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. Prothrombin Time & Activated PTT   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Prothrombin Time & Activated PTT
Specimen Type: Blood

Tube Type/Collection Container: Blue top (sodium citrate) tube

Collection Volume: 2.7 mL

Cause for rejection: Specimen hemolyzed, clotted, diluted with IV fluid; contaminated with heparin; improperly filled; not kept on ice; received > 1 hr after drawn

Storage: Refrigerated

Availability: Daily, 24 hours; STAT

Methodology: Optical Light Scatter Detection Clotting Assay

Special Instructions: Indicate clearly if a specimen has been drawn from an arterial line or from a line that has been rinsed with heparin. This information is absolutely essential to the laboratory personnel for proper handling of the specimen and the reporting of results. Please indicate if the patient is currently receiving anticoagulant therapy.

TAT: 4 hours


Lab/Phone: 330-746-9623

Additional Info: Reference ranges: PT 12-14 secs; APTT < 41 secs

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: