/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-97928-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 - Renal/Pancreas Transplant - Adult - Preoperative [2693]

IP - Renal/Pancreas Transplant - Adult - Preoperative [2693] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Transplant


IP - Renal/Pancreas Transplant - Adult - Preoperative [2693]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [187484]
*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 [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] 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:
Pre-Op Day Of Procedure
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admission Status [106266]
Page 1 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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:
Pre-Op Day Of Procedure
Admission Status [84058]
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:
Pre-Op Day Of Procedure
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Pre-Op Day Of Procedure
VTE Prophylaxis
VTE Prophylaxis [106118]
• If low risk for development of VTE - select VTE Prophylaxis - Reason Not Ordered
• If requires VTE prophylaxis AND
◦ LOW bleed risk - select pharmacologic agent only
◦ ABSOLUTE bleed risk - select mechanical agents only
◦ HIGH bleed risk - weigh risk of bleed vs risk of VTE development and select drug OR
mechanical agent
NOTE: Mechanical and pharmacologic agents should only be used together in patients
with a very high risk of VTE development
VTE Risk Factor Assessment Tool URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Sequential Compression Device (SCD) Panel
(TREATMENT AND SUPPLY) [206111]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
IntraOp
Page 2 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
IntraOp
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Pre-Op Day Of Procedure
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, ON CALL For 1 Doses
If patient scheduled for block, give after block placed
IntraOp
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE For 1 Occurrences, Routine
Reason Not Ordered:
Pre-Op Day Of Procedure
Patient Care Orders
Vital Signs [84066]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Pre-Op Day Of Procedure
Activity [84067]
Ambulate - Ad Lib [NURACT0008] CONTINUOUS, Starting today For Until specified,
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 [84350]
NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Pre-Op Day Of Procedure
Page 3 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Clear Liquid Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
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/Pancreas
Transplant
Modifiers: NPO EXCEPT MEDICATIONS
Pre-Op Day Of Procedure
Patient Monitoring [136299]
Measure Height [NURMON0052] ONCE For 1 Occurrences, Routine, Measure upon
admission. Must measure using anthropometric
"measuring rod", Pre-Op Day Of Procedure
Measure Weight - Once Upon Admission
[NURMON0015]
ONCE For 1 Occurrences, Routine
Weigh With?
Weigh when?
Pre-Op Day Of Procedure
Maintain Urinary Catheter [NURELM0013] CONTINUOUS, Routine, To discontinue this order,
enter a new order for "Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes in
the new order.
Type:
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Post-Op/Phase II
NG Tube Placement - Adult [120994]
Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Routine
Options:
Flush with: Normal saline
Flush Frequency: PRN
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed?
Device Status:
Refer to Policy 2.20 Enteral Tubes Used for
Instillation of Fluids, Medications, or Feeding
Recommendations for flush quantity:
For adult patients, 30 mLs of fluid should be
sufficient., Post-Op/Phase II
Page 4 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

lidocaine-oxymetazoline 4%-0.05% (ADULT)
nasal spray [785081]
2 spray, Nasal, ONCE For 1 Doses
For numbing prior to feeding tube insertion.
Slowly spray the chosen nostril once, if required may
repeat x1 in opposite nostril. Angle toward back of
throat spraying the anterior nostril and wait 30-60
seconds before introducing more local
anesthetic into the nostril. Caution: Entire bottle
should not be used for insertion of tube. Discard
excess solution when procedure completed.
Post-Op/Phase II
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 nasogastric 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 nasogastric
tube placement. The location of nasogastric 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
Post-Op/Phase II
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
INTERMITTENT (MAY REMOVE WHEN OFF
UNIT/BATHING), Starting today, Routine
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Post-Op/Phase II
Maintain Drain [NURTAD0003] CONTINUOUS, Starting today, Routine
Type: Closed Suction (Jackson-Pratt)
Site:
Location:
Drainage Options: Bulb
Irrigate Frequency:
Irrigate With:
Irrigant Volume (mL):
Strip:
Strip For:
Dressing Change Frequency:
Dressing Type:
Post-Op/Phase II
Non-Categorized Patient Care Orders [84351]
Pre-Transplant Verification Flowsheet
[NURCOM0022]
ONCE For 1 Occurrences, Please comment Pre-
Transplant Verification Flowsheet. Call B4/6 with
questions (263-8737).
Heel Protector (Foot Pillow and Positioner)
[NURCOM0022]
CONTINUOUS, Starting today, Prior to going to OR,
Pre-Op Day Of Procedure
Page 5 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] EVERY 4 HOURS, Starting today For 1 Occurrences,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia management
and monitoring as indicated in the Hypoglycemia
Management (Adult) panel.
If Conditional, What Condition?
Pre-Op Day Of Procedure
Contingency Parameters [84352]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg): 90
If diastolic blood pressure > (mmHg): 110
If diastolic blood pressure < (mmHg): 60
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 60
If respiratory rate >: 20
If respiratory rate <: 8
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other:
Pre-Op Day Of Procedure
Medications - Oral Hypoglycemia Treatment [154528]
Wisconsin Insulin Infusion Practice Protocol URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/?path=/content/delegationpractice-
protocols/practice-protocols/name-97448-en.cckm
Adult Hypoglycemia Treatment Algorithm" URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/diabetes-and-
endocrinology/related/name-97511-en.cckm
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? For blood glucose less
than 40 mg/dL and patient able to eat/swallow safely
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or greater,
Pre-Op Day Of Procedure
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today
If Conditional, What Condition? For blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or greater,
Pre-Op Day Of Procedure
glucose-vitamin C chew tab [50690] 16-32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference
For blood glucose 40-69 mg/dL give 16 g (4 tablets);
For blood glucose less than 40 mg/dL give 32 g (8
tablets).
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater
Pre-Op Day Of Procedure
Page 6 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Medications - Parenteral Hypoglycemia Treatment [154532]
Adult Hypoglycemia Treatment Algorithm URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/diabetes-and-
endocrinology/related/name-97511-en.cckm
glucagon 1 mg injection kit [107799] 1 mg, Subcutaneous, PRN, per hypoglycemia
treatment algorithm, Pre-Op Day Of Procedure
dextrose injection [800233] 12.5-25 g, Intravenous, PRN, per hypoglycemia
treatment algorithm, Pre-Op Day Of Procedure
Intravenous Therapy
Premedications for Needle Insertion [230426]
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.
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Pre-Op Day Of Procedure
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
Pre-Op Day Of Procedure
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.
Pre-Op Day Of Procedure
IV Fluids [84356]
dextrose 5%-NaCl 0.45% infusion [51613] at 50 mL/hr, Intravenous, CONTINUOUS, Pre-Op Day
Of Procedure
Medications - Pre-operative
Bowel Prep [84358]
Tap water enema rectally once preoperative
[NURCOM0022]
ONCE, Starting today For 1 Occurrences, Pre-Op Day
Of Procedure
erythromycin base (E-MYCIN) tab [37229] 1,000 mg, Oral, EVERY 2 HOURS For 3 Doses
Start on admission
Pre-Op Day Of Procedure
neomycin tab [40142] 1,000 mg, Oral, EVERY 2 HOURS For 3 Doses
Start on admission
Pre-Op Day Of Procedure
Aspirin [111850]
aspirin rectal suppository [34799] 300 mg, Rectal, ONCE For 1 Doses, Pre-Op Day Of
Procedure
Anti-emetics [241927]
Adult - Standard - Anti-emetics [241932]
Page 7 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line
Pre-Op Day Of Procedure
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.
Pre-Op Day Of Procedure
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
Pre-Op Day Of Procedure
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
Pre-Op Day Of Procedure
Anti-hypertensives [221595]
cloNIDINE (CATAPRES) tab [720040] 0.1 mg, Oral, EVERY 4 HOURS PRN, Systolic blood
pressure (SBP) greater than 170 mmHg or diastolic
blood pressure greater than 100 mmHg
For first line therapy. Max of 4 doses in 24 hours
Pre-Op Day Of Procedure
labetalol (NORMODYNE;TRANDATE) injection
RANGE [750053]
10-20 mg, Intravenous, EVERY 1 HOUR PRN,
Systolic blood pressure (SBP) greater than 170 mmHg
or diastolic blood pressure greater than 100 mmHg
For second line therapy. Administer if unable to
tolerate orally or no response to clonidine and heart
rate is greater than or equal to 85 beats per minute
for 2 Minutes, Pre-Op Day Of Procedure
hydrALAZINE (APRESOLINE) injection [750049] 10-20 mg, Intravenous, EVERY 1 HOUR PRN, blood
pressure greater than 170/100 mmHg
For second line therapy. Administer if patient unable to
tolerate orally or no response to first line therapy and
heart rate is less than 85 beats per minute
Pre-Op Day Of Procedure
Medications - Diabetes
Oral Treatment [154150]
Wisconsin Insulin Infusion Standard Dose-Adult
Practice Protocol
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/delegationpractice-
protocols/practice-protocols/related/name-97442-
en.cckm
Wisconsin Insulin Infusion HIGH dose-Adult-
Practice Protocol (ICU only)
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/delegationpractice-
protocols/practice-protocols/related/name-97441-
en.cckm
Page 8 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Adult Hypoglycemia Treatment Algorithm URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/diabetes-and-
endocrinology/related/name-97511-en.cckm
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? For blood glucose less
than 40 mg/dL and patient able to eat/swallow safely
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or greater,
Pre-Op Day Of Procedure
Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today
If Conditional, What Condition? For blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or greater,
Pre-Op Day Of Procedure
glucose-vitamin C chew tab [50690] 16-32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia
Use in patients able to safely eat/swallow but unable
to tolerate volume of fruit juice or per patient
preference
For blood glucose 40-69 mg/dL give 16 g (4 tablets);
For blood glucose less than 40 mg/dL give 32 g (8
tablets).
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater
Pre-Op Day Of Procedure
Parenteral Treatment [154151]
Adult Hypoglycemia Treatment Algorithm URL: https://uconnect.wisc.edu/clinical/references/ed-
resources/adult-hypoglycemia-treatment/
glucagon 1 mg injection kit [107799] 1 mg, Subcutaneous, PRN, per hypoglycemia
treatment algorithm, Pre-Op Day Of Procedure
dextrose injection [800233] 12.5-25 g, Intravenous, PRN, per hypoglycemia
treatment algorithm, Pre-Op Day Of Procedure
Medications - Intra-operative
Purine Synthesis Inhibitors [154153]
mycophenolate (CELLCEPT) intraVENOUS
[800198]
1,000 mg, Intravenous, ON CALL For 1 Doses
Send to O.R.
IntraOp
Note: Send Medications To: [950055] ON CALL For 1 Doses, IntraOp
Steroids [84362]
dexamethasone (DECADRON) intraVENOUS
[800037]
100 mg, Intravenous, ON CALL For 1 Doses
Send to OR
IntraOp
Wound Irrigations [84363]
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
IntraOp
amphotericin B CONVENTIONAL (FUNGIZONE)
50 mg in water (sterile) 1,000 mL POUR bottle
[700307]
Irrigation, ON CALL For 1 Doses
Send to OR
IntraOp
Note: Send Medications To: [950055] ON CALL For 1 Doses, IntraOp
Surgical Prophylaxis
First Line (Single Response) (Single Response) [197081]
URL:
Page 9 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

URL:
URL:
Patients weighing 80 kg or less [224509]
ampicillin (OMNIPEN) intraVENOUS [800009] 2 g, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
IntraOp
ceftriaxone (ROCEPHIN) intraVENOUS [800027] 1 g, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
IntraOp
fluconazole (DIFLUCAN) intraVENOUS [800044] 400 mg, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
Pre-Op Day Of Procedure
Patients weighing greater than 80 kg [224512]
ampicillin (OMNIPEN) intraVENOUS [800009] 2 g, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
IntraOp
ceftriaxone (ROCEPHIN) intraVENOUS [800027] 2 g, Intravenous
SEND ON CALL TO OR
IntraOp
fluconazole (DIFLUCAN) intraVENOUS [800044] 400 mg, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
Pre-Op Day Of Procedure
MRSA/Documentd MRSA History (Single Response) [197082]
URL:
URL:
URL:
Patients 40 - 160 kg [239953]
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
Pre-Op Day Of Procedure
ceftriaxone (ROCEPHIN) intraVENOUS [800027] 2 g, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
IntraOp
fluconazole (DIFLUCAN) intraVENOUS [800044] 400 mg, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
Pre-Op Day Of Procedure
Patients 161 kg and greater [239956]
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
Pre-Op Day Of Procedure
ceftriaxone (ROCEPHIN) intraVENOUS [800027] 3 g, Intravenous
SEND ON CALL TO OR
IntraOp
fluconazole (DIFLUCAN) intraVENOUS [800044] 400 mg, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
Pre-Op Day Of Procedure
MRSA Negative and Severe/Immediate Reactions to Penicillin or Known Cephalosporin Allergies (Single
Response) [197083]
URL:
URL:
URL:
Patients 40 - 160 kg [226823]
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
Pre-Op Day Of Procedure
Page 10 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

levofloxacin (LEVAQUIN) intraVENOUS [800052] 500 mg, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
IntraOp
fluconazole (DIFLUCAN) intraVENOUS [800044] 400 mg, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
Pre-Op Day Of Procedure
Patients 161 kg and greater [226825]
vancomycin (VANCOCIN) intraVENOUS
[800084]
15 mg/kg, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
Pre-Op Day Of Procedure
levofloxacin (LEVAQUIN) intraVENOUS [800052] 750 mg, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
IntraOp
fluconazole (DIFLUCAN) intraVENOUS [800044] 400 mg, Intravenous, ON CALL For 1 Doses
SEND ON CALL TO OR
Pre-Op Day Of Procedure
Patients with IgE-mediated or severe reaction to Beta-lactam AND MRSA or history of MRSA or MRSE
Risk (Single Response) [239972]
URL:
URL:
URL:
Patients who are 40 kg and greater [239975]
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Send on call to OR
Pre-Op Day Of Procedure
aztreonam (AZACTAM) intraVENOUS [800013] 2 g, Intravenous, ON CALL For 96 Hours
Send on call to OR
IntraOp
fluconazole (DIFLUCAN) intraVENOUS [800044] 400 mg, Intravenous, ON CALL For 1 Doses
Send on call to OR
Pre-Op Day Of Procedure
Laboratory
Laboratory [84366]
CBC WITH DIFFERENTIAL [CBC] 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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
Page 11 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
GGT [GGT] 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?
Pre-Op Day Of Procedure
LD, TOTAL [LDH] 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?
Pre-Op Day Of Procedure
MAGNESIUM [MAG] 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?
Pre-Op Day Of Procedure
AMYLASE [AMYL] 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?
Pre-Op Day Of Procedure
Page 12 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

LIPASE [LIPS] 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?
Pre-Op Day Of Procedure
LIPID PANEL [FVLIPID] 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?
Pre-Op Day Of Procedure
PHOSPHATE (Inorganic) [PHOS] 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?
Pre-Op Day Of Procedure
PROTHROMBIN TIME/INR [PT] 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?
Pre-Op Day Of Procedure
PTT [PTT] 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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
Page 13 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

HLA FLOW CROSSMATCH, PRE-TX
[HCHLAFXM]
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?
Pre-Op Day Of Procedure
HLA CLASS I DONOR SPECIFIC AB BY
LUMINEX, PRE TX [HCDSA1S]
STAT For 1 Occurrences, Routine
Indicate organ for transplant: Multiple
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, PRE TX [HCDSA2S]
STAT For 1 Occurrences, Routine
Indicate organ for transplant: Multiple
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, STAT
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
CULTURE, URINE [URC] ONCE, Starting today For 1 Occurrences, STAT
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
BETA-2 MICROGLOBULIN [XB2MS] 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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
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?
Pre-Op Day Of Procedure
Page 14 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

HCG, QUALITATIVE, URINE [UPREG] ONCE, 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?
For females post menarche., Pre-Op Day Of
Procedure
GLUCOSE [GLU] 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 if bedside blood
glucose monitoring is less than 40 or greater than 400
mg/dL
Pre-Op Day Of Procedure
EBV AB to Viral Capsid AG, IGG (Single Response) [135575]
Draw only if the patient has had a POSITIVE EBV in the past, they DO NOT need a repeat. If
was negative.patient has never had an EBV drawn or the one they had drawn
EBV AB TO VIRAL CAPSID AG, IGG
[HCEBVIGG]
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?
NOTE: Order if never drawn or if previously negative.,
Pre-Op Day Of Procedure
Not ordered [NURCOM0022] ONCE, Not ordered. Previous result positive., Pre-Op
Day Of Procedure
Varicella AB, IGG/IGM (Single Response) [135593]
If the patient has had a POSITIVE Varicella in the past, they DO NOT need a repeat. Draw only if
patient has never had a Varicella drawn or the one they had drawn was negative.
VARICELLA ZOSTER AB, IGG/IGM [HCVZVGM] 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?
NOTE: Order if never drawn or if previously negative.,
Pre-Op Day Of Procedure
Not ordered [NURCOM0022] ONCE, Not ordered. Previous result positive., Pre-Op
Day Of Procedure
CMV AB, IGG (Single Response) [135595]
Draw only if the patient has had a POSITIVE CMV in the past, they DO NOT need a repeat. If
was negative.patient has never had a CMV drawn or the one they had drawn
CMV AB, IGG (IMMUNE STATUS) [XCMVG] 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?
NOTE: Order if never drawn or if previously negative.,
Pre-Op Day Of Procedure
Not ordered [NURCOM0022] ONCE, Not ordered. Previous result positive., Pre-Op
Day Of Procedure
Laboratory - For Patients Receiving CDC High Risk Donor [94389]
HIV-1 RNA, QUANTITATIVE [XHIV1] STAT, 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
Page 15 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@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? For patients receiving
CDC high risk donor
Pre-Op Day Of Procedure
HEPATITIS B DNA, ULTRA QUANT, PCR
[XHBVD]
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 receiving
CDC high risk donor
Pre-Op Day Of Procedure
Tests
Tests [198872]
TYPE AND SCREEN [HCTS] STAT, 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., Pre-Op Day Of Procedure
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [84374]
ECG - 12 Lead Without Rhythm [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: Other (enter comments)
Comment: Evaluate for intraoperative MI
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.
Brief hx: Renal Failure and Type 1 Diabetes, 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? Evaluation for Pulmonary Edema
Relevant recent/past history? HX: Renal Failure and
Type 1 Diabetes
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Pre-Op Day Of Procedure
BestPractice
No Hospital Problems have yet been identified. [107349]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing., Pre-Op Day Of Procedure
Page 16 of 16
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 12:45:40 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org