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: Laser Optical Detection Clotting Assay

Special Instructions: Plasma or serum can't be used. Prepare capillary puncture site by warming fingertips or heel with warm water and/or warm washcloth.

TAT: 30 minutes


Lab/Phone: 330-543-8416

Additional Info: Reference range: PT = 12-14 secs

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: