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 :
BBANK
Specimen Type:
Blood
Tube Type:
Red top (no anticoagulant) tube
Collection Volume:
6.0 mL (minimum 4.0 mL)
Minimum Volume:
4.0 ml
Preferred Volume:
6.0 ml
Cause for Rejection:
Improperly identified specimen, gross hemolysis
Storage:
Room Temperature Transport
Availability:
Daily, 24 hours
Methodology:
Tube Testing
Special Instructions:
Valid for up to 3 days. Specimens drawn for a future surgery are valid for 30 days for a patient not previously transfused or pregnant within the last 3 months.
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:
330-543-8723
TAT:
1 hour (STAT) to 4 hours
CPT Code:
86900
