/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-97886-en.cckm

201606175

page

100

UWHC,UWMF,

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

IP - Vascular Surgery - Arteriogram - Radial/Brachial Approach - Adult - Intermediate/General Care - Postprocedure [1016]

IP - Vascular Surgery - Arteriogram - Radial/Brachial Approach - Adult - Intermediate/General Care - Postprocedure [1016] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Vascular Surgery


IP - Vascular Surgery - Arteriogram - Radial/Brachial Approach - Adult -
Intermediate/General Care - Postprocedure [1016]
Intended for Adult Patients Only
Admission Status
Level of Care (Single Response) [187485]
*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:
Post-Op/Phase II
Admit to Observation (Single Response) [188297]
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit to Outpatient Short Stay (Single Response)
[188298]
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admission Status (Single Response) [198873]
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:
Post-Op/Phase II
Admit To Observation [ADT0002] Attending:
Page 1 of 10
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Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admission Status (Single Response) [107912]
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:
Post-Op/Phase II
Admit To Observation [ADT0002] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Admit To Outpatient Short Stay [ADT0003] Attending:
Admitting Resident:
Requested Floor:
Service:
Post-Op/Phase II
Venous Thromboembolism (VTE) Prophylaxis
VTE Prophylaxis (Single Response) [131985]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/references/medication-
use-manual/anticoagulation-resources/resources/name-
26461-en.file
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered: Low Risk
Post-Op/Phase II
Moderate VTE Risk with Low Bleed Risk (Single
Response) [129778]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS, Post-
Op/Phase II
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
High VTE Risk with Low Bleed Risk [130127]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS, Post-
Page 2 of 10
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01/2016Lee Vermeulen, CCKM@uwhealth.org

Op/Phase II
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
High Bleed Risk (Single Response) [129757]
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Post-Op/Phase II
No VTE Prophylaxis [130084]
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered:
Post-Op/Phase II
VTE Prophylaxis (Single Response) [150174]
Caprini VTE Risk Assessment URL: https://uconnect.wisc.edu/clinical/references/medication-
use-manual/anticoagulation-resources/resources/name-
26461-en.file
Low VTE Risk [130084]
VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered: Low Risk
Post-Op/Phase II
Moderate VTE Risk with Low Bleed Risk (Single
Response) [129778]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS, Post-
Op/Phase II
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
High VTE Risk with Low Bleed Risk [198674]
enoxaparin (LOVENOX) subcutaneous injection
[800040]
40 mg, Subcutaneous, EVERY 24 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 12 HOURS, Post-
Op/Phase II
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, EVERY 8 HOURS, Post-
Op/Phase II
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
High Bleed Risk (Single Response) [129757]
Sequential Compression Device (SCD) / Foot Pump
[EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Type: Knee High
Post-Op/Phase II
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Post-Op/Phase II
No VTE Prophylaxis [130084]
Page 3 of 10
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01/2016Lee Vermeulen, CCKM@uwhealth.org

VTE Prophylaxis - Reason Not Ordered [COR0008] ONCE, Routine
Reason Not Ordered:
Post-Op/Phase II
Patient Care Orders
Vital Signs [13972]
Vital Signs [NURMON0013] SEE COMMENTS, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 15 minutes times 4, then every 30 minutes times 4,
then every hour times 4, then every 4 hours times 2, then
every 8 hours., Post-Op/Phase II
Patient Monitoring [198899]
Monitor Entry Site [NURMON0060] SEE COMMENTS, Starting today, Monitor entry site for
hematoma or new bleeding every 15 minutes times 4, then
every 30 minutes times 4, then every hour times 4, then every
4 hours times 2, then every 8 hours. Apply direct pressure to
procedure site for hematoma or persistent bleeding. Apply
armboard for immobilization and pressure dressing once
hemostasis has been achieved with manual compression.
Distal radial and ulnar pulses should be maintained and
continuous pulse oximetry should be monitored on the
affected thumb or index finger. Leave dressing and armboard
in place for *** hours and then remove if no evidence of
bleeding., Post-Op/Phase II
High Risk Entry Site [NURCOM0022] CONTINUOUS, Pain in the arm may indicate internal
bleeding. Notify Vascular Surgery resident on call., Post-
Op/Phase II
For bleeding, oozing, swelling, or hematoma at entry site
[NURCOM0022]
CONTINUOUS, For bleeding, oozing, swelling, or hematoma
at entry site
- Apply direct manual pressure
- Notify Vascular Surgery resident on call
- Do not apply sandbag, Post-Op/Phase II
Neurovascular Checks [NURMON0045] SEE COMMENTS, Starting today For Until specified, Routine,
Monitor neurovascular status.
Location: {right, left, bilateral:4001510} upper extremity.
Every 15 minutes times 4, then every 30 minutes times 4,
then every hour times 4, then every 4 hours times 2, then
every 8 hours., Post-Op/Phase II
Activity [14434]
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:
Post-Op/Phase II
Ambulate [NURACT0008] CONTINUOUS, Starting today, Routine
AD LIB:
AMBULATE: with assistance
Page 4 of 10
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01/2016Lee Vermeulen, CCKM@uwhealth.org

CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Post-Op/Phase II
Elevate Head Of Bed [NURACT0002] Equal to (degrees): 45
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today, Post-Op/Phase II
Elevate Extremity [NURACT0010] Extremity:
Equal to (degrees):
Greater than (degrees):
Less than (degrees):
Other options:
Routine, CONTINUOUS, Starting today For Until specified,
Post-Op/Phase II
Apply Brace/Splint, Upper Body [NURTRT0015] CONTINUOUS, Starting today For Until specified, Routine, If
ordering a Sarmiento Humeral Fracture Orthosis, please
contact the cast room technician at 265-0746.
Type: Elbow Splint - Dorsal
Left/Right/Bilateral?
Wearing schedule: Continuous
Post-Op/Phase II
Nutrition [13974]
NPO Except Medications [NUT0001] EFFECTIVE NOW, Starting today, Routine
General Diet:
Diabetic Diet:
NPO (If patient receiving tube feeding see question 25): NPO
EXCEPT MEDICATIONS
Liquids & Modified Consistency (If Dysphagia Protocol see
questions 21-24):
Fiber:
Renal & Dialysis Multi-Nutrient Restriction:
Lactose Restricted:
Protein:
Fat:
Sodium:
Potassium:
Phosphorus:
Other Minerals:
Calories:
Fluid Restriction: Total mLs/24 hours (IV & PO):
Research:
Metabolic:
Other Modifiers:
Infant Nutrition (Select product and calories per ounce):
Infant Formula (Calories per Ounce):
Dysphagia Protocol:
Dysphagia Protocol-Modified Consistency (Also select
Dysphagia Protocol Liquid Consistency and Dysphagia
Protocol-Supervision):
Dysphagia Protocol-Liquid Consistency:
Dysphagia Protocol-Supervision:
Tube Feeding (Use Tube Feeding Order Set to indicate order
Page 5 of 10
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01/2016Lee Vermeulen, CCKM@uwhealth.org

detail):
Room Service Class:
Post-Op/Phase II
Wound/Procedure Site Care [13975]
Wound Care [NURWND0015] CONTINUOUS, Starting today, Routine
Wound Type: Puncture
Wound Site: Arm
Wound Location:
Assess Frequency: EVERY 8 HOURS
Care Frequency: 1X DAILY
Wash With: Soap and Water
Irrigate/Rinse With:
Apply (Must also enter separate medication order to obtain
drug):
Primary Dressing: Gauze (With 1-inch fabric plaster
(ELASTOPLAST) in an "X" fashion)
Secondary Dressing:
Prior to discharge, remove dressing and apply Band-Aide©.,
Post-Op/Phase II
Leave Dressing in Place for 24 Hours [NURWND0018] CONTINUOUS, Starting today For 24 Hours, Post-Op/Phase
II
Non-Categorized Patient Care Orders [13976]
ACTIVATED CLOTTING TIME, POC [HCACTPOC] SEE COMMENTS, Routine
If Conditional, What Condition?
Every hour until less than 160 seconds., Post-Op/Phase II
Cardiac Rhythm Monitoring - Adult [NURMON0010] ONCE, Starting today, Routine
Notify Provider: Symptomatic Change in Rhythm,Serious
Arrhythmia
Functional Cardiac Defibrillator Present:
During sheath removal, Post-Op/Phase II
Measure Ankle/Brachial Index - Post Procedure
[NURMON0017]
ONCE For 1 Occurrences, Routine, To be done by nursing
upon return to inpatient unit., Post-Op/Phase II
Measure Ankle/Brachial Index - POD 1 [NURMON0017] ONCE For 1 Occurrences, Routine, To be done by nursing in
the morning on postoperative day 1. No need for formal
studies unless this is abnormal., Post-Op/Phase II
Contingency Parameters [13977]
Notify Provider [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 160
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm): 100
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: Any signs of bleeding,Any signs of bleeding,Absence
of lower extremity pulse,Change in pulse exam,Activated
Clotting Time less than or equal to 160 seconds,Back
pain,Any change in color or temperature of affected hand,If
Ankle/Brachial Index decreases by 0.15 or greater
Post-Op/Phase II
Page 6 of 10
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01/2016Lee Vermeulen, CCKM@uwhealth.org

Intravenous Therapy
Premedications for Needle Insertion [106327]
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
Post-Op/Phase II
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
Post-Op/Phase II
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
Post-Op/Phase II
IV Fluids [12940]
sodium chloride 0.9 % infusion [64367] Intravenous, CONTINUOUS, Post-Op/Phase II
Medications - General
Beta-Blockers [12869]
atenolol (TENORMIN) tab [720016] Oral
Hold for heart rate less than 50 beats per minute or systolic
blood pressure less than 100 mmHg.
Post-Op/Phase II
carvedilol (COREG) tab [54511] Oral, 2 X DAILY
Hold for heart rate less than 50 beats per minute or systolic
blood pressure less than 100 mmHg.
Post-Op/Phase II
labetalol (NORMODYNE;TRANDATE) injection [750053] 10-20 mg, Intravenous, EVERY 1 HOUR PRN, for systolic
blood pressure greater than 160 mmHg or diastolic blood
pressure greater than 100 mmHg
Hold for heart rate less than 50 beats per minute
for 2 Minutes, Post-Op/Phase II
metoprolol (LOPRESSOR) tab [720094] Oral
Hold for heart rate less than 50 beats per minute or systolic
blood pressure less than 100 mmHg
Post-Op/Phase II
Analgesics [12941]
acetaMINOPHEN (TYLENOL) tab [750000] 325-650 mg, Oral, EVERY 4 HOURS PRN, pain, For mild-
moderate pain or multi-modal therapy., Post-Op/Phase II
Page 7 of 10
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01/2016Lee Vermeulen, CCKM@uwhealth.org

Bowel Management - High Risk [122993]
Bowel Management - High Risk [122963]
senna-docusate (SENOKOT S) 8.6-50 MG per tab
[60530]
2 tab, Oral, 2 X DAILY Starting tomorrow
Hold for loose stool or suspected obstruction. Use rescue
therapy after first 48hrs if inadequate response to
scheduled bowel management.
Post-Op/Phase II
polyethylene glycol (MIRALAX) oral powder [61353] 17 g, Oral, 1 X DAILY PRN Starting tomorrow, constipation
Hold for suspected obstruction. Use as first line rescue
therapy if inadequate response to scheduled bowel
management.
Post-Op/Phase II
bisacodyl (DULCOLAX) rectal suppository - Use if no
response to first line rescue within 24 hours [35231]
10 mg, Rectal, 1 X DAILY PRN Starting tomorrow,
constipation
Use as second line rescue therapy if no response to first
line rescue therapy within 24 hours and notify Primary
Team.
Post-Op/Phase II
Non-categorized [12942]
aspirin chew tab [720014] 81 mg, Oral, 1 X DAILY, Post-Op/Phase II
aspirin chew tab [720014] 162 mg, Oral, 1 X DAILY, Post-Op/Phase II
aspirin EC tab [49098] 325 mg, Oral, 1 X DAILY, Post-Op/Phase II
clopidogrel (PLAVIX) tab [58345] 75 mg, Oral, 1 X DAILY, Post-Op/Phase II
Laboratory
Draw Postoperative Day 1 in AM [13979]
BUN [BUN] 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?
Post-Op/Phase II
CREATININE [CRET] 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?
Post-Op/Phase II
HEMATOCRIT [HCT] 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?
Post-Op/Phase II
PLATELET COUNT [PLT] 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?
Post-Op/Phase II
ELECTROLYTES [LYTE] 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?
Post-Op/Phase II
PROTHROMBIN TIME/INR [PT] 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?
Post-Op/Phase II
Diagnostic Tests and Imaging
Vascular Lab [13980]
Ankle/Brachial Index [VASC0001] ONCE, Starting tomorrow For 1 Occurrences, Routine
Page 8 of 10
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01/2016Lee Vermeulen, CCKM@uwhealth.org

Reason for exam:
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Performed in Heart Vascular Care Echo/Vasc Lab, Post-
Op/Phase II
Ultrasound Imaging of Peripheral Artery [VASC0007] ONCE, Starting tomorrow 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, Post-
Op/Phase II
Transcutaneous O2 Test [VASC0006] ONCE, Starting tomorrow For 1 Occurrences, Routine
Reason for exam:
What area of the body?
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Performed in Heart Vascular Care Echo/Vasc Lab, Post-
Op/Phase II
Consults
Consults [13981]
Consult Transplant Nephrology (Inpatient) [CON0083] ONCE
Purpose of Consult: EVALUATE AND TREAT PATIENT
Consulting Provider:
Reason for Consult: End stage renal disease.
Can this consult be done via video?
Post-Op/Phase II
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 (meter/insulin skills/other diabetes survival skills) for
patients/families with knowledge deficits and/or need for diabetes knowledge assessment.
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.
Consult Diabetes Management Service (DMS)
(Inpatient) [CON0022]
ONCE
Can this consult be done via video?
Intent:
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis):
Phone number:
Post-Op/Phase II
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).
· Learning Center staff are not available on holidays.
Type of Education:
Page 9 of 10
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01/2016Lee Vermeulen, CCKM@uwhealth.org

Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Post-Op/Phase II
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:
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Post-Op/Phase II
Consult Cardiac Rehab/Preventive Cardiology
(Inpatient) [CON0010]
ONCE, Starting today For 1 Occurrences, Routine
Reason for consult: Other (Comment) (Risk factor
assessment and modification)
Can this consult be done via video?
Post-Op/Phase II
BestPractice
No hospital problems have yet been identified [198967]
Specify Hospital Problem(s) [COR0018] You will be prompted to specify a hospital problem on
signing., Post-Op/Phase II
Page 10 of 10
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Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org