Fibrinogen
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Fibrinogen | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
FBG
Test Workstation :
ACOAG
Specimen Type:
Blood
Tube Type:
Lt Blue top (sodium citrate) tube
Collection Volume:
2.7 mL (minimum 1.8 mL)
Must use appropriate sodium citrate tube based on volume of blood drawn (1.8 mL or 2.7 mL tube)
Cause for Rejection:
Sample hemolyzed, clotted, diluted with IV fluid; contam with heparin; improperly filled; received >4 hrs after drawn.
Storage:
Ambient - Whole Blood
Availability:
Daily, 24 hours; STAT
Methodology:
Clottable Protein Assay (Clauss)
Special Instructions:
Indicate clearly if a specimen has been drawn from an arterial line or from a line that has been rinsed with heparin. Please indicate if the patient is currently receiving anticoagulant therapy. If collected at an offsite location send Whole blood by STAT courier to Akron Childrens Lab. Must be received within 4 hours.
Lab/Phone:
330-543-8416
TAT:
4 hours
Additional Info:
Reference range: 150-410 mg/dL
CPT Code:
85384
Synonyms:
Clottable Fibrinogen; Factor I; Fbg
