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. Wound Culture   
2.   
3.   
4.   
5.   
6.   

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

Specimen Type: Wound lesion or Abscess swab, material aspirated from wound site

Tube Type/Collection Container: Eswab

Collection Volume: 1.0 mL (minimum swab)

Cause for rejection: Specimen received on dry swabs. Specimen received in nonsterile container.

Storage: Ambient

Availability: Daily

Methodology: Culture

Special Instructions: All wound cultures include a gram stain. Collect an Eswab of wound/aspirate or 2.0 mL of material from wound site. Requisition must state specific site where specimen was taken along with any important information regarding patient diagnosis e.g. animal bite). If provider's orders are to culture for a specific organism, include this information on requisition.

TAT: 72 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: