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. Lithium   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Lithium
CPT Code: 80178

Specimen Type: Blood

Tube Type/Collection Container: Red top (no anticoagulant) tube

Collection Volume: 0.6 mL

Cause for rejection: Hemolysis

Storage: Refrigerated

Availability: Daily, 24 hours; STAT

Methodology: Spectrophotometric/Endpoint

Special Instructions: Indicate date, time, and amount of last dose. Collect samples for lithium determination at least 12 hours after the last dose. Separate from cells if analysis is not performed within 4 hours.

TAT: 1 hour


Lab/Phone: 330-543-8417

Additional Info: Therapeutic range: 0.5-1.2 mEq/L Toxic: > 2.0 mEq/L Critical Limit: >1.5 mEq/L

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: