Hemoglobin and Hematocrit
| 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. Hemoglobin and Hematocrit | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
H&H
Test Workstation :
AHEM1
Specimen Type:
Blood
Tube Type:
Purple top (EDTA) tube: Whole Blood
Collection Volume:
2.0 mL (minimum 0.3 mL)
Cause for Rejection:
Specimen hemolyzed, clotted, diluted with IV fluid; held at RT for more than 8 hours or at 4C for more than 24 hours
Storage:
Refrigerated
Availability:
Daily, 24 hours; STAT
Methodology:
Flow Cell Spectrophotometry/ Impedance measurement
Special Instructions:
Lipemic plasma or white count > 50,000/mm3 may falsely elevate the hemoglobin.
Lab/Phone:
330-543-8416
TAT:
4 hours
Additional Info:
Reference range is available on patient report
CPT Code:
85014, 85018
