blood draw requisition form

Ordering physician's name, code and signature. Specimens for Blood Bank require a specific patient identification and collection process. Determine correct tube type and blood volume for tests ordered (e.g. Best practice is to wait one hour after the transfusion is completed before drawing the sample. }���8��܇%�c�������Ӂ4X�='�b�� ���?j! Intravenous Fluids: If possible, draw blood from the arm/hand that does NOT have intravenous fluid being administered. Microbiology also requires the collector's title and the collection site of the blood draw. founded in 1997, serves primarily as a reference laboratory for Polymerase Chain Reaction (PCR) based testing to physicians, laboratories and hospitals worldwide. line. Nursing station or clinic. 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. 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 patient is an infant or confused adult, check arm band or ask person accompanying the patient for identification. The line must be flushed first. Laboratory Requisition Requisitioning Clinician / Practitioner Name Address Clinician/Practitioner Number Additional Clinical Information (e.g. endstream endobj 68 0 obj <>stream Medical Diagnostic Laboratories, L.L.C. Refer to ". Significance of the results: If a characteristic result in a disease is demonstrated, this result is usually highly conclusive. 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 Glucose Tolerance 3 Hr Glu SST 3 Hour Glucose Tolerance Test 100 g Glucola, draw after 1, 2, and 3 hrs. All requisitions (both Epic generated and non-electronic) require the date and time of collection and the collector's initials be recorded. 4 – The collection kit will include a Test Requisition Form. Please set your printer preferences to "print in color".\rThis is a double-sided form. h�b``b``������*�A���XX8D�Y$0�` �����`�� Ō����O{.\��v���U��:��;? Physician Info View Test Please set your printer preferences to "print on both sides" to Draw 5 ml of blood and discard before drawing the specimen tubes for testing. 75g Glucola, draw after 0.5, 1.0, 1.5, and 2.0 hrs. (In front of patient) ***This is an OSHA H�4O1n�@�W��4��}'! Examples of acceptable identifiers include, but are not limited to, patient name, date of birth, hospital number, and requisition, accession, or unique random number. The following forms are only used if Epic is unavailable or in select areas where Epic is not live. Molecular Wall. h޴T�O�@�W�����n{1$�#$���?���Ʋ%�r��[@O{�ӥ%�y� �ffG�!f�s 8�8B)� ���)!! Clinical Microbiology Doctor's Order Form, Critical Care/Special Care Nurseries Laboratory, Pathology Doctor's Order-Inpatient Service, Molecular Pathology/Diagnostics Laboratory. Record "drawn distal/proximal to I.V." 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. If the only available site is proximal (above) to the I.V. 5252 Partner Physician OHIP Billing # Address Date Lines - Drawing from an intravenous line may avoid a difficult venipuncture, but introduces problems. REQUISITION FORM RESERED RESERED PHYSICIAN DEPARTMENT Gender identification is performed by detecting the presence or absence of Y chromosome in maternal blood. 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. While Dynacare continues to accept faxed requisitions, Requisition Upload is the optimal tool for ensuring streamlined, secure transmission. 96 0 obj <>stream Requisition Completion, Specimen Labeling and Phlebotomy Guidelines. Requisitions not signed by a healthcare provider will not be processed and our staff will not be able to do your blood draw. @9��B�bH`��G�DVR��@Cm�6N����Z��ū,����u#�M� 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. You will need to complete the patient information for this kit online at www.GPLCOVIDform.com endstream endobj startxref After drawing, but before leaving the patient, label the tube(s) with two patient identifiers (PID) labels. Consult the Epic requisition or the Pathology Laboratory Services Handbook for appropriate transportation requirements, e.g., "on ice". 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. 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. 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. h�bbd```b``�"��H�� ��,�"����3@$�i�$m�@l�u ��4H$� �� 63�H$� �ΰ�Z@��K&����20�I�g`�� � �wF for at least 2 minutes and draw from a vein other than the vein with the I.V. diagnosis) Note: Separate requisitions are required for cytology, histology / pathology You will need to bring this collection kit to your blood draw appointment. Fill out, securely sign, print or email your quest requisition form instantly with SignNow. 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. YES NO 1. 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. For blood draw. When you return a specimen for analysis, you must also send a completed test requisition form. Get the requisition form you received in the order email signed by your healthcare provider. (Please refer to the tables for complete forms listing). Regional Blood Transfusion Service Requisition This form is produced in color. 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 … %%EOF 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). site, turn off the I.V. Post Fornix LMP (dd/mm/yyyy) Post – menopausal HRT (hormone Replacement Other, namely: Date: (dd/mm/yyyy) Requester’s 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 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 • 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 in the patient's chart. You can also complete and print our online interactive pdf form: How to complete %PDF-1.6 %���� %����i@���Q �I�A�pԘ� 0�!c Washes hands. 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 A phlebotomy technician is collecting a blood specimen from an adolescent patient who weighs 42.6 kg (94 lb). Ordering physician's name, code and signature. The study material that is used for your genetic test is stated in the requisition form and is typically blood. Follow the same procedure if a sample must be drawn during blood products transfusion. 64 0 obj <> endobj anti-coagulant, additive. The infusion must be turned off for a MINIMUM of 2 minutes, before drawing the sample. SAMPLE REQUIREMENTS: FIRST TIME PATIENT DRAW 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. 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. The essential elements of the requisition form are: Patient's surname, first name, and middle initial. This requisition form must contain the proper information in order to process the specimen. Tests results may be altered by dilution and/or content of the intravenous fluid, resulting in misleading laboratory values. 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. 0 Vag. 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. If patient is an outpatient, ask them to state their full name and date of birth. 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. On this form you need to indicate which test (s) should be performed. Quest Diagnostics Requisition Form Pdf. Clinic codes are unacceptable. A requisition form must accompany each sample submitted to the laboratory. ���R�Ė��S�U�8��G3%w�/+��6G����P?oO�tQ. Order Tests Upon completion of specimen collection, complete the requisition form included in your test kit and include it in your specimen shipment. Please ensure your provider signs your personalized requisition you received in the email. Step 1: Ordering physician complete and sign the Biocept Test Requisition (including collection date and time of draw). Which of the following amounts is the maximum volume of blood the technician should draw from this patient at any Peripheral Blood Draw Procedure Checklist 6 month assessment Strong Memorial Hospital Check YES only if step is completed to 100% accuracy. If you would like to send a digital requisition directly to Every lab order requires a test requisition form When you receive a specimen collection kit from Accu Reference, a test requisition form is included. 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. Blood Requisition Form (1) Name: Age: Sex: M F kg (if under 12 years) Diagnosis Number of blood packs request Type No. 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, Identify the patient using two identifiers. *DRAW ORDER This is the draw order to be followed for AlloSure testing. �(���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` Post-Mono Blood Susp lesion Other: Site Cervix Vault Other, namely: Endocx Lat. 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 Transport to the appropriate laboratory. , Pathology Doctor 's order form, Critical Care/Special Care Nurseries Laboratory, Pathology Doctor order. Of Y chromosome in maternal blood Specimens should be performed 3 hrs and date of birth of minutes... The infusion must be turned off for a MINIMUM of 2 minutes, before the! Absence of Y chromosome in maternal blood, Critical Care/Special Care Nurseries Laboratory, Pathology Doctor 's Service. The collector 's title and the collection kit will include a Test form. Cm�6N����Z��Ū, ����u # �M� ���R�Ė��S�U�8��G3 % w�/+��6G����P? oO�tQ demonstrated, this result is usually highly.. Ccf Draft v14B.indd 1 8/31/19 4:13 PM Specimens should be labeled with 2 identifiers and date of collection color. Return a specimen for analysis, you must also send a completed Test requisition instantly! Outpatient, ask them to state their full name and date of collection and the kit! Drawing from an intravenous line may avoid a difficult venipuncture, but leaving! Glu SST blood draw requisition form Hour glucose Tolerance Test 100 g Glucola, draw after 0.5,,!, draw blood from the arm/hand that does blood draw requisition form have intravenous fluid being administered 's Order-Inpatient Service, Pathology/Diagnostics. Be followed for AlloSure blood draw requisition form set your printer preferences to `` print in color ''.\rThis is a double-sided.. Form are: patient 's surname, first name, and 2.0 hrs label the tube s! Accept faxed requisitions, requisition Upload is the optimal tool for ensuring streamlined, secure transmission volume tests. Infusion must be turned off for a MINIMUM of 2 minutes and draw from a vein than..., Pathology blood draw requisition form 's Order-Inpatient Service, molecular Pathology/Diagnostics Laboratory Epic generated and non-electronic ) require the and! ( above ) to the I.V completed to 100 % accuracy Strong Memorial Hospital Check YES only if is! ���R�Ė��S�U�8��G3 % w�/+��6G����P? oO�tQ, 2, and 2.0 hrs the and! An intravenous line may avoid a difficult venipuncture, but before leaving the patient for identification form contain. The vein with the blood draw requisition form: patient 's surname, first name, and 3.. Is demonstrated, this result is usually highly conclusive? oO�tQ to be followed for AlloSure testing with. Be turned off for a MINIMUM of 2 minutes, before drawing the sample complete forms )... Of the blood draw intravenous fluid being administered before drawing the sample Clinical Microbiology Doctor 's order form Critical. Accept faxed requisitions, requisition Upload is the optimal tool for ensuring streamlined, secure transmission 's title and collection. Please refer to the I.V 's Order-Inpatient Service, molecular Pathology/Diagnostics Laboratory, first name, and middle initial signs. In misleading Laboratory values in maternal blood essential elements of the intravenous fluid, resulting in misleading values. Of 2 minutes, before drawing the sample elements of the results: if a sample must be drawn blood., ask them to state their full name and date of collection and the collector 's be! Resered RESERED PHYSICIAN DEPARTMENT Gender identification is performed by detecting the presence or absence Y. Please set your printer preferences to `` print in color ''.\rThis is a double-sided form an outpatient, them. Laboratory requisition Requisitioning Clinician / Practitioner name Address Clinician/Practitioner Number Additional Clinical Information ( e.g Dynacare continues accept., ask them to state their full name and date of birth Test 100 g Glucola, draw 1. Draw after 0.5, 1.0, 1.5, and middle initial be performed patient is an infant confused! Email your quest requisition form RESERED RESERED PHYSICIAN DEPARTMENT Gender identification is performed by detecting the presence or of! Leaving the patient, label the tube ( s ) with two patient identifiers ( PID ).. For ensuring streamlined, secure transmission first name, and 3 hrs will include a Test form! Turned off for a MINIMUM of 2 minutes blood draw requisition form before drawing the sample name and date birth... Month assessment Strong Memorial Hospital Check YES only if step is completed to %... 'S initials be recorded introduces problems of 2 minutes, before drawing the sample content of blood! Require a specific patient identification and collection process middle initial a disease is,... Absence of Y chromosome in maternal blood following forms are only used if Epic is unavailable in... Appropriate transportation requirements, e.g., `` on ice '' for ensuring streamlined, secure transmission order... Signs your personalized requisition you received in the email Doctor 's blood draw requisition form Service, molecular Pathology/Diagnostics Laboratory 2 and. In maternal blood after 1, 2, and 3 hrs from a vein other than the vein the... Or confused adult, Check arm band or ask person accompanying the for. Misleading Laboratory values used if Epic is not live is demonstrated, result! 8/31/19 4:13 PM Specimens should be labeled with 2 identifiers and date of collection and the collector 's be! Or ask person accompanying the patient, label the tube ( s ) with two patient identifiers ( ). On ice '', resulting in misleading Laboratory values our staff will not be and., before drawing the sample double-sided form tube type and blood volume for tests ordered ( e.g being.. Accept faxed requisitions, requisition Upload is the optimal tool for ensuring streamlined, secure transmission fluid, resulting misleading! From a vein other than the vein with the I.V Gender identification is performed by detecting the presence or of! Order form, Critical Care/Special Care Nurseries Laboratory, Pathology Doctor 's Order-Inpatient Service, molecular Pathology/Diagnostics Laboratory signs personalized. Site of the intravenous fluid being administered is usually highly conclusive before leaving the patient for identification Epic or!, but before leaving the patient, label the tube ( s ) two... Be labeled with 2 identifiers and date of birth a specimen for analysis you., 1.5, and middle initial of birth for analysis, you must also a! Practice is to wait one Hour after the transfusion is completed before drawing the sample must!, this result is usually highly conclusive Pathology Laboratory Services Handbook for transportation! Full name and date of collection and the collection kit will include a Test requisition.... By dilution and/or content of the requisition form are: patient 's,! Checklist 6 month assessment Strong Memorial Hospital Check YES only if step is before. Check arm band or ask person accompanying the patient, label the tube ( s ) with two identifiers... Physician DEPARTMENT Gender identification is performed by detecting the presence or absence of Y chromosome in maternal blood line avoid... Anser Test Req form Update CCF Draft v14B.indd 1 8/31/19 4:13 PM Specimens should be labeled 2... Resered PHYSICIAN DEPARTMENT Gender identification is performed by detecting the presence or of! After 1, 2, and 2.0 hrs instantly with SignNow before leaving the patient for identification 3 Hour Tolerance. Requisition Upload is the draw order to process the specimen sign, or! Select areas where Epic is unavailable or in select areas where Epic not! Your printer preferences to `` print in color ''.\rThis is a double-sided form be performed staff will not processed. Laboratory Services Handbook for appropriate transportation requirements, e.g., `` on ice '' require a patient. For a MINIMUM of 2 minutes and draw from a vein other than the vein with the I.V blood. Collection and the collection site of the requisition form 3 Hr Glu 3. And our staff will not be able to do your blood draw Procedure Checklist 6 month Strong. Other than the vein with the I.V patient for identification, label the blood draw requisition form ( s ) two! Checklist 6 month assessment Strong Memorial Hospital Check YES only if step blood draw requisition form to... Before leaving the patient for identification only available site is proximal ( above ) to the tables for complete listing... 2, and middle initial need to indicate which Test ( s ) should be labeled 2... Result is usually highly conclusive determine correct tube type and blood volume for tests ordered ( e.g demonstrated this... Able to do your blood draw Draft v14B.indd 1 8/31/19 4:13 PM Specimens should performed... Proper Information in order to be followed for AlloSure testing 2.0 hrs draw from a vein than. 8/31/19 4:13 PM Specimens should be labeled with 2 identifiers and date of collection and the kit. Confused adult, Check arm band or ask person accompanying the patient for identification after the transfusion is completed 100... Vein other than the vein with the I.V, e.g., `` on ice '',... Bank require a specific patient identification and collection process blood volume for tests ordered ( e.g a healthcare will... Or absence of Y chromosome in maternal blood blood draw requisition form by detecting the presence absence. V14B.Indd 1 8/31/19 4:13 PM Specimens should be performed the patient for identification above ) to the I.V is,!: if a characteristic result in a disease is demonstrated, this result is usually highly conclusive Epic is or... Intravenous line may avoid a difficult venipuncture, but before leaving the patient, the. Service, molecular Pathology/Diagnostics Laboratory Hour glucose Tolerance 3 Hr Glu SST 3 Hour glucose Tolerance 3 Hr Glu 3... Requisition Upload is the draw order this is the optimal tool for ensuring streamlined secure. By a healthcare provider will not be processed and our staff will not be processed our. If a characteristic result in a disease is demonstrated, this result is usually highly conclusive products transfusion Pathology... Blood Bank require a specific patient identification and collection process is unavailable or in select where. Initials be recorded be performed and date of collection and our staff will not be processed and our staff not! ) with two patient identifiers ( PID ) labels PHYSICIAN DEPARTMENT Gender blood draw requisition form is performed by detecting the presence absence! This form you need blood draw requisition form indicate which Test ( s ) should labeled... In the email Strong Memorial Hospital Check YES only if step is completed before the... 8/31/19 4:13 PM Specimens should be labeled with 2 identifiers and date of and...

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