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. Staph Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Staph Culture
CPT Code: 87081

Specimen Type: Nose, NPH, Umbilicus, Tracheal aspirate, Cath site, Wound

Tube Type/Collection Container: Eswab

Collection Volume: 0.5 mL (minimum - swab)

Cause for rejection: Specimen sent on dry swab. Specimen sent in nonsterile container, no swab in transport tube.

Storage: Ambient

Availability: Daily

Methodology: Culture

Special Instructions: These cultures are screened for Staphylococcus aureus only! No other pathogens will be reported. Any Staph aureus isolated will be tested for sensitivity to Methicillin. Orders must state specific site of specimen.

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: