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. Gases, Venous   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Gases, Venous
CPT Code: 82803

Specimen Type: Blood

Tube Type/Collection Container: Heparinized syringe, Green top (lithium heparin) tube

Collection Volume: 0.5 mL syringe; 4 mL green top - must be full

Cause for rejection: Clotted, air bubbles Sample in microtainer gel separator tube will not be accepted.

Storage: Room Temp

Availability: Daily, 24 hours; STAT

Methodology: ion selective electrode/Calculations

Special Instructions: Notify lab if patient's temperature is other than 37C to correct results (temperature dependent). Deliver immediately to laboratory at room temperature. For Outpatients, test should only be drawn in outpatient locations within the Hospital on the Beeghly campus.

TAT: 30 minutes

Panel Includes: Temperature, Hemoglobin, pH, pCO2, pO2, Tco2, O2 Saturation, O2 Hemoglobin, Std. Base Excess


Lab/Phone: 330-746-9623

Additional Info: Reference range is available on patient report

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: