/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-97939-en.cckm

201708216

page

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UWHC,UWMF,

Tools,

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

IP – Transplant Cardiology – Evaluation – Adult – Supplemental [1820]

IP – Transplant Cardiology – Evaluation – Adult – Supplemental [1820] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Transplant


IP - Transplant Cardiology - Evaluation - Adult - Supplemental [1820]
for Adult Patients OnlyIntended
Medications - General
Vaccinations [26534]
pneumococcal 13-valent vaccine (diphtheria conj)
(PREVNAR 13) injection susp [140032]
0.5 mL, Intramuscular, PRIOR TO DISCHARGE For 1
Doses
Do not give if the patient received pneumoccocal
vaccine (Pneumovax) within 12 months.
pneumococcal 23-valent vaccine (PNEUMOVAX)
25 mcg/0.5 mL vial - NOTE: Order if patient has
NOT received vaccine in the past 5 years [46215]
0.5 mL, Subcutaneous, ONCE For 1 Doses
Give if patient has not received vaccine in past 5 years
Do not give if the patient received pneumococcal 13-
valent vaccine (Prevnar 13) within 8 weeks
haemophilus B conjugate vaccine (PEDVAXHIB)
injection [164856]
0.5 mL, Intramuscular, ONCE For 1 Doses
influenza virus quadrivalent vaccine PF
(FLUZONE QUADRIVALENT) susp prefilled
syringe - NOTE: Give if seasonally appropriate
[166316]
0.5 mL, Intramuscular, ONCE For 1 Doses
Give if seasonally appropriate
tetanus-diphtheria-pertussis vaccine (Tdap)
injection susp - NOTE: Order if patient has not
received vaccine in past 10 years [107297]
0.5 mL, Intramuscular, ONCE For 1 Doses
Give if patient has not received vaccine in past 10
years
varicella virus vaccine (live) (VARIVAX) vial -
NOTE: Order if varicella titers are negative
[150813]
0.5 mL, Subcutaneous, EVERY 30 DAYS For 2 Doses
Give if varicella titers are negative. Repeat vaccination
in 1 month
hepatitis A virus vaccine (HAVRIX ADULT) 1440
EL U/ML injection - NOTE: Order if hepatitis A
antibody titer is negative [128839]
1,440 units, Intramuscular, ONCE For 1 Doses
Give if hepatitis A antibody titer is negative. Repeat
vaccination in 6 months.
NOTE:Order if hepatitis A antibody titer is negative
hepatitis B vaccine (ENGERIX-B) vial - NOTE:
Order if hepatitis B surface antibody is negativ
[63827]
20 mcg, Intramuscular, ONCE For 1 Doses
Give if hepatitis B surface antibody is negative.
Repeat vaccination in 1 and in 6 months
zoster vaccine (ZOSTAVAX) injection - NOTE:
Order for patients greater than 60 years AND
varicella positive [175485]
0.65 mL, Subcutaneous, ONCE For 1 Doses
NOTE: Order for patients greater than 60 years AND
varicella positive
Laboratory
Laboratory [28225]
ABO AND RH TYPING [ABO] NEXT AM, 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?
ABO AND RH TYPING (2ND COLLECTION FOR
UNOS) [TXPABO]
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?
Second ABO collection cannot be at the same draw
time as the first.
ALBUMIN [ALB] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALKALINE PHOSPHATASE [ALKP] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 1 of 16
Printed by LIND, JANNA S [JSL237] at 8/4/2017 9:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

ALKALINE PHOSPHATASE, BONE SPECIFIC
[XBSALK]
NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] NEXT AM, 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?
ANTIBODY SCREEN [ABSCR] NEXT AM, Starting today For 2 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
AST/SGOT [AST] NEXT AM, 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?
B-TYPE NATRIURETIC PEPTIDE [XBNP] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM [CA] NEXT AM, 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] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] NEXT AM, 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?
ESR [ESR] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
FERRITIN [FER] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 2 of 16
Printed by LIND, JANNA S [JSL237] at 8/4/2017 9:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

GLUCOSE, FASTING [HCFSGLU] NEXT AM, Starting today For 1 Occurrences, Routine,
Patient should have nothing to eat or drink (except
water) for a minimum of 8 hours before test.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Patient must be
fasting for 08-10 hours
HEMOGLOBIN A1C [HA1C] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
IRON AND TRANSFERRIN W/ TIBC,
SATURATION [FETRANS]
NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LD, TOTAL [LDH] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
LIPID PANEL [LIPID] NEXT AM, Starting today For 1 Occurrences, Routine,
Test includes Cholesterol, Total; HDL Cholesterol;
Triglyceride; LDL cholesterol, calculated; and non-
HDL cholesterol.
Patient must fast for a minimum of 10 hours and be
heparin free for 48 hours prior to specimen collection.
The patient can only have water during the fasting
period.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] NEXT AM, 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] NEXT AM, 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?
PREALBUMIN [XPRALB] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTEIN, TOTAL [TP] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR [PT] NEXT AM, 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?
PTH [HCPTHIN] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 3 of 16
Printed by LIND, JANNA S [JSL237] at 8/4/2017 9:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

PTT [PTT] NEXT AM, 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?
RETICULOCYTE COUNT [RET] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
URIC ACID [URIC] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 4 of 16
Printed by LIND, JANNA S [JSL237] at 8/4/2017 9:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

VITAMIN D, 25-HYDROXY BY HPLC (Vitamin D
Status) [HCLCD25]
NEXT AM, Starting today For 1 Occurrences, Routine,
Screening for Vitamin D deficiency is not covered by
Medicare. If this is the reason for the test, please
advise the patient of non-coverage via the ABN
process. Coverage is allowed in some other
circumstances. If one of these diagnoses is
appropriate for your patient, please associate the
corresponding code with this order.
252.00 (ICD-9); E21.3 (ICD-10) Hyperparathyroidism,
unspecified
252.01 (ICD-9); E21.0 (ICD-10) Primary
Hyperparathyroidism
252.02 (ICD-9); E21.1 (ICD-10) Secondary
Hyperparathyroidism, Non-Renal
252.08 (ICD-9); E21.2 (ICD-10) Other
Hyperparathyroidism
252.1 (ICD-9); E20.9 (ICD-10) Hypoparathyroidism
268.0 (ICD-9); E55.0 (ICD-10) Rickets Active
268.2 (ICD-9); M83.9 (ICD-10) Osteomalacia
Unspecified
268.9 (ICD-9); E55.9 (ICD-10) Established Vitamin D
Deficiency (monitoring efficacy of replacement
therapy)
275.3 (ICD-9); E83.30 (ICD-10) Disorders of
Phosphorus Metabolism
275.41 (ICD-9); E83.51 (ICD-10) Hypocalcemia
275.42 (ICD-9); E83.52 (ICD-10) Hypercalcemia
585.3 (ICD-9); N18.3 (ICD-10) Chronic Kidney
Disease, Stage III (Moderate)
585.4 (ICD-9); N18.4 (ICD-10) Chronic Kidney
Disease, Stage IV (Severe)
585.5 (ICD-9); N18.5 (ICD-10) Chronic Kidney
Disease, Stage V
585.6 (ICD-9); N18.6 (ICD-10) End Stage Renal
Disease
588.81 (ICD-9); N25.81 (ICD-10) Secondary
Hyperparathyroidism (of Renal Origin)
733.00 (ICD-9); M81.0 (ICD-10) Osteoporosis
Unspecified
Page 5 of 16
Printed by LIND, JANNA S [JSL237] at 8/4/2017 9:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

733.01 (ICD-9); M81.0 (ICD-10) Senile Osteoporosis
733.02 (ICD-9); M81.8 (ICD-10) Idiopathic
Osteoporosis
733.03 (ICD-9); M81.8 (ICD-10) Disuse Osteoporosis
733.09 (ICD-9); M81.8 (ICD-10) Other Osteoporosis
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
QUANTIFERON-TB GOLD [GM8455] NEXT AM, 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?
TSH [TSH] NEXT AM, 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?
T3, FREE [FT3] NEXT AM, 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?
T4, FREE [FT4] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Infectious Disease Serology [28226]
CMV IGG AB [XCMVG] NEXT AM, 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 IGM AB [XCMVM] NEXT AM, 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?
VARICELLA ZOSTER AB, IGG [VZIGG] NEXT AM, 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 AB TO VIRAL CAPSID AG, IGG
[HCEBVIGG]
NEXT AM, 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 AB TO VIRAL CAPSID AG, IGM [XEBVP2] NEXT AM, 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 6 of 16
Printed by LIND, JANNA S [JSL237] at 8/4/2017 9:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

HIV AB/AG COMBO [HIVABAG] NEXT AM, 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?
HERPES SIMPLEX 1 AND 2 AB, IGG/IGM
[XHSVC]
NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS A AB, IGG [HAVIGG] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS B CORE AB, TOTAL [HBCAB] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS B SURFACE AB (IMMUNE STATUS)
[HBSABI]
NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS B SURFACE AG [HBSAG] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEPATITIS C AB [HCV] NEXT AM, 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?
TOXOPLASMA AB, IGG/IGM [HCTOXO] NEXT AM, 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 7 of 16
Printed by LIND, JANNA S [JSL237] at 8/4/2017 9:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

RPR, CONFIRM IF POSITIVE [RPRFTA] NEXT AM, 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?
Fungal Serology [28227]
COCCIDIOIDES AB BY CF [XCOCAB] NEXT AM, 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?
HISTOPLASMA AB BY CF [XHSTAB] NEXT AM, Starting today For 1 Occurrences, Routine,
Please specify acute or convalescent for this test
order in the comment section. Parallel testing of acute
and convalescent specimens is recommended.
Convalescent specimens should be drawn within 30
days of the acute specimens.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BLASTOMYCES AG [HCBLSTAG] NEXT AM, 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?
BLASTOMYCES AB BY CF [XBLAS] NEXT AM, 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?
Other Labs [28228]
NICOTINE (INCLUDES COTININE), URINE
[HCUNCPNL]
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?
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?
OCCULT BLOOD (IMMUNOASSAY), SCREEN,
STOOL [IFOBT]
ONCE, Starting today For 1 Occurrences, Routine,
Multiple patient collections are not necessary.
Recommended frequency of screening is annually. If
multiple patient collections are received, they will be
canceled as duplicate.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
For Male Patients [28229]
PSA TOTAL, DIAGNOSTIC [PSA] NEXT AM, 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?
Histocompatibility [28230]
HLA CLASS I AB BY LUMINEX, PRE TX
[HCLUC1S]
NEXT AM, 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?
Page 8 of 16
Printed by LIND, JANNA S [JSL237] at 8/4/2017 9:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

HLA CLASS II AB BY LUMINEX, PRE TX
[HCLUC2S]
NEXT AM, 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, HOLD FOR POSSIBLE CROSSMATCH
[HCHLAR]
NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA CLASS I TYPING (A, B, C), PRE TX
[HCHLATS]
STAT - RN COLLECT, 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 DR/DQ BY PCR, PRE TX [HCDRDQS] STAT - RN COLLECT, 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?
IP- HLA DR/DQ, HEART PRE-TX [214626]
DRB1 LOCUS, PRE-TX [HCDRB1S] NEXT AM For 1 Occurrences, Routine
Indicate organ for transplant: Heart
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
DRB345 LOCUS, PRE-TX [HCDRB345S] NEXT AM For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
DQ LOCUS, PRE-TX [HCDQB1S] NEXT AM For 1 Occurrences, Routine
Indicate organ for transplant: Heart
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
DP LOCUS, PRE-TX [HCDPB1S] NEXT AM For 1 Occurrences, Routine
Indicate organ for transplant: Heart
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
IP- HLA CLASS I TYPING (A,B,C), HEART PRE-TX [214627]
HLA A LOCUS, PRE-TX [HCALOCS] NEXT DRAW For 1 Occurrences, Routine
Indicate organ for transplant: Heart
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA B LOCUS, PRE-TX [HCBLOCS] NEXT DRAW For 1 Occurrences, Routine
Indicate organ for transplant: Heart
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HLA C LOCUS, PRE-TX [HCCLOCS] NEXT DRAW For 1 Occurrences, Routine
Indicate organ for transplant: Heart
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 9 of 16
Printed by LIND, JANNA S [JSL237] at 8/4/2017 9:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Diagnostic Tests and Imaging
Radiology [28231]
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? Evaluate for infections source or disease
for pre-cardiac transplant
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
X-RAY PANOREX (ORTHOPANTOGRAM)
[R70355]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Evaluation for cardiac transplant
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where?
Transport Method: Floor Determined/Entered
US ABDOMEN COMPLETE [R76700] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Radiology Specialty Area: ULTRASOUND
Current signs and symptoms?
What specific question(s) would you like answered by
this exam? Evaluation for cardiac transplant
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
US Carotid Doppler [VASC0002] ONCE For 1 Occurrences, Routine
Reason for exam: OTHER (COMMENT)
Other (Comment):
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Left, Right, or Bilateral?
Performed in Heart Vascular Care Echo/Vasc Lab,
Performed remotely in Heart and Vascular Clinic.
Page 10 of 16
Printed by LIND, JANNA S [JSL237] at 8/4/2017 9:04:45 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

BONE MINERAL DENSITY AXIAL (W
APPENDICULAR & VERTEBRAL FRACTURE
ASSESSMENT (VFA) (PRN) (BMD) [R07029]
ONCE-RAD NEXT AVAILABLE, Routine
Perform the Appendicular exam per protocol?
Perform the VFA exam per protocol?
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
Has the patient had a PET or Nuclear Medicine
procedure in last 48 hours or Radiology procedures
with contrast (oral and/or IV) within the last two
weeks?
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
Last patient height? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Ankle/Brachial Index (Performed in HVC-NID Lab)
[VASC0001]
ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: OTHER (COMMENT)
Other (Comment): Evaluation for cardiac transplant
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Performed in Heart Vascular Care Echo/Vasc Lab
MAMMOGRAM DIGITAL SCREENING
BILATERAL [R77057B]
ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Why are you ordering this exam? Order diagnostic
mammogram for new clinical finding or abnormal
breast imaging.
Is patient pregnant?
Also perform diagnostic mammogram and/or breast
ultrasound as needed per radiologist determination.
No
Current signs and symptoms? Evaluation for cardiac
transplant
Is patient breastfeeding?
Does patient have breast implants?
Does this patient have previous breast imaging
studies at another facility? If yes, place facility and
date of study in comments box at bottom.
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
For female patients greater than or equal to 40 years
old.
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CT CHEST W IV CONTRAST [R71260] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history:
Can Patient be given oral contrast?
Pt needs creatinine level w/in 30 days of exam? ( >
60 yrs old, Diabetes managed w/ meds, using
metformin combinations, chemo or amnioglycoside,
hist of renal disease [incl tumor, surg, kidney
transplant, dialysis], has hypertension w/ medical
therapy):
Last creatinine value? (will auto pull in date and value
in comment):
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
CT CHEST W/ O IV CONTRAST [R71250] ONCE-RAD NEXT AVAILABLE, Routine
Radiology Specialty Area: CT
What specific question(s) would you like answered by
this exam? Please include relevant recent/past
history:
Can Patient be given oral contrast?
Pt needs creatinine level w/in 30 days of exam? ( >
60 yrs old, Diabetes managed w/ meds, using
metformin combinations, chemo or amnioglycoside,
hist of renal disease [incl tumor, surg, kidney
transplant, dialysis], has hypertension w/ medical
therapy):
Last creatinine value? (will auto pull in date and value
in comment):
For scheduling purposes, does the patient require
general anesthesia, sedation or anxiolytics? Note:
ordering provider is responsible for prescribing oral
anxiolytics or arranging peds anesthesia / sedation
services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
Other Tests [28232]
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: OTHER (COMMENT)
Exercise Stress Test [EKG0006] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: OTHER (COMMENT)
Type of stress:
Type of equipment:
Indicate any medication holds:
Cardiopulmonary (EVO2) stress test:
Bring comfortable shoes and wear pants.
NPO 4 hours; no caffeine or tobacco 12 hours
Cardiopulmonary EVO2 Stress Test (ADULT)
[181447]
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Most commonly ordered for heart failure or cardiopulmonary transplant patients. This specialized
exercise test includes measurements of oxygen uptake (VO2), carbon dioxide output (VCO2),
minute ventilation (VE), and other variables during an exercise stress test. Test performed in the
Echo Vascular Lab at UW Hospital. Please call Preventive Cardiology at 263.6630 with questions.
Cardiopulmonary EVO2 Stress Test (Adult)
(Order 1 of 2) [EKG0023]
ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: Other (Comment)
Type of stress:
Type of equipment:
Indicate any medication holds:
Bring comfortable shoes and wear pants.
NPO 4 hours; no caffeine or tobacco 12 hours
Cardiopulmonary EVO2 Stress Test (Adult)
(Order 2 of 2) [EKG0028]
ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: Other (Comment)
Type of stress:
Type of equipment:
Indicate any medication holds:
NPO 4 hours; no caffeine or tobacco for 12 hours
Heart And Vascular Care Procedure - Cath Lab
[CARD0006]
ONCE, Starting today For 1 Occurrences, Routine
Procedure to Perform:
Reason for Cath Procedure: Pre-Transplant
Evaluation - Note Organ in Comments
Do you want a Left Heart Pressure? No
Do you want a Right Heart Cath? No
State indication for Right Heart Cath:
Allergies to IV Contrast or Iodine?
Last patient height? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
Last creatinine value? (will auto pull in date and value
in comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Last INR value? (will auto pull in date and value in
comment):
Assess patient for Cardiovascular Lab Ankle Brachial
Index? Yes
Heart transplant
Pulmonary Lab Testing [999992] ONCE, Starting today For 1 Occurrences, Routine
Reason for Exam: Assessment of pulmonary function
for cardiac transplant
Specify Test: ABG on Oxygen (Please indicate FIO2
desired in comments),Pre-Op Thoracic Surgery
(Spirometry, Bronchodilators if indicated, Lung
Volumes, Diffusion)
Colonoscopy [GI0002] ONCE, Starting today For 1 Occurrences, Routine
Reason for Exam: Evaluation for cardiac transplant
For patients greater than or equal to 50 years old.
Transthoracic Resting Echocardiogram
[ECH0003]
ONCE, Routine
Reason for exam: HEART OR LUNG TRANSPLANT
Do you want Agitated Bubble Study?
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Consults
Consults [28233]
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Consult Cardiac Rehab/Preventive Cardiology
(Inpatient) [CON0010]
ONCE, Starting today For 1 Occurrences, Routine
Reason for consult:
Can this consult be done via video?
Consult Cardiac Surgery (Inpatient) [CON0011] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Evaluate for cardiac
transplant
Consult Social Work (Inpatient) [CON0076] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: OTHER (Evaluate for cardiac
transplant)
***
Consult Transplant Coordinator [CON0156] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Evaluate for cardiac transplant
Consult Transplant Financial Coordinator
[CON0157]
ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Financial matters related to
cardiac transplant.
***
Consult Nutrition (Inpatient) [CON0043] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult:
Delegate to Initiate and Manage Tube Feeding:
Delegate to Manage Diet Order/Supplement Order:
Delegate to Dysphagia Diet Order Progression:
Can this consult be done via video?
***
Consult Dental (Inpatient) [CON0019] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Evaluate for cardiac
transplant
***
Behavioral Health Consults (select below)
[210272]
amp, transplant), - adjustment, protocol (eg. burn, trauma, rehab, pre-Psychology Health
noncompliance, grief, pain
Addictive Disorders - alcohol or drug related problems (eg. treatment recommendations,
withdrawal mgmt)
Psychiatry - safety, agitation, capacity, med mgmt, psychotropic SE
ACE - 60 and older - delirium, dementia, depression, decisional capacity, sleep (also for non-
behavioral geriatric syndromes; overall geriatric evaluation, mobility/falls, functional decline,
social/caregiver issues, disposition, medication management)
Consult Health Psychology (Inpatient)
[CON0033]
ONCE, Routine, Please notify consulting provider if
patient needs to be seen same day (Monday-Friday)
or if special assessment needs.
Intent for Consult: Protocol: BURN, REHAB, PRE-
AMP, TRANSPLANT EVALUATION, TRAUMA
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis): Evaluate
for cardiac transplant
***
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Consult Addictive Disorders (Inpatient)
[CON0003]
ONCE, Routine, This order is for ADULT patients.
Please use the Consult Adolescent/Pediatric AODA
Counselor order for adolescent/pediatric patients
instead.
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Consult Psychiatry (Inpatient) [CON0064] ONCE
Intent for Consult:
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Can this consult be done via video?
Call back number:
Consult Ace/Geriatric (Inpatient) [CON0001] ONCE, Routine
Reason for Consult:
Can this consult be done via video?
Consult Infectious Disease (Inpatient) [CON0037] ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Evaluate for cardiac
transplant
Consult Ophthalmology-General (Inpatient)
[CON0048]
ONCE
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Evaluate for cardiac
transplant
For patients with diabeties or greater than 50 years of
age.
Consult Women's Health Evaluation [CON0158] ONCE, Starting today For 1 Occurrences, Routine
Reason for Consult: Evaluate for cardiac transplant,
pap smear and pelvic exam
Follow-Up Orders
Follow-Up [28234]
Schedule Appointment - Varicella Virus Vaccine
(Live)(VARIVAX) [NURCOM0026]
Reason for Hospital Follow Up Appointment:
Completion of Varicella Virus vaccination series
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty:
Schedule Appointment - Hepatitis A Vaccine
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Completion of Hepatitis A vaccination series
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty:
Schedule Appointment - Hepatitis B Vaccine
[NURCOM0026]
Reason for Hospital Follow Up Appointment:
Completion of Hepatitis B vaccination series
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty:
Schedule Appointment - Infectious Diseases
[NURCOM0026]
Reason for Hospital Follow Up Appointment: Evaluate
for cardiac transplant
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Infectious Diseases
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Schedule Appointment - Ophthalmology
[NURCOM0026]
Reason for Hospital Follow Up Appointment: Evaluate
for cardiac transplant
Which Provider: Other Provider or Specialist
When do you want appointment:
Which Clinic or Specialty: Ophthalmology
Page 16 of 16
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org