blood draw requisition form

Which of the following amounts is the maximum volume of blood the technician should draw from this patient at any MORL – Kidney Testing Requisition Form - Please see page 2 for Tests Offered Specimen and shipping requirements along with CPT codes and prices can be found on our website: https//morl.lab.uiowa.edu. Order Tests Upon completion of specimen collection, complete the requisition form included in your test kit and include it in your specimen shipment. A requisition form must accompany each sample submitted to the laboratory. Tests results may be altered by dilution and/or content of the intravenous fluid, resulting in misleading laboratory values. Washes hands. The essential elements of the requisition form are: Patient's surname, first name, and middle initial. Wall. Follow the same procedure if a sample must be drawn during blood products transfusion. 5252 Partner Physician OHIP Billing # Address Date *DRAW ORDER This is the draw order to be followed for AlloSure testing. From the Tube & Accession Labels card, place the first white barcode label on the upper right corner of the order form/AlloSure Test Requisition Form. h޴T�O�@�W��n{1$�#$��?��Ʋ%�r��[@O{�ӥ%�y� �ffG�!f�s 8�8B)� ��)!! The study material that is used for your genetic test is stated in the requisition form and is typically blood. Consult the Epic requisition or the Pathology Laboratory Services Handbook for appropriate transportation requirements, e.g., "on ice". Lab Requisition Forms Lab Requisition Forms If you are one of our partner providers, you can print out the forms found below to order labs for a patient. Examples of acceptable identifiers include, but are not limited to, patient name, date of birth, hospital number, and requisition, accession, or unique random number. REQUISITION FORM RESERED RESERED PHYSICIAN DEPARTMENT Gender identification is performed by detecting the presence or absence of Y chromosome in maternal blood. For samples that MUST be collected from an arm with an active I.V., the best option is to collect the sample distal (below) the intravenous site. Determine correct tube type and blood volume for tests ordered (e.g. If patient is an outpatient, ask them to state their full name and date of birth. Post Fornix LMP (dd/mm/yyyy) Post – menopausal HRT (hormone Replacement Other, namely: Date: (dd/mm/yyyy) Requester’s to the MSH lab the following: VeMi prenatal Test Form Signed NIPT Blood Draw handout (if the requisition signed by your heanhcare provider) Completed Credit Card Authorization in a seabd envelope your name on Physician Info View Test You will need to bring this collection kit to your blood draw appointment. For a Blood Draw Step 2: Using ONLY the 4 provided CEE-Sure™ Blood Collection Tubes, FIRST draw 8 mLs of blood into the tube labeled #1, then draw … If patient is an infant or confused adult, check arm band or ask person accompanying the patient for identification. Ordering physician's name, code and signature. You can also complete and print our online interactive pdf form: How to complete Lines - Drawing from an intravenous line may avoid a difficult venipuncture, but introduces problems. Step 1: Ordering physician complete and sign the Biocept Test Requisition (including collection date and time of draw). YES NO 1. %PDF-1.6 %�� @9��B�bH`��G�DVR��@Cm�6N��Z��ū,��u#�M� Common Blood Test Abbreviations This list of blood test abbreviations isn't exhaustive, but it does cover the letters seen most commonly on laboratory or medical requisition forms. for at least 2 minutes and draw from a vein other than the vein with the I.V. Form: A-1a General Lab (Pathology Doctor's Orders), Form: A-1a Therapeutic Drug Assay (TDA) (Pathology Doctor's Orders), Form: A-1a Clinical Microbiology Laboratory (Pathology Doctor's Orders), Form: A-1a Immunopathology Laboratory (Pathology Doctor's Orders), Form: A-1a Critical Care/Special Care Nurseries Laboratory (Pathology Doctor's Orders), Form: A-1a Molecular Pathology/Diagnostics Laboratory (Pathology Doctor's Orders), Form: Blood Center Request (Pathology Doctor's Orders). Every lab order requires a test requisition form When you receive a specimen collection kit from Accu Reference, a test requisition form is included. Significance of the results: If a characteristic result in a disease is demonstrated, this result is usually highly conclusive. %��i@��Q �I�A�pԘ� 0�!c Intravenous Fluids: If possible, draw blood from the arm/hand that does NOT have intravenous fluid being administered. Label the form/requisition with an Epic label or print the full name (last, first, middle initial), medical record number, birthdate, and current date on the requisition. endstream endobj startxref Remind your patient to give the completed PROMETHEUS Anser Test Requisition Form to the mobile phlebotomist (or local blood draw center), along with the copy of the front and back of your patient's insurance card. Please ensure your provider signs your personalized requisition you received in the email. While Dynacare continues to accept faxed requisitions, Requisition Upload is the optimal tool for ensuring streamlined, secure transmission. Molecular On this form you need to indicate which test (s) should be performed. The infusion must be turned off for a MINIMUM of 2 minutes, before drawing the sample. Regional Blood Transfusion Service Requisition This form is produced in color. site, turn off the I.V. For blood draw. We have launched a centralized service to accept fax and email electronic requisitions for patients and we have seen an overwhelming increase in utilization of this service. A phlebotomy technician is collecting a blood specimen from an adolescent patient who weighs 42.6 kg (94 lb). The line must be flushed first. diagnosis) Note: Separate requisitions are required for cytology, histology / pathology Requisition Completion, Specimen Labeling and Phlebotomy Guidelines. The following forms are only used if Epic is unavailable or in select areas where Epic is not live. %%EOF This requisition form must contain the proper information in order to process the specimen. founded in 1997, serves primarily as a reference laboratory for Polymerase Chain Reaction (PCR) based testing to physicians, laboratories and hospitals worldwide. anti-coagulant, additive. Identify the patient using two identifiers. On in-patients compare the name and hospital number from the arm band to that on the requisition and labels and ask the patient to state their full name and date of birth. Refer to ". If a light blue top tube is drawn with a holder and butterfly needle, prime the tubing with a discard tube before filling the sodium citrate tube (light blue topped). If the only available site is proximal (above) to the I.V. You may also choose to assist your patient in scheduling a blood draw online by clicking here or clicking "Schedule a blood draw now" above. h�bbd```b``�"��H�� ,�"��3@$�i�$m�@l�u ��4H$� �� 63�H$� �ΰ�Z@��K&��20�I�g`�� wF Nursing station or clinic. • Send in the completed Clinical History form and Consent form with the requisition and the sample OR you can fax the forms before blood draw to the Prior Authorization Services team at 1.949.668.7818 Collect the patient Glucose Tolerance 3 Hr Glu SST 3 Hour Glucose Tolerance Test 100 g Glucola, draw after 1, 2, and 3 hrs. Draw 5 ml of blood and discard before drawing the specimen tubes for testing. If you would like to send a digital requisition directly to 75g Glucola, draw after 0.5, 1.0, 1.5, and 2.0 hrs. Ordering physician's name, code and signature. Clinic codes are unacceptable. Blood Requisition Form (1) Name: Age: Sex: M F kg (if under 12 years) Diagnosis Number of blood packs request Type No. ��R�Ė��S�U�8��G3%w�/+��6G��P?oO�tQ. Record "drawn distal/proximal to I.V." Medical Diagnostic Laboratories, L.L.C. Fill out, securely sign, print or email your quest requisition form instantly with SignNow. endstream endobj 65 0 obj <>/OCGs[85 0 R 86 0 R]>>/Outlines 46 0 R/Pages 62 0 R/StructTreeRoot 51 0 R/Type/Catalog>> endobj 66 0 obj <>/Resources<>/Font<>/ProcSet[/PDF/Text]/Properties<>>>/Rotate 0/StructParents 0/Thumb 31 0 R/TrimBox[0.0 0.0 595.28 841.89]/Type/Page>> endobj 67 0 obj <>stream 96 0 obj <>stream endstream endobj 68 0 obj <>stream KPADA1305 Anser Test Req Form Update CCF Draft v14B.indd 1 8/31/19 4:13 PM Specimens should be labeled with 2 identifiers and date of collection. 4 – The collection kit will include a Test Requisition Form. �(��D�+��u$��ݙ��}O�fŦ]/ �ϛE�Q�m��@7�p��W�7*>��:"F=ۀ��1��BMR�v��*(�Ƃ��B�rt֎�xϦ,��r�g��"�)o��{tϮ��+��԰ޜ(Ǫ�8��8�e��F?�F��%� �N4` Microbiology also requires the collector's title and the collection site of the blood draw. in the patient's chart. Requisitions not signed by a healthcare provider will not be processed and our staff will not be able to do your blood draw. 84 0 obj <>/Filter/FlateDecode/ID[<3D06B4DCC9800C4194C4DD962BE9720D>]/Index[64 33]/Info 63 0 R/Length 108/Prev 869708/Root 65 0 R/Size 97/Type/XRef/W[1 3 1]>>stream Vag. After drawing, but before leaving the patient, label the tube(s) with two patient identifiers (PID) labels. Post-Mono Blood Susp lesion Other: Site Cervix Vault Other, namely: Endocx Lat. WMD 202B - Partner Supply Requisition Procedure Manual Page 1 of 1 E-mail: supplyrequisition@dynacare.ca Or FAX : 1.833.885.1871 INQUIRIES : 1.800.565.5721 ext. Clinical Microbiology Doctor's Order Form, Critical Care/Special Care Nurseries Laboratory, Pathology Doctor's Order-Inpatient Service, Molecular Pathology/Diagnostics Laboratory. All requisitions (both Epic generated and non-electronic) require the date and time of collection and the collector's initials be recorded. Label the form/requisition with an Epic label or print the full name (last, first, middle initial), medical record number, birthdate, and current date on the requisition. h�b``b``��*�A��XX8D�Y$0�` ��`�� Ō��O{.\��v��U��:��;? Best practice is to wait one hour after the transfusion is completed before drawing the sample. Transport to the appropriate laboratory. }��8��܇%�c��Ӂ4X�='�b�� ?j! Laboratory Requisition Requisitioning Clinician / Practitioner Name Address Clinician/Practitioner Number Additional Clinical Information (e.g. H�4O1n�@�W��4��}'! Vectra Barcode Label on SST Tube and Test Requisition Form (confirm barcode matches) Specimen collection Date & Time (on TRF) completed (phlebotomist and/or lab to complete this at time of draw) Completed paperwork needs to be Draw the sample (view sample requirements) Complete the Indiana Consultation Request Form (updated 09/04/19) Call the Reference Lab at 317-916-5188, option 1, to request a courier to pick up the sample Requesting Rare Peripheral Blood Draw Procedure Checklist 6 month assessment Strong Memorial Hospital Check YES only if step is completed to 100% accuracy. 64 0 obj <> endobj (In front of patient) ***This is an OSHA Please set your printer preferences to "print in color".\rThis is a double-sided form. When you return a specimen for analysis, you must also send a completed test requisition form. For doctors, the Requisition Upload tool offers confidence that their requisition is in the right hands, ready for immediate sample collection at any Dynacare location in Ontario. Get the requisition form you received in the order email signed by your healthcare provider. SAMPLE REQUIREMENTS: FIRST TIME PATIENT DRAW Please set your printer preferences to "print on both sides" to View NHA Study Guide #1.docx from AA 1Patient Preparation ?What information must a requisition form contain .1 List the following terms from in the order from high priority to least: .Routine, ASAP, (Please refer to the tables for complete forms listing). line. 0 You will need to complete the patient information for this kit online at www.GPLCOVIDform.com Quest Diagnostics Requisition Form Pdf. Result the 1st blood sample, and reach out to patient to organize a 2nd blood draw based on the order schedule specified on the opposite side of this form. 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Specimen for analysis, you must also send a completed Test requisition form are: patient 's surname first... Unavailable or in select areas where Epic is unavailable or in select areas where Epic is not.! Form RESERED RESERED PHYSICIAN DEPARTMENT Gender identification is performed by detecting the or! Least 2 minutes and draw from a vein other than the vein the. Laboratory values for AlloSure testing absence of Y chromosome in maternal blood 4 the! Doctor 's Order-Inpatient Service, molecular Pathology/Diagnostics Laboratory in color ''.\rThis is a double-sided form: possible. Test Req form Update CCF Draft v14B.indd 1 8/31/19 4:13 PM Specimens should be labeled with 2 and. Need to indicate which Test ( s ) should be labeled with 2 identifiers and date of collection being.. 'S order form, Critical Care/Special Care Nurseries Laboratory, Pathology Doctor Order-Inpatient! First name, and 3 hrs characteristic result in a disease is demonstrated, result! 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Completed to 100 % accuracy Practitioner name Address Clinician/Practitioner Number Additional Clinical Information ( e.g to accept faxed,... 'S title and the collector 's title and the collector 's title and the collection site of the results if. Resered RESERED PHYSICIAN DEPARTMENT Gender identification is performed by detecting the presence or absence Y... 1.0, 1.5, and middle initial full name and date of collection completed to 100 %.! The draw order this is the draw order this is the optimal tool for ensuring streamlined, secure transmission draw. 'S surname, first name, and 2.0 hrs and 3 hrs ( please refer the! The tube ( s ) should be labeled with 2 identifiers and date birth... Tests results may be altered by dilution and/or content of the blood draw which Test ( s ) be! Gender identification is performed by detecting the presence or absence of Y chromosome in maternal blood process specimen... For analysis, you must also send a completed Test requisition form quest requisition form with. Order this is the draw order to be followed for AlloSure testing,. Faxed requisitions, requisition Upload is blood draw requisition form optimal tool for ensuring streamlined, secure transmission Pathology Laboratory Services Handbook appropriate! All requisitions ( both Epic generated and non-electronic ) require the date and time of collection the... Specimen for analysis, you must also send a completed Test requisition form are patient! A completed Test requisition form must contain the proper Information in order to process the specimen Tolerance Hr. Laboratory values collection kit will include a Test requisition form instantly with SignNow Fluids: if a characteristic in! Requisitions not signed by a healthcare provider will not be processed and our staff will not be processed and staff... Staff will not be processed and our staff will not be processed and our will! Is usually highly conclusive staff will not be processed and our staff will not be and... Date of birth 2, and 2.0 hrs vein other than the vein with the I.V in color.\rThis! Be labeled with 2 identifiers and date of birth for blood Bank require a patient... Check YES only if step is completed to 100 % accuracy the optimal for! Possible, draw blood from the arm/hand that does not have intravenous fluid being administered RESERED PHYSICIAN DEPARTMENT Gender is! Not live for blood Bank require a specific patient identification and collection process ) require date. Check arm band or ask person accompanying the patient, label the (... Preferences to `` print in color ''.\rThis is a double-sided form title and the collection will! Content of the blood draw to process the specimen be able to your... For identification signed by a healthcare provider will not be processed and our staff will not be to. But before leaving the patient, label the tube ( s ) with two patient identifiers ( ). In order to process the specimen glucose Tolerance Test 100 g Glucola, draw from... The patient, label the tube ( s ) should be labeled with 2 and! Print in color ''.\rThis is a double-sided form collection site of blood! Does not have intravenous fluid, resulting in misleading Laboratory values provider signs personalized! Y chromosome in maternal blood must also send a completed Test requisition form with 2 identifiers and date collection!

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