Dilute RVVT Screen Ratio with Reflex
| 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. Dilute RVVT Screen Ratio with Reflex | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
DRVTI
Test Workstation :
MAYO
Specimen Type:
Plasma
Tube Type:
Sodium citrate (Blue) tube
Collection Volume:
2.7 mL in 2.7mL Sodium Citrate tube
(1.0 mL plasma sent to Reference Lab, frozen)
Cause for Rejection:
Grossly hemolyzed, grossly lipemic, grossly icteric.
Storage:
Frozen
Availability:
Sent to Reference Laboratory
Methodology:
Clot-based Assay
Special Instructions:
Testing while the patient is on anticoagulant therapy, including warfarin, dabigatran, or a direct Xa inhibitor may cause a false positive result.
Lab/Phone:
330-543-8418
TAT:
1-4 days
Additional Info:
Reference value: ratio <1.20
CPT Code:
85613 (x3 if appropriate)
Panel Includes:
DRVVT Screen
DRVVT Mix and Confirm will be performed if the DRVVT screen is > or = 1.2
Synonyms:
Lupus Anticoagulant,
Dilute Russell Viper Venom Time
