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. ED Stat Panel   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for ED Stat Panel
Specimen Type: Blood

Tube Type/Collection Container: Green top (lithium heparin) or heparinized syringe 600 uL

Collection Volume: minimum 400 uL

Cause for rejection: clotted, not sent on ice, air bubbles

Storage: On Ice

Availability: Daily, 24 hours; STAT

Methodology: Ion Selective Electrode/Calculations

Special Instructions: Notify laboratory if patient's temperature is other than 37 C to correct results (temperature dependnet). Place specimen on ice and deliver to laboratory immediately.

TAT: 30 minutes

Panel Includes: Venous Gases, Whole blood Analytes to include: Ionized Calcium, Chloride, Glucose, Potassium, Sodium, Lactate


Lab/Phone: 330-543-8417

Additional Info: Reference ranges available under individual tests.

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: