/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/vascular-surgery/,

/clinical/cckm-tools/content/order-sets/inpatient/vascular-surgery/name-97882-en.cckm

201712341

page

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UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Vascular Surgery

IP – Vascular Surgery – Adult – General – Admission [1151]

IP – Vascular Surgery – Adult – General – Admission [1151] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Vascular Surgery


IP - Vascular Surgery - Adult - General - Admission [1151]
for Adult Patients OnlyIntended
Admission Status
Level of Care (Single Response) [186484]
*An admit patient order has already been written, but the level of care at which the patient
should be placed still needs to be identified.
Place Patient on General Care [ADT0018] General Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Place Patient on Intermediate Care (IMC)
[ADT0018]
Intermediate Care, has already been signed. This
order will ensure that the patient is placed at the
appropriate level of care.
Place Patient on Intensive Care (ICU) [ADT0018] Intensive Care, has already been signed. This order
will ensure that the patient is placed at the appropriate
level of care.
Admit to Inpatient (Single Response) [188296]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-
only surgery, or a previously-authorized inpatient
stay. Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Admit to Observation (Single Response)
[188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit to Outpatient Short Stay (Single
Response) [188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status (Single Response) [82665]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
Page 1 of 14
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12/2017CCKM@uwhealth.org

Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Admission Status [7248]
Admit To Inpatient [ADT0001] Attending:
Admitting Resident:
Requested Floor:
Service:
I certify that an inpatient stay is medically necessary
because of either an anticipated LOS >2 midnights,
complexity and/or severity of illness, an inpatient-only
surgery, or a previously-authorized inpatient stay.
Rationale listed below. Yes
C - CLEAR DIAGNOSIS:
E - EVALUATIONS PLANNED:
R - RESULTS EXPECTED:
T - TREATMENTS ORDERED:
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) [150170]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Moderate VTE Risk with Low Bleed Risk (Single
Response) [241126]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD) / Foot
Pump [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
High VTE Risk with Low Bleed Risk [130127]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Page 2 of 14
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Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
High Bleed 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:
VTE Prophylaxis (Single Response) [131982]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE, Routine
Reason Not Ordered: Low Risk
Moderate VTE Risk with Low Bleed Risk (Single
Response) [241114]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS
Sequential Compression Device (SCD) / Foot
Pump [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
High VTE Risk with Low Bleed Risk [130127]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 12 HOURS
heparin subcutaneous injection [800290] 5,000 units, Subcutaneous, EVERY 8 HOURS
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
High Bleed 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:
Page 3 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:34:59 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Patient Care Orders
Vitals [14513]
Vital Signs [NURMON0013] EVERY 4 HOURS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Measure Blood Pressure [NURMON0019] ONCE, Starting today For 1 Occurrences, Routine
BP Source:
BP Location: Bilateral Arms
BP Position:
BP Restrictions:
On admission.
Activity [14514]
Bed Rest [NURACT0008] CONTINUOUS, Starting today, 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:
Bed Rest with Bathroom Privileges
[NURACT0008]
CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST: with bathroom privileges
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Ambulate Ad Lib [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB: ad lib
AMBULATE:
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 [14516]
NPO [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: Strict NPO
Bedside Meal Instructions:
Room Service Class:
Page 4 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:34:59 AM
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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:
Respiratory [14517]
Pulse Oximetry [NURMON0009] ONCE, Starting today For 1 Occurrences, Routine, On
admission.
Pulse Oximetry [NURMON0009] EVERY 4 HOURS, Starting today, Routine
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine
Oxygen Therapy [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%) Titrate to Keep Sats >/= to ___%:
Liter Flow:
Titrate oxygen to maintain O2 sat at (%): 88
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen? Yes
Wound Care [14518]
Wound Care - Dressing Change [NURWND0015] CONTINUOUS, Starting today, Routine
Wound Type:
Wound Site:
Wound Location:
Assess Frequency:
Care Frequency:
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing:
Secondary Dressing:
Intake and Output [14519]
Measure Intake And Output [NURMON0005] EVERY 8 HOURS, Starting today, Routine
Non-Categorized Patient Care Orders [14520]
Measure Weight [NURMON0015] 1X DAILY, Starting today, Routine
Weigh With?
Weigh when?
And on admission.
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
INTERMITTENT (MAY REMOVE WHEN OFF
UNIT/BATHING), Starting today, Routine
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Page 5 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:34:59 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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:
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Urinary Catheterization-Intermittent
[NURELM0018]
EVERY 6 HOURS PRN, Starting today, Routine, If
unable to void and bladder scan greater than 400 mL.
Contingency Parameters [14521]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg): 100
If diastolic blood pressure < (mmHg): 50
If temperature > (C): 38.5
If temperature < (C):
If heart rate > (bpm): 100
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL): 30 mL/hour
Other: Pain not controlled with ordered analgesics or
ordered interventions
Intravenous Therapy
Premedications for Needle Insertion [106310]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is immediate.
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
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.
IV Fluids [14741]
dextrose 5%-NaCl 0.45% infusion [51613] Intravenous, CONTINUOUS
sodium chloride 0.45 % infusion [42187] Intravenous, CONTINUOUS
sodium chloride 0.9 % infusion [64367] Intravenous, CONTINUOUS
Page 6 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:34:59 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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Insert and Maintain Peripheral IV: Peripheral
Capped Line [NURVAD0013]
CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Medications
Analgesics-Acetaminophen [240540]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, EVERY 4 HOURS PRN, pain/fever,
temperature greater than 38.5 degrees Celsius or pain
See Pain management Algorithm for the Selection of
As-needed Analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg
Analgesics-Oral Opioids (Single Response) [240541]
hydrocodone-acetaminophen (NORCO) 5-325
MG per tab [750021]
1-2 tab, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-needed Analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg
oxycodone-acetaminophen (PERCOCET) 5-325
MG per tab [750033]
1-2 tab, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-needed Analgesics
No more than 4 grams acetaminophen per 24 hours
for adults or 15mg/kg per dose for peds <40kg
oxycodone tab [750032] 5-10 mg, Oral, EVERY 4 HOURS PRN, pain
See Pain Management Algorithm for the Selection of
As-needed Analgesics
Analgesics- Intravenous Opioids [14743]
HYDROmorphone PF (DILAUDID) injection
[750050]
0.4-1 mg, Intravenous, EVERY 1 HOUR PRN, pain
See Pain Management Algorithm for the Selection of
As-needed Analgesics
for 3 Minutes
Anti-emetics [14745]
Adult - Standard - Anti-emetics [241797]
ondansetron (ZOFRAN ODT) disintegrating tab
[64224]
4 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line
ondansetron (ZOFRAN) injection [800202] 4 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use first line if unable to take medications by mouth
or enteral tube OR if immediate effect is needed.
prochlorperazine (COMPAZINE) tab [41372] 10 mg, Oral, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line if there is inadequate response to
first line anti-emetic within 30 minutes. If there is no
response to second line therapy within 30 minutes,
notify provider
prochlorperazine (COMPAZINE) injection [41369] 10 mg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting
Use second line. Use if there is inadequate
response to first line anti-emetic within 30 minutes
and if unable to take medications by mouth or
enteral tube OR if immediate effect is needed. If
there is no response to second line therapy within 30
minutes, notify provider
Beta-Blockers [14754]
Page 7 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:34:59 AM
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12/2017CCKM@uwhealth.org

atenolol (TENORMIN) tab [720016] Oral
Hold for heart rate less than 50 beats/minute or
systolic blood pressure less than 100 mmHg.
carvedilol (COREG) tab [54511] Oral, 2 X DAILY
Hold for heart rate less than 50 beats/minute or
systolic blood pressure less than *** mmHg.
labetalol (NORMODYNE;TRANDATE) injection
[750053]
10-20 mg, Intravenous, EVERY 1 HOUR PRN,
systolic blood pressure greater than 160 mmHg or
diastolic blood pressure greater than 100 mmHg
Hold for heart rate less than 50 beats/minute
for 2 Minutes
metoprolol (LOPRESSOR) tab [720094] Oral, 2 X DAILY
Hold for heart rate less than 50 beats/minute or
systolic blood pressure less than 100 mmHg
Bowel Management [14755]
Adult - Bowel Management - Scheduled
[242161]
senna-docusate (SENOKOT S) 8.6-50 MG per
tab [60530]
2 tab, Oral, 2 X DAILY
Adult - Bowel Management - As Needed
[241598]
polyethylene glycol (MIRALAX) oral packet
[61829]
17 g, Oral, 1 X DAILY PRN, constipation
First Line Therapy
magnesium hydroxide (MILK OF MAGNESIA)
susp [65443]
30 mL, Oral, 1 X DAILY PRN, constipation
Second line therapy, if no response to first line
therapy within 12 hours
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal, 1 X DAILY PRN, constipation
If unable to take medications by mouth or enteral
tube OR if need immediate laxation OR if failure of
second line agent after 6 hours
Hypnotics (Single Response) [228331]
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
melatonin tab [119466] 3 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Trazodone - Melatonin [227992] "And" Linked Panel
traZODONE (DESYREL) tab [720150] 50 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use first line.
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
melatonin tab [119466] 3 mg, Oral, 1 X DAILY (HS) PRN, sleep
Use second line if failure to respond to trazodone
within 60 minutes
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Hypnotics (Single Response) [228334]
Page 8 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:34:59 AM
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12/2017CCKM@uwhealth.org

traZODONE (DESYREL) tab [720150] 25 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
If needed, give prior to midnight if possible. May
contribute to sedation the following day.
melatonin tab [119466] 1 mg, Oral, 1 X DAILY (HS) PRN, sleep
Offer only after failure of non-pharmacologic
interventions (see RN Care Problem Sleep/Rest
Disturbance Adult)
Platelet Inhibitors [14757]
aspirin chew tab [720014] 81 mg, Oral, 1 X DAILY
aspirin EC delayed release tab [49098] 325 mg, Oral, 1 X DAILY
clopidogrel (PLAVIX) tab [58345] 75 mg, Oral, 1 X DAILY
Statins (Single Response) [14759]
atorvastatin (LIPITOR) tab [720017] 40 mg, Oral, 1 X DAILY (HS)
pravastatin (PRAVACHOL) tab [46294] 40 mg, Oral, 1 X DAILY (HS)
simvastatin (ZOCOR) tab [46562] 20 mg, Oral, 1 X DAILY (HS)
simvastatin (ZOCOR) tab [46562] 40 mg, Oral, 1 X DAILY (HS)
Laboratory
Now [14522]
ELECTROLYTES [LYTE] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GLUCOSE [GLU] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM [CA] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 9 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:34:59 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

PHOSPHATE [PHOS] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITH DIFFERENTIAL [CBC] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR [PT] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PTT [PTT] NEXT DRAW, Starting today For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
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?
Diagnostic Test and Imaging
Studies [14523]
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
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
Page 10 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:34:59 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12/2017CCKM@uwhealth.org

MRA PELVIS LOWER EXTREMITY W OR W/ O
CONTRAST [R07009]
ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Study Needed Within:
Is patient pregnant?
Does patient have a pacemaker or defibrillator?
Allergy to Gadolinium (MRI) contrast?
For Scheduling purposes, is the patient claustrophobic
or require any form of sedation? Note: ordering
provider is responsible for prescribing oral anxiolytic or
ordering sedation services.
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.
Relevant Surgical History (Select all applicable or
None):
Implanted Devices? (Select all applicable or None):
History of Metal in Body? (Select all applicable or
None):
Has patient had a colonoscopy/endoscopy in the last 8
weeks?
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 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:
CT ANGIO AORTOBIFEMOROILIAC [R75635] ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
Allergies to IV contrast or iodine?
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):
Transport Method:
Page 11 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:34:59 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

CT ANGIO CHEST ABDOMEN & PELVIS
[R07031]
ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
Allergies to IV contrast or iodine?
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):
Transport Method:
CT ANGIO ABDOMEN & PELVIS [R07030] ONCE-RAD NEXT AVAILABLE, Routine
Current signs and symptoms?
What specific question(s) would you like answered by
this exam?
Relevant recent/past history?
Is patient pregnant?
Allergies to IV contrast or iodine?
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):
Transport Method:
Vascular Laboratory [14524]
Ultrasound Carotid Duplex (UW Hospital, East
Clinic) [VASC0002]
ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
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
Pulse Volume Recording (UW Hospital, East
Clinic) [VASC0004]
ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
With exercise?
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Performed in Heart Vascular Care Echo/Vasc Lab
Page 12 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:34:59 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Ultrasound Imaging of Vein (UW Hospital, East
Clinic) [VASC0009]
ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
Which extremity?
Left, Right, or Bilateral?
Study type:
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Performed in Heart Vascular Care Echo/Vasc Lab
Ultrasound Imaging of Artery (UW Hospital, East
Clinic) [VASC0007]
ONCE, Starting today For 1 Occurrences, Routine
Reason for exam:
Which extremity?
Left, Right, or Bilateral?
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Performed in Heart Vascular Care Echo/Vasc Lab
Consults
Consults [14525]
Consult Renal-End Stage (Inpatient) [CON0070] ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Management of
hemodialysis
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 13 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:34:59 AM
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

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 Cardiac Rehab/Preventive Cardiology
(Inpatient) [CON0010]
ONCE, Starting today For 1 Occurrences, Routine
Reason for consult: Other (Comment)
Indications: Risk factor assessment and modification.
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 14 of 14
Printed by BENNETT, SARA J [SJB008] at 12/7/2017 11:34:59 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org