Type and Screen
| 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. Type and Screen | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
T/S
Test Workstation :
MBBNK
Specimen Type:
Blood
Tube Type:
Lavender(EDTA)tube
Collection Volume:
<4 months: 2 lavender (EDTA) microtainers; Special Care Nursery only. All other locations, please contact Mahoning Valley Laboratory for specimen requirements and information
Minimum Volume:
contact the laboratory
Preferred Volume:
contact the laboratory
Cause for Rejection:
Improperly labeled specimen, gross hemolysis
Storage:
Refrigerated
Availability:
Daily, 24 hours
Methodology:
Tube Testing
Special Instructions:
Valid for only 3 days.
Label the tube with a patient identification label (2 identifiers). Collector employee ID#, date and time must be added to the label at collection.
All Blood Bank specimens must be accompanied by a completely filled out Blood Bank Requisition to include two signatures at the time of specimen collection.
Mislabeled Blood Bank Specimens will not be processed, regardless of the situation. Specimens for Blood Bank testing with any type of mismatched or missing information must be redrawn.
Lab/Phone:
330-746-9623
Additional Info:
Sendout to St. Elizabeth's or Akron Childrens Hospital Akron Campus
CPT Code:
86900
