Gram Stain
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
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| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
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| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Gram Stain | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
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Test ID :
GRAM
Test Workstation :
MIC1
Specimen Type:
E-swab or smear from specimen for bacterial culture.
Cause for Rejection:
Quantity not sufficient, improper specimen type, improper storage/transport, improper swab, dry swab, multiple swabs per vial, mislabeled, or unlabeled.
Storage:
Refer to storage conditions for related cultures.
Availability:
Mon-Sun (0700-1600)
Methodology:
Microscopic examination
Lab/Phone:
330-543-8406
TAT:
24 hours
Additional Info:
Gram stains are automatically added to all CSF, Aerobe, Wound, Sputum, and Tracheal aspirate cultures and do not need to be ordered separately.
CPT Code:
87205
Synonyms:
Bacterial Stain; Direct Stain for Bacteria
