Blood Culture
| 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. Blood Culture | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Specimen Type:
Blood
Tube Type:
Blood Culture Bottle
Do not submit an anaerobic (Orange) bottle without an aerobic (Green) bottle.
If only one bottle can be drawn, an aerobic bottle (Green) should be used.
Collection Volume:
Weight: <1 Kg: collect 2 mL in Aerobic Green FA Plus.
Weight: 1.1 to 2 Kg: collect 4 mL
(Aerobic Green FA Plus = 2 ml;
Anaerobic Orange FN Plus = 2 mL).
Weight: 2.1 to 12.7 Kg: collect 6 mL (Aerobic Green FA Plus = 4 mL; Anaerobic Orange FN Plus = 2 mL).
Weight: 12.8 to 36.3 Kg: collect 10 mL
(Aerobic Green FA Plus = 5 mL;
Anaerobic Orange FN Plus = 5 mL).
Weight: >36.3 Kg: collect 20 mL
(Aerobic Green FA Plus = 10 mL;
Anaerobic Orange FN Plus = 10 mL).
Minimum Volume:
1 mL
Storage:
Ambient
Special Instructions:
Blood cultures should be drawn prior to initiation of antimicrobial therapy. Ideally 2 separate sites (2 separate collections) are preferred when obtaining aerobic and anaerobic cultures. If more than 1 culture is drawn, specimens should be from different sites. This is the recommended order for yeast blood infection. The most important priority is the total volume of any individual blood culture collection.
Lab/Phone:
330-746-9623
TAT:
5 days
Additional Info:
Additional collection Instructions:
Perform Hand Hygiene prior to and during procedure.
Use appropriate PPE: Sterile Gloves and Surgical Mask.
Effective key-site disinfection: Scrub Time 30 secs and Dry Time 30 secs.
Protect Key Site and Key Parts from contamination: Non-touch.
Maintain aseptic field management during procedure.
CPT Code:
87040
Synonyms:
Blood CX
