Plasma Hemoglobin
| 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. Plasma Hemoglobin | |
| 2. | |
| 3. | |
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| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
PLHGB
Test Workstation :
SPHEM
Specimen Type:
Blood
Tube Type:
Purple Top Tube (EDTA)
Collection Volume:
2.5 mL blood purple top (EDTA)tube
Storage:
Refrigerated
Availability:
Daily 24hr; Stat
Methodology:
Hemocue
Special Instructions:
Available on ECMO patients only. Any other requests must have a pathologists approval.
Lab/Phone:
330-543-8416
TAT:
2 hours
Additional Info:
Therapeutic Range for ECMO patient <41 mg/dL
CPT Code:
83051
Synonyms:
Free Hemoglobin; Plasma Free Hemoglobin
