Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


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. Sputum Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Sputum Culture
CPT Code: 87070

Specimen Type: Sputum

Tube Type/Collection Container: Specimen container

Collection Volume: 5.0 mL (minimum 1.0 mL)

Cause for rejection: Specimen received in nonsterile container. Sputum specimen containing food particles. Specimen sent on swab is not appropriate for culture.

Storage: Ambient

Availability: Daily

Methodology: Culture

Special Instructions: Sputum culture includes gram stain to check the quality of the specimen. A gram stain showing >25 squamous epithelial cells indicates that the specimen is contaminated with saliva and should be repeated if possible. The laboratory will communicate with the nurse or doctor if the specimen is contaminated to ascertain whether the specimen should be cultured. A CF patient will be processed regardless of gram stain result per CF protocol.

TAT: 48 hours


Lab/Phone: 330-543-8412

Additional Info: Preliminary report available after 24 hours

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: