/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-97926-en.cckm

201706156

page

100

UWHC,UWMF,

Tools,

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

IP - Renal Transplant - Pediatric - Preoperative [2719]

IP - Renal Transplant - Pediatric - Preoperative [2719] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Transplant


IP - Renal Transplant - Pediatric - Preoperative [2719]
Patient Care Orders
Vital Signs [85104]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
While awake., Pre-Op Day Of Procedure
Activity [85105]
Ambulate Ad Lib [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: ad lib
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Pre-Op Day Of Procedure
Nutrition [85106]
Clear Liquid Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Pediatric
Diet Type: Diet Modifications
Diet Modifications: Liquid
Liquid: Clear Liquid
No Red or Purple Dye:
Liquid Thickness: Thin
Bedside Meal Instructions:
Room Service Class:
Pre-Op Day Of Procedure
NPO for Procedure - Hold Diet [DIE0007] EFFECTIVE MIDNIGHT, Starting today For 1 Days,
Routine
NPO For Which Procedure? Renal Transplant
Modifiers: STRICT NPO
Pre-Op Day Of Procedure
Non-Categorized Patient Care Orders [85107]
Wrap Fistula or Dialysis Graft Lightly with
Wrapping Gauze (KERLIX) and Label
[NURWND0018]
ONCE, Starting today For 1 Occurrences, Pre-Op
Day Of Procedure
Pre-Transplant Verfication Flowsheet
[NURCOM0022]
ONCE For 1 Occurrences, Please comment in the
Pre-Transplant Verification Flowsheet. Call B4/6 with
questions (263-8737), Pre-Op Day Of Procedure
Contingency Parameters for Child Less Than 2 Years of Age [107913]
Page 1 of 11
Printed by STRAKA, KEVIN F [KFS1] at 5/31/2017 4:16:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
If systolic blood pressure > (mmHg): 120
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 75
If diastolic blood pressure < (mmHg):
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): ***
If blood glucose < (mg/dL): ***
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): *** mL/hour
Other: Central venous pressure less than ***
mmHg,Sudden decrease in urine output,Notify
Pediatric Nephrologist and Transplant Fellow when
Patient Arrives to Floor
Pre-Op Day Of Procedure
Contingency Parameters for Patients 2 to 12 Years of Age [107914]
Notify Provider [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
If systolic blood pressure > (mmHg): 130
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg): 85
If diastolic blood pressure < (mmHg):
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): ***
If blood glucose < (mg/dL): ***
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): *** mL/hour
Other: Central venous pressure less than ***
mmHg,Sudden decrease in urine output,Notify
Pediatric Nephrologist and Transplant Fellow when
Patient Arrives to Floor
Pre-Op Day Of Procedure
Contingency Parameters for Patients Greater than 12 Years of Age [107915]
Page 2 of 11
Printed by STRAKA, KEVIN F [KFS1] at 5/31/2017 4:16:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Notify Provider [NURCOM0001] CONTINUOUS
Provider to Notify: Provider
If systolic blood pressure > (mmHg): 140
If systolic blood pressure < (mmHg): 110
If diastolic blood pressure > (mmHg): 95
If diastolic blood pressure < (mmHg):
If temperature > (C): 38
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): ***
If blood glucose < (mg/dL): ***
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): *** mL/hour
Other: Central venous pressure less than ***
mmHg,Sudden decrease in urine output,Notify
Pediatric Nephrologist and Transplant Fellow when
Patient Arrives to Floor
Pre-Op Day Of Procedure
Respiratory [107916]
OG Tube Placement - Pediatric [121660]
Insert and Maintain Orogastric Tube
[NURTAD0015]
CONTINUOUS, Routine
Options:
Flush with:
Flush Frequency: EVERY 8 HOURS
Check Residual:
Does this need to be inserted/placed?
Device Status:
Recommendations for flush quantity:
For patients < 30 kg, use 1mL of fluid per 1 kg.
For patients >30 kg, 30 mLs of fluid should be
sufficient.
In general, consider the amount of fluid needed to
clear the tube and patient’s fluid status before
determining flush quantity., Pre-Op Day Of
Procedure
X-RAY ABDOMEN AP VIEW (KUB) [R74000] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms?
What specific question(s) would you like answered
by this exam? Evaluate orogastric tube placement
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
If Conditional, What Condition? Evaluate orogastric
tube placement. The location of orogastric tube
should be confirmed prior to the instillation of fluids,
medications, or feedings. Refer to Policy 2.20
Enteral Tubes Used for Instillation of Fluids,
Medications, or Feeding
Pre-Op Day Of Procedure
Page 3 of 11
Printed by STRAKA, KEVIN F [KFS1] at 5/31/2017 4:16:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Intravenous Therapy
Premedication for Needle Insertion [84316]
Lidocaine [152737]
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, prior to needle
sticks to reduce pain. See "LMX Use Instructions"
order in Active Orders report or the Admin
Instructions for application details
FOR PATIENTS 5 Kg OR LESS: Do NOT apply to
area greater than 100 square centimeters.
(maximum 1 g/site; maximum 1 site per hour, 6
times per day).
FOR PATIENTS 5.1-10 Kg: Do NOT apply to area
greater than 100 square centimeters. (maximum 1
g/site; maximum 2 sites per hour, 6 times per day).
FOR PATIENTS GREATER THAN 10 Kg: Do NOT
apply to area greater than 200 square centimeters.
(maximum 2.5 g/site; maximum 4 sites per hour, 6
times per day).
For patients less than 1 year old do NOT leave on
longer than 1 hour. For patients 1 year or older do
NOT leave on longer than 2 hours
Pre-Op Day Of Procedure
LMX Use Instructions for Premedication Prior to
Needle Insertion [NURCOM0095]
Pre-Op Day Of Procedure
IV Fluids [108079]
dextrose 2.5%-NaCl 0.2% with 30 mEq sodium
bicarbonate - NOTE: Suggested rate 0.5
mL/kg/hr [710000]
Intravenous, CONTINUOUS
Base equivalent to dextrose 2.5%-NaCl 0.2%. Send
to OR
NOTE: Suggested rate 0.5 mL/kg/hr
Surgical Prophylaxis
First Line (Single Response) [85113]
cefazolin (ANCEF) intraVENOUS - NOTE:
Suggested dose 30 mg/kg (Maximum 2 g/dose)
[800000]
30 mg/kg, Intravenous, ON CALL For 1 Doses
Send on call to OR Administer over 30 minutes
NOTE: Suggested dose 30 mg/kg (Maximum 2
g/dose)
IntraOp
MRSA / Documented MRSA History (Single Response) [148723]
Order Both Cefazolin and Vancomycin [146545]
cefazolin (ANCEF) intraVENOUS [800000] 30 mg/kg, Intravenous, ON CALL For 1 Doses,
IntraOp
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Severe or Immediate IgE-Mediated Reaction (Single Response) [148728]
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, ON CALL For 1 Doses, Pre-
Op Day Of Procedure
Medications
Analgesics [85112]
Page 4 of 11
Printed by STRAKA, KEVIN F [KFS1] at 5/31/2017 4:16:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

aspirin rectal suppository - NOTE: Suggested
dose 10 mg/kg (Maximum dose 300 mg) [34799]
Rectal, ON CALL For 1 Doses
Give when called to operating room
NOTE: Suggested dose 10 mg/kg (Maximum dose
300 mg)
Pre-Op Day Of Procedure
Immunosuppressants - Zero Mismatch [85115]
mycophenolate mofetil (CELLCEPT) susp -
NOTE: Suggested dose 300 mg/m2/dose
(Maximum dose 1 g) [61374]
300 mg/m2, Oral, ONCE Starting today at 8:00 PM
For 1 Doses
Give at 2000 day prior to surgery
NOTE: Suggested dose 300 mg/m2/dose (Maximum
dose 1 g)
IntraOp
prednisolone (PRELONE) syrup - NOTE:
Sugested dose 2 mg/kg/dose (Maximum dose 80
mg) [46299]
2 mg/kg, Oral, ONCE (HS) For 1 Doses
Give at 2000 night before surgery
NOTE: Sugested dose 2 mg/kg/dose (Maximum dose
80 mg)
Pre-Op Day Of Procedure
Immunosuppressants - Non-HLA Identical [85116]
basiliximab (SIMULECT) bag - NOTE: Suggested
dose 12 mg/m2 (Maximum 20 mg/dose) [700156]
12 mg/m2, Intravenous, ONCE For 1 Doses
Administer over 30 minutes two hours prior to
transplant
NOTE: Suggested dose 12 mg/m2 (Maximum 20
mg/dose)
IntraOp
methylprednisolone sodium succ. (SOLU-
MEDROL) intraVENOUS [800058]
10 mg/kg, Intravenous, ONCE For 1 Doses
Send to OR
NOTE: Suggested dose 10 mg/kg (Maximum 1000
mg/dose)
IntraOp
alemtuzumab (CAMPATH) bag [700039] 20 mg/m2, Intravenous, ONCE For 1 Doses
Administer dose in OR after methylprednisolone
IntraOp
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose
10mg/kg/dose (Maximum dose 650 mg) [800005]
10 mg/kg, Oral, ONCE For 1 Doses
Premedication for alemtuzumab
NOTE: Suggested dose 10mg/kg/dose (Maximum
dose 650 mg)
IntraOp
diphenhydramine (BENADRYL) injection - NOTE:
Suggested dose 1 mg/kg/dose. (Maximum dose
50 mg) [800106]
1 mg/kg, Intravenous, ONCE For 1 Doses
Premedication for alemtuzumab
Wound Irrigations [85117]
gentamicin irrigation POUR bottle 50 mg/500 mL
[700311]
Irrigation, ON CALL For 1 Doses
Send to OR for bladder irrigation
IntraOp
bacitracin 50,000 Units, gentamicin
(GARAMYCIN) 20 mg in sodium chloride 0.9%
200 mL POUR bottle [700309]
Irrigation, ON CALL For 1 Doses
Send to OR for wound irrigation
IntraOp
sodium bicarbonate 22.3 mEq, mannitol 25 g,
heparin 10,000 Units in lactated ringers 1,000 mL
- NOTE: Order for living related transplants
[700344]
Irrigation, ON CALL For 1 Doses
Send to OR
IntraOp
Laboratory
Laboratory [85120]
Page 5 of 11
Printed by STRAKA, KEVIN F [KFS1] at 5/31/2017 4:16:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
PTT [PTT] 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?
Pre-Op Day Of Procedure
LIPID PANEL [LIPID] NEXT DRAW, 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 or black coffee
during the fasting period.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
PHOSPHATE [PHOS] 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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
Page 6 of 11
Printed by STRAKA, KEVIN F [KFS1] at 5/31/2017 4:16:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
Liver Function Tests [85121]
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
Renal Function Tests [85122]
BETA-2 MICROGLOBULIN [XB2MS] 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?
Pre-Op Day Of Procedure
Page 7 of 11
Printed by STRAKA, KEVIN F [KFS1] at 5/31/2017 4:16:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Viral Test Labs [85123]
HEPATITIS A AB, IGG [HAVIGG] 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?
Pre-Op Day Of Procedure
HEPATITIS B SURFACE AB (IMMUNE
STATUS) [HBSABI]
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?
Pre-Op Day Of Procedure
HEPATITIS B SURFACE AG [HBSAG] 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?
Pre-Op Day Of Procedure
HEPATITIS B CORE AB, TOTAL [HBCAB] 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?
Pre-Op Day Of Procedure
HEPATITIS C AB [HCV] 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?
Pre-Op Day Of Procedure
CMV IGG AB [XCMVG] 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?
Pre-Op Day Of Procedure
VARICELLA ZOSTER AB, IGG [VZIGG] 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?
Pre-Op Day Of Procedure
EBV AB TO VIRAL CAPSID AG, IGG
[HCEBVIGG]
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?
Pre-Op Day Of Procedure
Page 8 of 11
Printed by STRAKA, KEVIN F [KFS1] at 5/31/2017 4:16:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

HIV AB/AG COMBO [HIVABAG] NEXT DRAW, 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?
Pre-Op Day Of Procedure
Peritoneal Fluid Labs [85124]
CULTURE, BODY FLUID WITH GRAM STAIN
[HCBFC]
ONCE, Starting today For 1 Occurrences, Routine,
For peritoneal, pericardial, pleural, synovial and
dialysate fluids order Culture, Body Fluid, Aer/Ana
with Gram stain and use blood culture bottles.
Indicate source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pre-Op Day Of Procedure
CELL COUNT, PERITONEAL FLUID [HCPECC] ONCE, Starting today For 1 Occurrences, Routine
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?
Pre-Op Day Of Procedure
Urine Labs [85125]
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?
Pre-Op Day Of Procedure
Page 9 of 11
Printed by STRAKA, KEVIN F [KFS1] at 5/31/2017 4:16:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

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?
Pre-Op Day Of Procedure
PROTEIN, URINE [UTPR] 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?
Pre-Op Day Of Procedure
CREATININE, URINE [UCRR] 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?
Pre-Op Day Of Procedure
Histocompatability [85126]
HLA FLOW CROSSMATCH, PRE-TX
[HCHLAFXM]
NEXT DRAW, 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?
Pre-Op Day Of Procedure
Laboratory - For Patients Receiving CDC High Risk Donor [94389]
HIV-1 RNA, QUANTITATIVE [XHIV1] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, This test is not used for the
diagnosis of HIV-1 infection. This test is used to
determine viral burden in known HIV-1 positive
patients.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? For patients receiving
CDC high risk donor
Pre-Op Day Of Procedure
HEPATITIS C RNA, QUANT, PCR [XHCVRQ] STAT - RN COLLECT, 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 receiving
CDC high risk donor
Pre-Op Day Of Procedure
HEPATITIS B DNA, ULTRA QUANT, PCR
[XHBVD]
STAT - RN COLLECT, 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 receiving
CDC high risk donor
Pre-Op Day Of Procedure
Tests
Tests [100542]
Page 10 of 11
Printed by STRAKA, KEVIN F [KFS1] at 5/31/2017 4:16:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

TYPE AND SCREEN [HCTS] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, As good clinical practice and
for patient safety, the Transfusion Service will
automatically crossmatch 2 packed RBCs on all
patients with antibodies to ensure blood would be
available in the event it is needed. If you would like to
opt out of this automatic order for this patient please
contact the UWHC Blood Bank at (608) 263-8367 or
The American Center Lab at (608) 234-6600 as
appropriate.
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [85134]
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: OTHER (COMMENT)
Pre-Op Day Of Procedure
X-RAY CHEST PA & LAT VIEWS [R71020] 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? Major surgery, End Stage Renal Disease
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Pre-Op Day Of Procedure
Consults
Consults [85136]
Consult Pediatric Renal - Nephrology (Inpatient)
[CON0100]
ONCE
Intent:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis): Pre-renal
Transplant; End Stage Renal Disease
Pre-Op Day Of Procedure
Consult Transplant Financial Coordinator
[CON0157]
ONCE, Routine
Reason for Consult: To register for Medicare
Can this consult be done via video?
Pre-Op Day Of Procedure
Page 11 of 11
Printed by STRAKA, KEVIN F [KFS1] at 5/31/2017 4:16:32 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org