Coma Panel
| 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. Coma Panel | |
| 2. | |
| 3. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
COMA
Test Workstation :
SUMMA
Specimen Type:
Blood & Urine
Tube Type:
Red top (no anticoagulant) tube; Urine container
Collection Volume:
12.0 mL blood and
12.0 mL urine
Minimum Volume:
8.0 ml Blood, 6.0 ml urine
Storage:
Refrigerated
Availability:
Sent to reference lab
Methodology:
Gas Chromatography
Special Instructions:
Specify which of the drugs, if any, are suspected.
For the most ideal results the blood and urine specimens should be collected within 4 hours of each other, but must be collected within 24 hours of each other.
Lab/Phone:
330-543-8418
TAT:
24 hours
Additional Info:
Reference range: None Detected
CPT Code:
80301
