Gram Stain
| 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. Gram Stain | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
GRAM
Test Workstation :
MMIC2
Specimen Type:
E-swab or smear from specimen for bacterial culture
Tube Type:
Specimen container, E-swab
Collection Volume:
1 swab or 0.5 mL liquid specimen
Cause for Rejection:
Specimen sent in nonsterile container. Specimen sent on dry swab.
Storage:
Ambient
Availability:
Daily
Methodology:
Microscopic examination
Special Instructions:
Gram stain slides may be prepared at the bedside by the physician except for sputum, tracheal aspirate, wound, CSF, body fluids, or urine. Smears on these specimen types will be prepared in the laboratory. An Eswab should be sent for gram stain for those specimens where a swab is appropriate for culture.
Lab/Phone:
330-746-9623
TAT:
2 hours CSF, all other stains read by day shift Microbiology staff
Additional Info:
NOTE: Gram stains are automatically added to all CSF, Wound, Sputum, and Tracheal aspirate cultures and do not need to be ordered separately.
CPT Code:
87205
Synonyms:
Bacterial Stain; Direct Stain for Bacteria
