State Metabolic Screen
| 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. State Metabolic Screen | |
| 2. | |
| 3. | |
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| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
NBSCN
Test Workstation :
OHIO
Specimen Type:
Blood
Collection Volume:
Five blood soaked circles on special filter paper
Cause for Rejection:
Clotted; filter paper not thoroughly saturated; layering of blood,
Storage:
Ambient
Availability:
Sent to reference lab
Methodology:
Tandem Mass Spectrophotometry/ Isoelectric Focusing/ Wallac
Special Instructions:
Allow a large drop of blood to fall on filter paper, soaking through to opposite side.
Lab/Phone:
330-543-8418
TAT:
7-21 days
Additional Info:
Reference range is available on patient report
CPT Code:
84443, 83789, 83516, 82776, 83498, 82261, 83020
Panel Includes:
See the ODH Newborn screening website for tests contained in the panel
Synonyms:
Phenylketonuria, PKU Card, ODH Card
