Creatinine Clearance 12 hr

Centralized Core Laboratory : Chemistry

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. Creatinine Clearance 12 hr
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

UCC12 ACHM5

Specimen Type:

Blood and Urine

Tube Type:

Green top (lithium heparin) tube and Urine container

Collection Volume:

1.5 mL blood and entire 12 hour urine collection. See Special Instructions

Storage:

Shipping- Send Refrigerated; Storage-Plasma- Room Temp & Refrigerated: 7 days; Frozen 3 months; Urine: R.T. 2 days, Refrig 6 days, Frozen 6 months

Availability:

24 hours/day, 7 days/week

Methodology:

Roche-Enzymatic Colorimetric

Special Instructions:

Collect 1.5 mL Green top (lithium heparin) tube and 12 hour urine in an urine collection container. Due to compliance regulations blood creatinine must be collected during the 12 hours that the urine is being collected. Instruct patient on 12 hour urine collection. Refrigerate 12 hour urines during collection. Do not use urine preservatives. Mark each collection container with the following information required for resulting: patient demographic information, patient height (centimeters), patient weight (kilograms), and date and time collection was started and finished. Deliver specimens promptly to the lab.

Lab/Phone:

330-543-8417

TAT:

1 hour

Additional Info:

Ref. range is age dependent; avail on patient report

CPT Code:

82575