationDate=1297119505697
UWHC
Nosocomial
Pneumonia
Algorithm
URL: http://workspaces.uconnect.wisc.edu/download/attachments/10327345/Nosocomial+Pneumonia+Algorithm.pdf?
version=1&modificationDate=1297275105217
UWHC Health Care Acquired
Pneumonia In Non-Intubated
Patients
URL: http://workspaces.uconnect.wisc.edu/download/attachments/10327345/HCAP+In+Non-
Inbated+Patient+Algorithm.pdf?version=1&modificationDate=1297275046357
Anti-Infectives for Patients with suspected MRSA (Single Response) [152423]
Page 5 of 15
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Treatment of Patients with Reported Allergies to Beta-
Lactam Antibiotics - Adult - Inpatient - Clinical Practice
Guidelin
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/infection-and-isolation/name-97535-
en.cckm
Cefepime - Vancomycin Note (Maximum Dose 2000 mg)
[226803]
cefepime (MAXIPIME) intraVENOUS [800016] 2 g, Intravenous, EVERY 8 HOURS
Do NOT delay administration of 1st dose pending sputum
collection. Give first dose NOW if not done in ED.
Note: Vancomycin Dosing Per Pharmacy [950027] CONTINUOUS
Maximum Dose of Vancomycin is 2 grams
For Severely Ill patients (ADD-ON) (Single Response) [208476]
tobramycin (NEBCIN) intraVENOUS [800081] 5 mg/kg, Intravenous, EVERY 24 HOURS
Do NOT delay admininstration of 1st dose pending sputum
collection. Give first dose NOW if not done in ED. NOTE: After
first dose, Pharmacy to adjust susequent doses.
Medications - General
Analgesics [31381]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain
See Pain management Algorithm for the Selection of As-
needed Analgesic
No more than 4 grams acetaminophen per 24 hours for adults
or 15mg/kg per dose for peds <40kg.
oxycodone tab RANGE [750032] 5-10 mg, Oral, EVERY 3 HOURS PRN, pain
See Pain management Algorithm for the Selection of As-
needed Analgesic
Anti-emetics [205886]
Adult - Standard - Anti-emetics [242135]
ondansetron (ZOFRAN ODT) disintegrating tab [64224] 4 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting
Use first line
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 6 HOURS PRN, nausea/vomiting
Use first line if unable to take medications by mouth or
enteral tube OR if immediate effect is needed.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN, nausea/vomiting
Use second line if there is inadequate response to first line
anti-emetic within 30 minutes. If there is no response to
second line therapy within 30 minutes, notify provider
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line. Use if there is inadequate response to first
line anti-emetic within 30 minutes and if unable to take
medications by mouth or enteral tube OR if immediate effect
is needed. If there is no response to second line therapy
within 30 minutes, notify provider
Bronchodilators [31384]
albuterol HFA (VENTOLIN HFA) 90 mcg/act inhaler
[53730]
2 puff, Inhalation, RT 4 X DAILY
albuterol neb soln (3 mL) [800248] 2.5 mg, Nebulization, RT 4 X DAILY
Bowel Management - As Needed [205887]
Adult - Bowel Management - Scheduled [240446]
senna-docusate (SENOKOT S) 8.6-50 MG per tab
[60530]
2 tab, Oral, 2 X DAILY
Adult - Bowel Management - As Needed [240448]
polyethylene glycol (MIRALAX) oral packet [61829] 17 g, Oral, 1 X DAILY PRN, constipation
First Line Therapy
magnesium hydroxide (MILK OF MAGNESIA) susp
[65443]
30 mL, Oral, 1 X DAILY PRN, constipation
Second line therapy, if no response to first line therapy within
12 hours
bisacodyl (DULCOLAX) rectal suppository [35231] 10 mg, Rectal, 1 X DAILY PRN, constipation
If unable to take medications by mouth or enteral tube OR if
need immediate laxation OR if failure of second line agent
after 6 hours
Immunosuppressants (Single Response) [31388]
methylprednisolone sodium succ. (SOLU-MEDROL)
intraVENOUS - 500 mg [800058]
500 mg, Intravenous, 1 X DAILY For 3 Doses
dexamethasone (DECADRON) intraVENOUS [800037] 2 mg, Intravenous, EVERY 8 HOURS
Page 6 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Hypnotics (Single Response) [228331]
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic interventions (see
RN Care Problem Sleep/Rest Disturbance Adult)
melatonin tab [119466] 3 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic interventions (see
RN Care Problem Sleep/Rest Disturbance Adult)
Trazodone - Melatonin [227992] "And" Linked Panel
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use first line.
Offer only after failure of non-pharmacologic interventions
(see RN Care Problem Sleep/Rest Disturbance Adult)
melatonin tab [119466] 3 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use second line if failure to respond to trazodone within 60
minutes
Offer only after failure of non-pharmacologic interventions
(see RN Care Problem Sleep/Rest Disturbance Adult)
Hypnotics (Single Response) [228334]
traZODONE (DESYREL) tab [720150] 25 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic interventions (see
RN Care Problem Sleep/Rest Disturbance Adult)
If needed, give prior to midnight if possible. May contribute to
sedation the following day.
melatonin tab [119466] 1 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic interventions (see
RN Care Problem Sleep/Rest Disturbance Adult)
Magnesium Sulfate (Single Response) [102289]
Magnesium Supplemental Scale [950039] PRN - NOTIFY PHARMACY WHEN NEEDED, magnesium
supplementation - see Admin Instructions
Non-cardiac patients: For serum magnesium 1.6-1.8 mg/dL - do
not replace
Cardiac patients: For serum magnesium 1.6-1.8 mg/dL give
0.05 g/kg IV x1
For serum magnesium 1.0-1.5 mg/dL give 0.1 g/kg IV x1
For serum magnesium less than 1 mg/dL give 0.15 g/kg IV x1
Administer each 2 gram bag over 3 hours at a frequency of one
bag every 4 hours.
Maximum 6 grams per replacement dose
Reminder: Pharmacist to adjust per UWHC Renal Dosing
Protocol if applicable
Magnesium Supplemental Scale - NOTE: Order in
patients with RENAL impairment (CrCl < 30 mL/min)
[950039]
PRN - NOTIFY PHARMACY WHEN NEEDED, magnesium
supplementation - see Admin Instructions
Non-cardiac patients: For serum magnesium 1.6-1.8 mg/dL - do
not replace
Cardiac patients: For serum magnesium 1.6-1.8 mg/dL give
0.025 g/kg IV x1
For serum magnesium 1.0-1.5 mg/dL give 0.05 g/kg IV x1
For serum magnesium less than 1 mg/dL give 0.075 g/kg IV x1
Administer each 2 gram bag over 3 hours at a frequency of one
bag every 4 hours.
Maximum 6 grams per replacement dose
Reminder: Pharmacist to adjust per UWHC Renal Dosing
Protocol if applicable
NOTE: Order in patients with RENAL impairment (CrCl < 30
mL/min)
Potassium Chloride - Intravenous (Single Response) [91079]
potassium chloride 20 mEq/ 50 mL bag CENTRAL LINE
ONLY [46256]
20 mEq, Intravenous, PRN, Potassium Supplementation - See
Administration Instructions
For serum potassium between 3.8 - 4.0 mmol/L give 20 mEq x1
For serum potassium between 3.5 - 3.7 mmol/L give 20 mEq x2
For serum potassium between 3.2 - 3.4 mmol/L give 20 mEq x3
for 60 Minutes
Page 7 of 15
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12/2017CCKM@uwhealth.org

potassium chloride 10 mEq/100 mL bag [46253] 10 mEq, Intravenous, PRN - NOTIFY PHARMACY WHEN
NEEDED, potassium supplementation - See Administration
Instructions
For serum potassium between 3.5 - 3.7 mmol/L give 10 mEq x1
For serum potassium between 3.2 - 3.4 mmol/L give 10 mEq x2
NOTE: Order for patients with renal impairment (CrCl less than
30 mL/min)
for 60 Minutes
Potassium Chloride - Oral Capsule (Single Response) [104019]
potassium chloride ER cap [49087] 20 mEq, Oral, PRN, potassium supplementation - See Admin
Instructions
For serum potassium between 3.8 - 4.0 mmol/L give 20 mEq x1
For serum potassium between 3.5 - 3.7 mmol/L give 20 mEq x2
For serum potassium between 3.2 - 3.4 mmol/L give 20 mEq x3
Swallow whole; do not break, chew, or open capsule
potassium chloride ER cap - NOTE: Order for patients
with renal impairment (CrCl less than 30 mL/min) [49087]
10 mEq, Oral, PRN, potassium supplementation - See
Administration Instructions
For serum potassium between 3.5 - 3.7 mmol/L give 10 mEq x1
For serum potassium between 3.2 - 3.4 mmol/L give 10 mEq x2
Swallow whole; do not break, chew, or open capsule
NOTE: Order for patients with renal impairment (CrCl less than
30 mL/min)
Vitamins/Minerals [31387]
magnesium elemental tab [720083] 250 mg, Oral, 2 X DAILY (AT MEALTIME)
calcium carbonate (TUMS) chew tab [44477] 1,000 mg, Oral, 2 X DAILY (AT MEALTIME)
cholecalciferol (VITAMIN D-3) tab [720036] 1,000 units, Oral, 1 X DAILY
Medications - For Cystic Fibrosis/Bronchiectasis Patients
Non-categorized [31380]
sodium chloride-sodium bicarbonate (SINU-CLEANSE)
nasal Kit [114345]
Nasal, 1 X DAILY
multivitamin cystic fibrosis cap [800234] Oral
Pancreatic Enzymes [108294]
Note: Self Administered Medication Program
Documentation [950000]
ONCE For 1 Doses
Patient may self-administer pancreatic enzymes
Note: Patient may use home supply of pancreatic
enzymes if available [950018]
ONCE For 1 Doses
Patient may use home supply of pancreatic enzymes if
available
pancrelipase (CREON) 12000 units delayed release cap
[136488]
Oral, 3 X DAILY (AT MEALTIME)
With meals
pancrelipase (CREON) 12000 units delayed release cap
[136488]
Oral, PRN, snacks
pancrelipase (CREON) 24000 units delayed release cap
[136489]
Oral, 3 X DAILY (AT MEALTIME)
pancrelipase (CREON) 24000 units delayed release cap
[136489]
Oral, PRN, snacks
pancrelipase (ZENPEP) 5000 units delayed release cap
[138296]
Oral, 3 X DAILY (AT MEALTIME)
With meals
pancrelipase (ZENPEP) 5000 units delayed release cap
[138296]
Oral, PRN
pancrelipase (ZENPEP) 10000 units delayed release cap
[138297]
Oral, 3 X DAILY (AT MEALTIME)
With meals
pancrelipase (ZENPEP) 10000 units delayed release cap
[138297]
Oral, PRN, snacks
pancrelipase (ZENPEP) 15000 units delayed release cap
[138298]
Oral, 3 X DAILY (AT MEALTIME)
With meals
pancrelipase (ZENPEP) 15000 units delayed release cap
[138298]
Oral, PRN, snacks
pancrelipase (ZENPEP) 20000 units delayed release cap
[138299]
Oral, 3 X DAILY (AT MEALTIME)
With meals
pancrelipase (ZENPEP) 20000 units delayed release cap
[138299]
Oral, PRN, snacks
Laboratory
Draw on Admission [29612]
Page 8 of 15
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CBC WITH DIFFERENTIAL [CBC] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
GLUCOSE [GLU] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
BUN [BUN] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
CREATININE [CRET] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
CALCIUM [CA] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
ALBUMIN [ALB] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
PROTEIN, TOTAL [TP] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
AST/SGOT [AST] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
ALKALINE PHOSPHATASE [ALKP] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
LD, TOTAL [LDH] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
GGT [GGT] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR [PT] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Page 9 of 15
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:54:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CMV QUANTITATIVE BY PCR [HCCMVDNA] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
EBV QUANTITATIVE BY PCR [HCEBVPCR] NEXT DRAW, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
HLA CLASS I DONOR SPECIFIC AB BY LUMINEX
[HCDSA1B]
NEXT DRAW, Starting today For 1 Occurrences, Routine
Indicate organ for transplant: Lung
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
HLA CLASS II DONOR SPECIFIC AB BY LUMINEX
[HCDSA2B]
NEXT DRAW, Starting today For 1 Occurrences, Routine
Indicate organ for transplant: Lung
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
BETA GLUCAN, (1,3) [HCGLUCAN] COLLECT UPON ADMISSION, 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?
GALACTOMANNAN, BLOOD [HCGLACTS] COLLECT UPON ADMISSION, 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?
PROCALCITONIN [HCPRCTON] STAT For 1 Occurrences, Routine, Accepted uses:
1. Diagnosis of community acquired pneumonia
2. Antibiotic de-escalation/discontinuation in patients improving
from bacterial pneumonia or culture-negative sepsis
It should NOT be ordered in the following conditions:
1. Evaluation of aspiration as it cannot differentiate chemical
from bacterial pneumonitis
2. Immunosuppressed patients
3. Culture-positive septicemia
4. Decompensated heart failure
5. Infectious disease syndromes other than pneumonia or
sepsis
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
CULTURE, BLOOD, BACTERIA/YEAST (2 SITES)
[116728]
.Practices for Blood Culturing Best This order equals 2 sites (4 bottles). See link below for
CULTURE, BLOOD, BACTERIA AND YEAST [GM4045] NEXT DRAW, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic episode.
Cultures on subsequent days are of minimal diagnostic
value. Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
Page 10 of 15
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:54:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CULTURE, BLOOD, BACTERIA AND YEAST [GM4045] NEXT DRAW, Routine, For optimum diagnosis of sepsis,
sample 3-4 sites only on the first day of a septic episode.
Cultures on subsequent days are of minimal diagnostic
value. Culture detects bacteria, Candida and Cryptococcus.
If filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
CULTURE, SPUTUM WITH GRAM STAIN [HCSPUCS] ONCE, Starting today For 1 Occurrences, Routine, For patients
with an ET tube or tracheostomy, quantitative mini-BAL by RT
or bronchoscopic BAL are the preferred methods of specimen
collection.
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
CULTURE, SPUTUM, CF PATIENT, WITH GRAM STAIN
[HCCFCS]
ONCE, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
CULTURE, URINE [URC] ONCE, Starting today For 1 Occurrences, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
STREP PNEUMONIAE AG, URINE [GM4545] 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?
LEGIONELLA URINARY AG [GM4910] 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?
C DIFF TOXIN B PCR, NAP1 IF POSITIVE [130522]
C DIFF TOXIN B PCR, NAP1 IF POSITIVE
[HCCDIFPCR]
ONCE, Starting today For 1 Occurrences, Routine, Reserve
testing for patients with 3 or more unformed stools in 1 or
more days. Do not repeat a negative test within 7 days. Do
not perform for test of cure. Samples positive for the C.
difficile toxin B gene (tcdB) will also be tested for the
hypervirulent epidemic strain (O27/NAP1/BI).
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Enhanced Contact Isolation - CDIFF or Acute
Gastroenteritis [ISO0348]
What is the reason for isolation? CDIFF
Page 11 of 15
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:54:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

RESPIRATORY VIRUS PANEL WITH BORDETELLA,
PCR [RVPBPCR]
ONCE For 1 Occurrences, Routine, The Respiratory Virus
Panel with Bordetella test includes detection of the following:
Influenza A, Influenza A subtype H1, Influenza A subtype H3,
Influenza B, RSV A, RSV B, Parainfluenza 1, Parainfluenza 2,
Parainfluenza 3, Parainfluenza 4, Human Metapneumovirus,
(hMPV), Human Rhinovirus, Adenovirus, Bordetella pertussis,
Bordetella parapertussis/bronchiseptica, and Bordetella
holmesii.
This test is most appropriate for transplant and select other
immunocompromised patients. All others should consider
'Influenza A, Influenza B, and RSV by PCR'- [HCFLURSV].
During peak influenza season consider ordering 'Influenza A,
Influenza B, and RSV by PCR'- [HCFLURSV].
If testing for only Bordetella species is desired, order
'Bordetella species by PCR ' - [BORDPCR]
Collect Nasopharyngeal Minitip swab (flocked swab) and place
in UTM. BAL is also acceptable. Room temperature M4
(M4RT) is not acceptable.
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Influenza A and B and RSV Detection [130091]
INFLUENZA A AND B AND RSV DETECTION
[HCFLURSV]
ONCE For 1 Occurrences, Routine, Includes Influenza A and
B by PCR and RSV by PCR.
Collect Nasopharyngeal Minitip swab (flocked swab) and
place in UTM. Refrigerated M4 viral media and room
temperature M4 (M4RT) are not acceptable.
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
Contact/Droplet Isolation - Respiratory Virus [ISO0342] What is the Reason for Isolation?
Draw in AM [29644]
CYCLOSPORINE [XCYCA] SPECIFIC TIME, Starting tomorrow at 7:00 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?
TACROLIMUS [HCTAC] SPECIFIC TIME, Starting tomorrow at 7:00 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?
CBC WITHOUT DIFFERENTIAL [HEMO] 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?
ELECTROLYTES [LYTE] 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?
GLUCOSE [GLU] 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?
BUN [BUN] 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?
Page 12 of 15
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:54:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CREATININE [CRET] 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?
CALCIUM [CA] 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?
MAGNESIUM [MAG] 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?
MYCOPHENOLATE [HCMPA] 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?
Conditional Labs [29645]
POTASSIUM [K] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Draw 1 hour after IV
replacement and 4 hours after oral replacement
MAGNESIUM [MAG] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Draw AM following completion
of infusion
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [29646]
X-RAY CHEST AP VIEW [R71010] ONCE-ON SPECIFIC DATE, Starting tomorrow For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by this
exam?
Relevant recent/past history? Status post lung transplant
Is patient pregnant?
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
CT CHEST W/ O IV CONTRAST [R71250] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: CT
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:
Bronchoscopy [PUL0001] ONCE, Starting tomorrow For 1 Occurrences, Routine
Reason for Exam: Status post lung transplant
In AM.
Consults
Consults [29647]
Diabetes Consult Order Panel (Adult) [188497]
Page 13 of 15
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:54:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

Diabetes Management Service : Will provide management or treatment recommendations for patients with
hyperglycemia and/or those who report outpatient use of insulin or other diabetes medications. Patients should
be expected to remain inpatient > 24 hrs from time of consult. Consult is required for patients with insulin pumps
or who use U-500 insulin. Consult Endocrine for any non-diabetes-related endocrine questions.
Learning Center - Diabetes Education (Adult): Diabetes Education (Adult): Diabetes education (meter/insulin
skills/other diabetes survival skills) for patients/families with knowledge deficits and/or need for diabetes
knowledge assessment. Recommended for all new diagnoses or patients with A1C > 9.
Diabetes Education – Nutrition : Diabetes nutrition therapy including nutrition assessment, carbohydrate
education (consistent carbohydrate meals, use of insulin-to-carbohydrate ratio), and/or individualized, nutritious
meal planning for carbohydrates, portions, or considering other comorbidities. Recommended for all new
diagnoses or patients with A1C > 9
Consult Diabetes Management Service (DMS) (Inpatient)
[CON0022]
ONCE
Can this consult be done via video?
Call back number:
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Consult Learning Center - Diabetes Education (Adult)
[CON0021]
ONCE, Routine, - If patient is newly diagnosed or is new to
insulin, provide 24 hours notice to allow adequate time for
education,
- Indicate diabetes medication/treatment plan if known.
- Consults requested after 1600 on Fridays may not be seen
until following Monday. Learning Center available Mon-Sat
0800-1630 (only 1 RN available on Saturday for CSC and
AFCH).
- Staff may be contacted by Pager 7927 on weekdays and
Pager 3276 on weekends.
- Learning Center staff are not available on holidays.
Type of Education: Diabetes Self-Management Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Consult Diabetes Education - Nutrition (Inpatient)
[CON0126]
ONCE, Routine, · If your patient is newly diagnosed and/or is
new to insulin therapy, provide 24 hours notice to allow
adequate time for nutrition education.
· Indicate diabetes medication/treatment plan if known.
· Consults requested after 1300 on Friday may not be
completed until the following Monday.
· If you are placing a consult on a weekend day for a patient
who will be discharging that weekend, please have the
Paging Center contact the on-call dietitian to help you
facilitate the diabetes nutrition education session prior to the
patient's discharge.
Type of Education: Diabetes Self-Management Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Consult Infectious Disease (Inpatient) [CON0037] 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 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: Evaluation of nutritional needs.
Page 14 of 15
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:54:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Consult Transplant Nephrology (Inpatient) [CON0083] 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:
BestPractice
No Hospital Problems have yet been identified. [107035]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on signing.
Page 15 of 15
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:54:52 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org