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/clinical/cckm-tools/content/order-sets/inpatient/transplant/name-97930-en.cckm

201704104

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UWHC,UWMF,

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

IP - Renal/Pancreas Transplant - Rejection - Adult - Medical Readmission [766]

IP - Renal/Pancreas Transplant - Rejection - Adult - Medical Readmission [766] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Transplant


IP - Renal/Pancreas Transplant - Rejection - Adult - Medical Admission [766]
for Adult Patients OnlyIntended
Admission Status
Admission Status [122544]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: RENAL TRANSPLANT
Rationale for LOS greater than 2 midnights:
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) [122545]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service: RENAL TRANSPLANT
Rationale for LOS greater than 2 midnights:
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 PF 5000 UNIT/0.5ML injection [156571] 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
Page 1 of 18
Printed by STRAKA, KEVIN F [KFS1] at 4/12/2017 12:52:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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 PF 5000 UNIT/0.5ML injection [156571] 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:
Patient Care Orders
Vital Signs [8351]
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:
Activity [8352]
Bedrest [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: other (comment)
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Page 2 of 18
Printed by STRAKA, KEVIN F [KFS1] at 4/12/2017 12:52:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Chair [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR: other (comment)
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Ambulate [NURACT0008] CONTINUOUS, Starting today For Until specified,
Routine
AD LIB:
AMBULATE: other (comment)
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 [8353]
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:
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:
General Diet [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: General (no Modifications)
Bedside Meal Instructions:
Room Service Class:
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:
Page 3 of 18
Printed by STRAKA, KEVIN F [KFS1] at 4/12/2017 12:52:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

Restrict Fluids (2000 mLs/Day) [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Fluid Restriction
Fluid Restriction Total mLs/24H (IV/PO): 2000 mL
Bedside Meal Instructions:
Room Service Class:
Restrict Fluids (1500 mLs/Day) [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Fluid Restriction
Fluid Restriction Total mLs/24H (IV/PO): 1500 mL
Bedside Meal Instructions:
Room Service Class:
Restrict Fluids (1000 mLs/Day) [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Fluid Restriction
Fluid Restriction Total mLs/24H (IV/PO): 1000 mL
Bedside Meal Instructions:
Room Service Class:
Non-Categorized Patient Care Orders [8354]
Monitoring and Insulin Supplemental" Order Set for all Glucose -Adult -to "Diabetes Management Refer
Therapy
Glucose, POC [IPGLUCOSE] 4X DAILY, Starting today For 4 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?
4 times daily for diabetic patients
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Starting today, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today, 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: Indwelling Single Lumen
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Intermittent Manual Urinary Catheter Irrigation
[NURELM0070]
PRN, Routine, Low urine output is not an indication
for irrigation.
Irrigation through the catheter sampling port is NOT
recommended practice.
Does not apply to Pediatric patients.
Indication for Irrigation: Suspected Blood Clot
Irrigate With: Normal Saline
Amount to irrigate with: Other (Comment) (30 mLs)
Method of Irrigation:
Page 4 of 18
Printed by STRAKA, KEVIN F [KFS1] at 4/12/2017 12:52:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

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:
Contingency Parameters [32129]
Notify Provider [NURCOM0001] CONTINUOUS
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): 240 mL/8 hours
Other:
Patient Monitoring [109539]
Monitoring and Insulin Supplemental" Order Set for all Glucose -Adult -to "Diabetes Management Refer
Therapy
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Routine
Measure Weight Daily [NURMON0015] 1X DAILY, Routine
Weigh With?
Weigh when?
Medications - Admission-Specific
Immune Globulin [18675]
immune globulin 10% (GAMMAGARD LIQ) bag
[143798]
100 mg/kg, Intravenous, ONCE For 1 Doses
immune globulin 10% (GAMMAGARD LIQ) bag
[143798]
200 mg/kg, Intravenous, EVERY 14 DAYS For 3
Doses
immune globulin 10% (GAMMAGARD LIQ) bag
[143798]
500 mg/kg, Intravenous, EVERY 7 DAYS For 4
Doses
Steroids [18676]
dexamethasone (DECADRON) intraVENOUS
[800037]
100 mg, Intravenous, ONCE For 1 Doses
dexamethasone (DECADRON) intraVENOUS
[800037]
50 mg, Intravenous, ONCE Starting tomorrow at
12:00 PM For 1 Doses
Non-Categorized [138557]
nystatin (MYCOSTATIN) susp [40456] 5 mL, Swish & Swallow, 2 X DAILY For 30 Days
Medications - General
Premedications for Needle Insertion [106310]
Page 5 of 18
Printed by STRAKA, KEVIN F [KFS1] at 4/12/2017 12:52:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

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 within 1 minute. Choice of medication should be based on patient’s previous
experience/preference, history of lidocaine allergy and ease of access.
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
lidocaine (XYLOCAINE) 1% injection [39034] 0.1-0.4 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. Choice of medication should be based on
patient’s previous experience/preference, history of
lidocaine allergy and ease of access
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. Choice of medication should be based on
patient’s previous experience/preference, history of
lidocaine allergy and ease of access
Analgesics - Acetaminophen - Oral - PRN [221619]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain
No more than 4 grams acetaminophen per 24 hours
for adults or 15 mg/kg per dose for peds < 40 kg
Mild to moderate pain, multimodal therapy, or fever
greater than 38.2 degrees C
Analgesics - Opioids - Oral - PRN (Single Response) [221620]
hydrocodone-acetaMINOPHEN (NORCO) 5-325
MG per tab RANGE - NOTE: Order for patients
50 kg or greater [750021]
1-2 tab, Oral, EVERY 4 HOURS PRN, pain
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg
NOTE: Order for patients 50 kg or greater
hydrocodone-acetaMINOPHEN (NORCO) 5-325
MG per tab - NOTE: Order for patients less than
50 kg [71425]
1 tab, Oral, EVERY 4 HOURS PRN, pain, severe pain
No more than 2 grams acetaminophen per 24 hours
for adults or 7.5 mg/kg per dose for peds <40kg
NOTE: Order for patients less than 50 kg
Anti-hypertensives - As Needed [18289]
cloNIDINE (CATAPRES) tab [720040] 0.1 mg, Oral, EVERY 4 HOURS PRN, systolic blood
pressure (SBP) greater than 170 mmHg or diastolic
blood pressure (DBP) greater than 100 mmHg
For first line therapy - Max of 4 doses in 24 hours
Page 6 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

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 (DBP) greater than
100 mmHg
For second line therapy. Administer if unable to
tolerate orally or no response to first line therapy and
heart rate is more than 85 beats per minute. Do not
administer if heart rate is less than 60 beats per
minute
for 2 Minutes
hydrALAZINE (APRESOLINE) injection [750049] 10-20 mg, Intravenous, EVERY 1 HOUR PRN,
systolic blood pressure (SBP) greater than 170
mmHg or diastolic blood pressure (DBP) greater than
100 mmHg
For third line therapy. Administer if unable to tolerate
orally or no response to first line therapy and heart
rate is more than 85 beats per minute
Anti-emetics [89656]
ondansetron (ZOFRAN) tab [45939] 4 mg, Oral, EVERY 8 HOURS PRN, nausea/vomiting
For 1st line therapy
Post-Op/Phase II
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 8 HOURS PRN,
nausea/vomiting
For 1st line therapy. Administer if patient unable to
tolerate orally
Post-Op/Phase II
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN, nausea
Second line therapy. Administer when no response
to first line antiemetic in 30 minutes
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Second line therapy. Administer when no response
to first line antiemetic in 30 minutes and patient
unable to tolerate orally
Bowel Management - As Needed [221622]
polyethylene glycol (MIRALAX) oral powder
[61829]
17 g, Oral, 1 X DAILY PRN, constipation
1st line therapy
Dissolve in 240 mL of liquid
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation
2nd line therapy. Administer when there is no
response to first line laxative within 24 hours or when
there is need for immediate laxation
Hypnotics (Single Response) [221623]
traZODONE (DESYREL) tab RANGE [750040] 25-50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Administer 25 mg initially and may repeat times 1 if
no effect from first dose in 60 minutes
Anti-virals [18679]
valganciclovir (VALCYTE) tab [66847] 900 mg, Oral, 1 X DAILY
Medications - Pneumocystis Jiroveci Pneumonia (PJP) Prophylaxis - NOTE:
Order one regimen only
PJP Prophylaxis [19958]
sulfamethoxazole-trimethoprim (BACTRIM DS)
800-160 MG per tab [46804]
1 tab, Oral, 1 X DAILY Starting today at 12:00 PM For
90 Days
PJP Prophylaxis - NOTE: Order BOTH for patients allergic to sulfa [11833]
Page 7 of 18
Printed by STRAKA, KEVIN F [KFS1] at 4/12/2017 12:52:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

pentamidine (PENTAM) neb soln - NOTE: Order
BOTH pentamidine AND albuterol for patients
allergic to sulfa [780161]
300 mg, Nebulization, EVERY 30 DAYS Starting
4/17/17 at 12:00 PM For 180 Days
NOTE: Order BOTH pentamidine AND albuterol for
patients allergic to sulfa
albuterol neb soln (3 mL) - NOTE: Order BOTH
pentamidine AND albuterol for patients allergic to
sulfa [800248]
2.5 mg, Nebulization, EVERY 30 DAYS Starting
4/17/17 at 12:00 PM For 180 Days
Give prior to pentamidine
NOTE: Order BOTH pentamidine AND albuterol for
patients allergic to sulfa
Laboratory
Draw on Admission [8355]
ELECTROLYTES [LYTE] 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?
CREATININE [CRET] 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?
GLUCOSE [GLU] 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?
CALCIUM [CA] 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?
BILIRUBIN, TOTAL [TBIL] 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?
ALBUMIN [ALB] 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?
ALKALINE PHOSPHATASE [ALKP] 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?
ALT/SGPT [ALT] 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?
CBC WITH DIFFERENTIAL [CBC] 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?
Page 8 of 18
Printed by STRAKA, KEVIN F [KFS1] at 4/12/2017 12:52:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

BETA-2 MICROGLOBULIN [XB2MS] 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?
PROTHROMBIN TIME/INR [PT] 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?
PTT [PTT] 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?
MAGNESIUM [MAG] 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?
PHOSPHATE [PHOS] 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?
GGT [GGT] 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?
LD, TOTAL [LDH] 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?
URINALYSIS WITH MICROSCOPY [UA] 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?
CMV QUANTITATIVE BY PCR [HCCMVDNA] 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?
EBV QUANTITATIVE BY PCR [HCEBVPCR] 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?
AMYLASE [AMYL] 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?
Pancreas and Kidney Pancreas only.
Page 9 of 18
Printed by STRAKA, KEVIN F [KFS1] at 4/12/2017 12:52:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

LIPASE [LIPS] 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?
Pancreas and Kidney Pancreas only.
HLA CLASS I DONOR SPECIFIC AB BY
LUMINEX [HCDSA1B]
COLLECT UPON ADMISSION, Starting today For 1
Occurrences, Routine
Indicate organ for transplant:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA CLASS II DONOR SPECIFIC AB BY
LUMINEX [HCDSA2B]
COLLECT UPON ADMISSION, 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?
CD 19 AND 20 [HCF1920] COLLECT UPON ADMISSION, Starting today For 1
Occurrences, Routine, A WBC and Differential must
be ordered at same time.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FLOW CYTOMETRY, CD 19 AND 20 WITH
WBC AND DIFFERENTIAL [116749]
Lab Test Directory URL: https://uconnect.wisc.edu/clinical/tools-
resources/lab-test-directory/flow-
cytometry/name-68946-en.labtest
WHITE CELL COUNT AND DIFFERENTIAL
[WBCD]
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?
FLOW CYTOMETRY, CD 19 AND 20 [HCF1920] COLLECT UPON ADMISSION, Starting today For
1 Occurrences, Routine, A WBC and Differential
must be ordered at same time.
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition?
Draw Daily - Days 1-7 [8356]
BUN [BUN] NEXT AM For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 1-7
CREATININE [CRET] NEXT AM For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 1-7
HEMATOCRIT [HCT] NEXT AM For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 1-7
Page 10 of 18
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04/2017CCKM@uwhealth.org

WHITE CELL COUNT [WBC] NEXT AM For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 1-7
POTASSIUM [K] NEXT AM For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 1-7
GLUCOSE [GLU] NEXT AM For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 1-7
BETA-2 MICROGLOBULIN [XB2MS] NEXT AM For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 1-7
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT For 7 Days, 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? Central line as
needed for temp > 38.5 C
If add on test, what should lab do if unable to add test
to previous specimen?
Days 1-7
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT For 7 Days, 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? Peripheral as needed
for temp > 38.5 C
If add on test, what should lab do if unable to add test
to previous specimen?
Days 1-7
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL - RN COLLECT For 7 Days, Routine
If Conditional, What Condition? As needed for temp >
38.5 C
If add on test, what should lab do if unable to add test
to previous specimen?
Days 1-7
Page 11 of 18
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04/2017CCKM@uwhealth.org

CULTURE, URINE [URC] CONDITIONAL - RN COLLECT For 7 Days, 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? As needed for temp >
38.5 C
Days 1-7
CULTURE, STOOL [ST] CONDITIONAL - RN COLLECT For 7 Days, Routine,
Because these agents do not cause hospital acquired
infection, specimens on patients who have been
hospitalized greater than 3 days will require approval
of the Director of Microbiology or Pathology Resident.
If Conditional, What Condition? As needed for
diarrhea
If add on test, what should lab do if unable to add test
to previous specimen?
Days 1-7.
AMYLASE [AMYL] NEXT AM For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pancreas and Kidney Pancreas only. Days 1-7
LIPASE [LIPS] NEXT AM For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pancreas and kidney pancreas only. Days 1-7
GLUCOSE [GLU] CONDITIONAL - RN COLLECT For 7 Days, STAT
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
Days 1-7
TACROLIMUS [HCTAC] NEXT AM For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 1-7
CYCLOSPORINE [XCYCA] NEXT AM For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 1-7
ELECTROLYTES [LYTE] NEXT AM For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 1-7
CALCIUM [CA] NEXT AM For 7 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 1-7
Draw Daily - Days 8-14 [32010]
Page 12 of 18
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04/2017CCKM@uwhealth.org

BUN [BUN] NEXT AM, Starting 4/19/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 8-14
CREATININE [CRET] NEXT AM, Starting 4/19/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 8-14
HEMATOCRIT [HCT] NEXT AM, Starting 4/19/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 8-14
WHITE CELL COUNT [WBC] NEXT AM, Starting 4/19/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 8-14
POTASSIUM [K] NEXT AM, Starting 4/19/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 8-14
GLUCOSE [GLU] NEXT AM, Starting 4/19/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 8-14
BETA-2 MICROGLOBULIN [XB2MS] NEXT AM, Starting 4/19/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 8-14
Page 13 of 18
Printed by STRAKA, KEVIN F [KFS1] at 4/12/2017 12:52:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 4/19/17 For
7 Days, 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? Central line as
needed for temp > 38.5 C
If add on test, what should lab do if unable to add test
to previous specimen?
Days 8-14
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
CONDITIONAL - RN COLLECT, Starting 4/19/17 For
7 Days, 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? Peripheral as needed
for temp > 38.5 C
If add on test, what should lab do if unable to add test
to previous specimen?
Days 8-14
URINALYSIS WITH MICROSCOPY [UA] CONDITIONAL - RN COLLECT, Starting 4/19/17 For
7 Days, Routine
If Conditional, What Condition? As needed for temp >
38.5 C
If add on test, what should lab do if unable to add test
to previous specimen?
Days 8-14
CULTURE, URINE [URC] CONDITIONAL - RN COLLECT, Starting 4/19/17 For
7 Days, 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? As needed for temp >
38.5 C
Days 8-14
AMYLASE [AMYL] NEXT AM, Starting 4/19/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pancreas and Kidney Pancreas only. Days 8-14
LIPASE [LIPS] NEXT AM, Starting 4/19/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Pancreas and kidney pancreas only. Days 8-14
Page 14 of 18
Printed by STRAKA, KEVIN F [KFS1] at 4/12/2017 12:52:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org

GLUCOSE [GLU] CONDITIONAL - RN COLLECT, Starting 4/19/17 For
7 Days, STAT
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
Days 8-14
TACROLIMUS [HCTAC] NEXT AM, Starting 4/19/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 8-14
CYCLOSPORINE [XCYCA] NEXT AM, Starting 4/19/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 8-14
ELECTROLYTES [LYTE] NEXT AM, Starting 4/19/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 8-14
CALCIUM [CA] NEXT AM, Starting 4/19/17 at 5:00 AM For 7
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Days 8-14
Draw Every Monday and Friday - Week 1 [221704]
MAGNESIUM [MAG] EVERY MONDAY AND FRIDAY, Starting today with
First Occurrence As Scheduled For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 1
PHOSPHATE [PHOS] EVERY MONDAY AND FRIDAY, Starting today with
First Occurrence As Scheduled For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 1
CALCIUM [CA] EVERY MONDAY AND FRIDAY, Starting today with
First Occurrence As Scheduled For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 1
Draw Every Monday and Friday - Week 2 [221705]
Page 15 of 18
Printed by STRAKA, KEVIN F [KFS1] at 4/12/2017 12:52:56 PM
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04/2017CCKM@uwhealth.org

MAGNESIUM [MAG] EVERY MONDAY AND FRIDAY, Starting 4/19/17
with First Occurrence As Scheduled For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 2
PHOSPHATE [PHOS] EVERY MONDAY AND FRIDAY, Starting 4/19/17
with First Occurrence As Scheduled For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 2
CALCIUM [CA] EVERY MONDAY AND FRIDAY, Starting 4/19/17
with First Occurrence As Scheduled For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Week 2
Draw on Wednesdays - Week 1 [8357]
HLA CLASS I DONOR SPECIFIC AB BY
LUMINEX [HCDSA1B]
EVERY WEDNESDAY, Starting today with First
Occurrence As Scheduled For 7 Days, 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?
Week 1
HLA CLASS II DONOR SPECIFIC AB BY
LUMINEX [HCDSA2B]
EVERY WEDNESDAY, Starting today with First
Occurrence As Scheduled For 7 Days, 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?
Week 1
Draw on Wednesdays - Week 2 [32009]
HLA CLASS I DONOR SPECIFIC AB BY
LUMINEX [HCDSA1B]
EVERY WEDNESDAY, Starting 4/19/17 with First
Occurrence As Scheduled For 7 Days, 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?
Week 2
HLA CLASS II DONOR SPECIFIC AB BY
LUMINEX [HCDSA2B]
EVERY WEDNESDAY, Starting 4/19/17 with First
Occurrence As Scheduled For 7 Days, 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?
Week 2
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [8358]
Page 16 of 18
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04/2017CCKM@uwhealth.org

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?
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
US TRANSPLANT KIDNEY [R76776] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
If being performed remotely, where?
Transport Method: Floor Determined/Entered
Consults
Consults [29682]
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: OTHER
Evaluate and treat patient.
Diabetes Consult Order Panel (Adult) [188497]
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):
Page 17 of 18
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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 Infusion Center (Inpatient) [CON0123] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Apheresis settings
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 18 of 18
Printed by STRAKA, KEVIN F [KFS1] at 4/12/2017 12:52:56 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
04/2017CCKM@uwhealth.org