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   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Prothrombin Time
CPT Code: 85610

Specimen Type: Blood

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

Collection Volume: 2.7 mL

Cause for rejection: Sample 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 CCL personnel for the 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 range: 12-14 secs. Recommended Therapeutic Range for Oral Anticoagulant Therapy: Prophylaxis of venous thrombosis, Treatment of venous thrombosis, Treatment of pulmonary embolism, Prevention of systemic, and Tissue heart valves- INR 2.0-3.0, Myocardial infarction ( to prevent systemic embolism), Valvular heart disease, Atrial fibrillation, Mechanical prosthetic valves - INR 2.0-3.0

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: