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