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. Physician Info View Test 0 If patient is an outpatient, ask them to state their full name and date of birth. For blood draw. 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. While Dynacare continues to accept faxed requisitions, Requisition Upload is the optimal tool for ensuring streamlined, secure transmission. YES NO 1. Please set your printer preferences to "print in color".\rThis is a double-sided form. Please ensure your provider signs your personalized requisition you received in the email. • 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 Regional Blood Transfusion Service Requisition This form is produced in color. %PDF-1.6 %���� Post Fornix LMP (dd/mm/yyyy) Post – menopausal HRT (hormone Replacement Other, namely: Date: (dd/mm/yyyy) Requester’s Washes hands. 75g Glucola, draw after 0.5, 1.0, 1.5, and 2.0 hrs. 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. Nursing station or clinic. SAMPLE REQUIREMENTS: FIRST TIME PATIENT DRAW 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). Follow the same procedure if a sample must be drawn during blood products transfusion. Fill out, securely sign, print or email your quest requisition form instantly with SignNow. Quest Diagnostics Requisition Form Pdf. @9��B�bH`��G�DVR��@Cm�6N����Z��ū,����u#�M� Order Tests Upon completion of specimen collection, complete the requisition form included in your test kit and include it in your specimen shipment. 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. 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 Refer to ". Examples of acceptable identifiers include, but are not limited to, patient name, date of birth, hospital number, and requisition, accession, or unique random number. Microbiology also requires the collector's title and the collection site of the blood draw. Identify the patient using two identifiers. You will need to complete the patient information for this kit online at www.GPLCOVIDform.com line. Which of the following amounts is the maximum volume of blood the technician should draw from this patient at any 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 When you return a specimen for analysis, you must also send a completed test requisition form. founded in 1997, serves primarily as a reference laboratory for Polymerase Chain Reaction (PCR) based testing to physicians, laboratories and hospitals worldwide. The line must be flushed first. If patient is an infant or confused adult, check arm band or ask person accompanying the patient for identification. 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. Vag. 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. 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. }���8��܇%�c�������Ӂ4X�='�b�� ���?j! H�4O1n�@�W��4��}'! 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, Step 1: Ordering physician complete and sign the Biocept Test Requisition (including collection date and time of draw). %%EOF *DRAW ORDER This is the draw order to be followed for AlloSure testing. Requisition Completion, Specimen Labeling and Phlebotomy Guidelines. for at least 2 minutes and draw from a vein other than the vein with the I.V. If you would like to send a digital requisition directly to Glucose Tolerance 3 Hr Glu SST 3 Hour Glucose Tolerance Test 100 g Glucola, draw after 1, 2, and 3 hrs. h�bbd```b``�"��H�� ��,�"����3@$�i�$m�@l�u ��4H$� �� 63�H$� �ΰ�Z@��K&����20�I�g`�� � �wF (Please refer to the tables for complete forms listing). The essential elements of the requisition form are: Patient's surname, first name, and middle initial. Blood Requisition Form (1) Name: Age: Sex: M F kg (if under 12 years) Diagnosis Number of blood packs request Type No. Ordering physician's name, code and signature. This requisition form must contain the proper information in order to process the specimen. All requisitions (both Epic generated and non-electronic) require the date and time of collection and the collector's initials be recorded. Wall. The study material that is used for your genetic test is stated in the requisition form and is typically blood. 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. Clinic codes are unacceptable. 5252 Partner Physician OHIP Billing # Address Date Ordering physician's name, code and signature. On this form you need to indicate which test (s) should be performed. Please set your printer preferences to "print on both sides" to 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. You can also complete and print our online interactive pdf form: How to complete 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. Best practice is to wait one hour after the transfusion is completed before drawing the sample. If the only available site is proximal (above) to the I.V. Get the requisition form you received in the order email signed by your healthcare provider. h�b``b``������*�A���XX8D�Y$0�` �����`�� Ō����O{.\��v���U��:��;? A phlebotomy technician is collecting a blood specimen from an adolescent patient who weighs 42.6 kg (94 lb). The following forms are only used if Epic is unavailable or in select areas where Epic is not live. Remind your patient to give the completed PROMETHEUS Anser Test Requisition Form to the mobile phlebotomist (or local blood draw center), along with the copy of the front and back of your patient's insurance card. A requisition form must accompany each sample submitted to the laboratory. h޴T�O�@�W�����n{1$�#$���?���Ʋ%�r��[@O{�ӥ%�y� �ffG�!f�s 8�8B)� ���)!! to the MSH lab the following: VeMi prenatal Test Form Signed NIPT Blood Draw handout (if the requisition signed by your heanhcare provider) Completed Credit Card Authorization in a seabd envelope your name on 4 – The collection kit will include a Test Requisition Form. �(���D�+���u$��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` in the patient's chart. Determine correct tube type and blood volume for tests ordered (e.g. site, turn off the I.V. 96 0 obj <>stream Medical Diagnostic Laboratories, L.L.C. Specimens for Blood Bank require a specific patient identification and collection process. Lines - Drawing from an intravenous line may avoid a difficult venipuncture, but introduces problems. Peripheral Blood Draw Procedure Checklist 6 month assessment Strong Memorial Hospital Check YES only if step is completed to 100% accuracy. 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).

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