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IP - Urology - Pediatrics - Discharge [4894]

IP - Urology - Pediatrics - Discharge [4894] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Urology


IP - Urology - Pediatrics - Discharge [4894]
Skilled Nursing Facility Orders
This Patient is going to a skilled nursing facilty, directly below is a group of orders commonly
associated with this patient population. Please review the orders below and select the
appropriate ones for this patient. If this patient is not going to a SNF, contact Case Management
to update the discharge plan. Updating the discharge plan will remove this set of SNF orders from
the order set.
Skilled Nursing Facility Certification Statement [114940]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Certification Statement [118260]
Facility Certification Statement [NURCOM0069] Routine
Skilled Nursing Facility Admit Order [114941]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Admit Order [118261]
Admit to Skilled Nursing Facility [ADT0015] Routine
Skilled Nursing Facility Patient Care Orders [111713]
For dyspnea, Oxygen at 2 L/minute per nasal
canula; If this is an acute change for the patient
call PCP with assessment ASAP after oxygen is
started. Suction PRN to clear airways.
[NURCOM0022]
Routine
DME - Home Oxygen [1009468] Patient's O2 Requirements Assessed and Meets
Criteria for Home O2:
Delivery Device:
Equipment Needed:
Continuous (liters/min):
Continuous (FiO2):
With Activity (liters/min):
With Activity (FiO2):
With Sleep (liters/min):
With Sleep (FiO2):
Length of Need:
Vendor:
DME - CPAP [1009443] Formal Sleep Study Completed:
Diagnosis:
CPAP Pressure (cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessed and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Page 1 of 7
Printed by WILLIAMS, HEATHER R S [HRS0] at 3/22/2017 9:45:23 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

DME - BiPAP (S) [1009441] Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S):
Diagnosis:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessed and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
DME - BiPAP (S/T) [1009442] Patient Has Been Assessed and Meets Criteria for
Home BiPAP (S/T):
Diagnosis:
Respiratory Rate:
BiPAP Pressure - IPAP - Inspiratory Pressure
(cmH2O):
BiPAP Pressure - EPAP - Expiratory Pressure
(cmH2O):
Oxygen Bleed-In (Liters/min):
Oxygen Bleed-In (FiO2):
If New Prescription for Oxygen Bleed-In, Patient's O2
Requirements Assessed and Meets Criteria for Home
O2:
Vendor:
Vendor City:
Vendor Phone:
Vendor Fax:
Patient may self administer medication per RN
assessment [NURCOM0022]
Routine
Patient medications (per Skilled Nursing Facility
policy) may be left at bedside [NURCOM0022]
Routine
Facility Therapy Needs [113391]
Physical Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Occupational Therapy to Evaluate and Treat at
Next Facility [NURCOM0022]
Routine
Speech Therapy to Evaluate and Treat at Next
Facility [NURCOM0022]
Routine
Communicable Diseases [111717]
State Law requires at least one of the following statements be checked for your patient. May check both
if applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have
any other clinically apparent communicable
diseases. [NURCOM0022]
Routine
Page 2 of 7
Printed by WILLIAMS, HEATHER R S [HRS0] at 3/22/2017 9:45:23 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Communicable Diseases [118262]
State Law requires at least one of the following statements be checked for your patient. May check both
if applicable
DHS 132.52 URL: http://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132/V/52
Patient has been screened for TB within the last
90 days prior to admission and does not have
any other clinically apparent communicable
diseases. [NURCOM0022]
Routine
Patient has been found to have a communicable
disease, procedures to treat and limit the spread
of the disease have been ordered.
[NURCOM0022]
Routine
Analgesics [111708]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, 1 tab, 1, starting 3/22/17, No Print
acetaMINOPHEN (TYLENOL) suppository
[34153]
650 mg, 1 suppository, 1, starting 3/22/17, No Print
Blood Glucose Management [111710]
glucagon 1 mg injection kit [107799] 1 mg, 1 each, 1, starting 3/22/17, No Print
Glucose 40 % oral gel [118089] 10 g, 1 Tube, 1, starting 3/22/17, No Print
Nursing Communication [NURCOM0022] Routine, Notify {Notify for Blood Glucose:3004146} if
blood glucose is greater than 400 mg/dL or less than
40 mg/dL
Diabetes Care Instructions [NURCOM0112] Routine, - Patient's blood glucose goal range before
meals is *** mg/dL.
- Monitor patient's blood glucose {Glucose Monitoring
Frequency:25242}.
- If your patient's blood glucoses are uncontrolled
contact provider.
- "Uncontrolled" blood glucoses mean:
* Blood glucose above 150 mg/dL more than half the
time during a week.
* Blood glucose over *** mg/dL.
* Blood glucose less than 70 mg/dL two or more times
per week (or if having signs/symptoms of low blood
glucose such as shaking, sweating, or light-
headedness).
Bowel Management [111709]
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, 1 suppository, 1, starting 3/22/17, No Print
Senna-Docusate Sodium 8.6-50 MG per tab
[70181]
1-2 tab, 1 tab, 1, starting 3/22/17, No Print
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, 1 Bottle, 1, starting 3/22/17, No Print
polyethylene glycol (MIRALAX) oral powder
[61353]
17 g, 1 Bottle, 1, starting 3/22/17, No Print
Non-categorized Medications [111711]
guaifenesin-dextroMETHORPHAN
(ROBITUSSIN DM) syrup [51568]
10 mL, 1 Bottle, 1, starting 3/22/17, No Print
carbamide peroxide (DEBROX) 6.5% otic soln
[35545]
3 drop, 1 Bottle, 1, starting 3/22/17 until 3/27/17, No
Print
Page 3 of 7
Printed by WILLIAMS, HEATHER R S [HRS0] at 3/22/2017 9:45:23 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

alum-mag-simeth (MYLANTA ES) susp [44073] 30 mL, 1 Bottle, 1, starting 3/22/17, No Print
Patient Care Orders
Confirmed Discharge Date/Time [151653]
Confirmed Discharge Date/Time [ADT0013] Confirmed Discharge Date:
Confirmed Discharge Time:
Conditions for Discharge:
Provider to be Present at Discharge?
Reason For Hospitalization [131061]
Why You Were Hospitalized [NURCOM0073] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, {Reasons:3022231}
Activity [131062]
Activity - General [NURACT0008] Routine
Discharge Activity:
Activity - End Cutaenous Ureterostomy
[NURACT0008]
Routine
Discharge Activity: See Instructions
- No Physical Education classes for 3 weeks
- No lifting greater than 5 pounds for 3 weeks
- No sports for 3 weeks
Activity - Extravesical Dismembered Ureteral
Reimplantation [NURACT0008]
Routine
Discharge Activity: See Instructions
- No Physical Education classes for 3 weeks
- No lifting greater than 5 pounds for 3 weeks
- No sports for 3 weeks
Activity - Hypospadias Repair [NURACT0008] Routine
Discharge Activity: See Instructions
- No straddling toys for 2 weeks after surgery
- No physical education class or recess for 2 weeks
- No sports for 3 weeks.
Activity - Mitrofanoff [NURACT0008] Routine
Discharge Activity: See Instructions
- No Physical Education classes for 3 weeks
- No lifting greater than 5 pounds for 3 weeks
- No sports for 3 weeks
Activity - Nephrectomy [NURACT0008] Routine
Discharge Activity: See Instructions
- Limit activity for 2 weeks
- No lifting greater than 5 pounds for 2 weeks
- No physical education classes for 2 weeks
- No sports for 3 weeks.
Driving Restrictions [NURACT0011] Routine
Nutrition [131063]
Diet - General (No Modifications) [NUT8888] Routine
General: General (No Modifications)
Diet Modifications:
Other Diet Modifications:
Wound Care [131065]
Wound Care [NURWND0015] Routine, Monitor wound(s) for signs and symptoms of
infection (redness, swelling, drainage, odor).
Double Diapering [NURWND0018] Routine
Bathing Instructions [NURWND0018] Routine, No tub baths for 2 days. Patient may shower
or sponge bath.
Page 4 of 7
Printed by WILLIAMS, HEATHER R S [HRS0] at 3/22/2017 9:45:23 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

Bathing Instructions for Hypospadius
[NURWND0018]
Routine, No tub baths while stent/catheter is in place.
After stent/catheter removed, begin sitz baths. One
ounce (30 mL) betadine solution in enough warm
water to cover the penis. Soak 10 minutes for three
times daily for one week, then two times daily for one
week.
Bladder Care [131066]
Bladder Care [NURELM0067] Routine
Bowel Care [131067]
Bowel Care [NURELM0068] Routine
Other Patient Care Instructions [131068]
Other Discharge Patient Care Instructions
[NURCOM0071]
Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan., Routine, No NSAIDS or Aspirin for 2 weeks.
When to Call Your Doctor [131069]
When to Call Your Doctor [NURCOM0079] Please complete in PATIENT FRIENDLY terms. This
order will appear on the patient's After Hospital Care
Plan.
You should include specific instructions on when and
who to call.
You should include actual provider names (i.e. not
'PCP').
You should NOT include the discharging unit as a
contact., Routine, Call your doctor if you have any of
these symptoms: Increased pain, not relieved by
medication, fever over 101.5 degrees for 24 hours, or
signs or symptoms of wound infection (redness,
swelling, drainage, odor).
Call Pediatric Urology Clinic with any questions or
concerns during normal business hours: 608-263-
6420. On evenings, weekends and holidays call the
Urology Resident on call: 608-263-6400.
Follow-Up Care
Follow-Up Apoointments [131072]
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Which Provider:
Discharge Labs [134929]
Page 5 of 7
Printed by WILLIAMS, HEATHER R S [HRS0] at 3/22/2017 9:45:23 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

Please use the table below to determine what type of order to use to place discharge lab
orders.
Discharge Labs Workflow URL: https://uconnect.wisc.edu/growth/training--
education/health-link/10-minutes/inpatient-
discharge-consult/resources/name-82993-en.file
Recommended Discharge Labs [NURCOM0075] Details
Who is Responsible for the
Result?
Where Will Labs be
Completed?
What Order Should You
Use?
Current Attending Provider UW Health Lab Specific lab orders (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
(B)
Current Consulting Provider
UW Health Lab
Specific lab orders with
AUTHORIZING PROVIDER
CHANGED TO
CONSULTANT (A)
Non-UW Health Lab
Specific lab orders with order
class changed to OUTSIDE
and AUTHORIZING
PROVIDER CHANGED TO
CONSULTANT (B)
Another Provider
UW Health Lab
Recommended Discharge
Labs (C)
Non-UW Health Lab
Recommended Discharge
Labs (C)
(A) SPECIFIC LAB ORDERS:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have the labs completed at a
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient's care will be responsible for
the result, you must change the AUTHORIZING PROVIDER on the order to the
CONSULTING PROVIDER before signing the order. To do this, click the Providers button
near the top of the Review, Sign & Hold tab of the discharge navigator. Update the
authorizing provider to the consulting provider.
(B) SPECIFIC LAB ORDER WITH ORDER CLASS CHANGED TO OUTSIDE:
These orders should be used if the CURRENT ATTENDING OR CONSULTING PROVIDER
will be responsible for the result of the lab AND the patient will have labs completed at a NON-
UW HEALTH LAB.
If a CONSULTING PROVIDER currently involved in the patient’s care will be responsible for
the result, you must change the AUTHORIZING PROVIDER on the order to the
CONSULTING PROVIDER before signing the order. To do this, click the Providers button
near the top of the Review, Sign & Hold tab of the discharge navigator. Update the
authorizing provider to the consulting provider.
The patient will receive a paper order to take to the lab.
(C) RECOMMENDED DISCHARGE LABS:
This order should be used to recommend to another provider labs that a patient should have
completed after discharge. The provider designated in the 'Send Recommendations To' field
is responsible for PLACING the lab orders AND will be responsible for the RESULTS of any
ordered labs.
Page 6 of 7
Printed by WILLIAMS, HEATHER R S [HRS0] at 3/22/2017 9:45:23 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org

Labs [131074]
Consulting Provider lab orders should only be used if the current Attending Provider or These
lab.will be responsible for the result of the
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:7/22/17 MANUAL,Count:1,
Normal, Routine
BASIC METABOLIC PANEL [BMET] Status: Standing, Expires:7/22/17 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:4/23/18 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:7/22/17 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:7/22/17 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:4/23/18 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:7/22/17 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:7/22/17 MANUAL,Count:1,
Normal, Routine
BILIRUBIN, TOTAL [TBIL] Status: Standing, Expires:7/22/17 MANUAL,Count:1,
Normal, Routine
PROTEIN, TOTAL [TP] Status: Standing, Expires:7/22/17 MANUAL,Count:1,
Normal, Routine
ALBUMIN [ALB] Status: Standing, Expires:7/22/17 MANUAL,Count:1,
Normal, Routine
ALKALINE PHOSPHATASE [ALKP] Status: Standing, Expires:7/22/17 MANUAL,Count:1,
Normal, Routine
AST/SGOT [AST] Status: Standing, Expires:4/23/18 MANUAL,Count:1,
Normal, Routine
ALT/SGPT [ALT] Status: Standing, Expires:4/23/18 MANUAL,Count:1,
Normal, Routine
URINALYSIS WITH MICROSCOPY AND
CULTURE IF >5 WBC/HPF [HCUACULT]
Status: Standing, Expires:7/22/17 MANUAL,Count:1,
Normal, Routine
Imaging [131075]
US KIDNEY OR AORTA [R76770] Status: Future, Expires: 5/22/18, Normal, Routine
GU INTRAVENOUS PYELOGRAM [R74400] Status: Future, Expires: 5/22/18, Normal, Routine
Page 7 of 7
Printed by WILLIAMS, HEATHER R S [HRS0] at 3/22/2017 9:45:23 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2017CCKM@uwhealth.org