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. PT by Monitor   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for PT by Monitor
CPT Code: 85610

Specimen Type: Fresh Whole Peripheral Blood

Tube Type/Collection Container: None

Collection Volume: 0.05 mL Whole Blood

Cause for rejection: Specimen diluted with IV fluid or heparin; containing anticoagulants; collected in glass tubes or syringes

Storage: None

Availability: Daily, 24 hours; STAT

Methodology: Electronic Optical Detection Clotting Assay; cartridge-based

Special Instructions: Testing is done on unanticoagulated blood at the bedside. Plasma or serum can't be used. Prepare capillary puncture site by warming fingertips or heel with warm water and/or warm washcloth. Testing can be drawn at Akron Campus only.

TAT: 30 minutes


Lab/Phone: 330-543-8416

Additional Info: Reference range: PT = 12-14 secs Only INR will be reported. This testing can ONLY be used for patients on stable oral anticoagulant therapy. There is no significant contribution to the diagnosis or treatment of patients whose Prothrombin Time is prolonged for other reasons.

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: