Direct Antiglobulin Test

Centralized Core Laboratory - : Blood Bank

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. Direct Antiglobulin Test
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

DAT

Test Workstation :

BBANK

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant) or red microtube

Alternate Tube Type:

Green top (lithium heparin), Purple top (EDTA)microtubes

Collection Volume:

1.0 mL

Minimum Volume:

1.0 ml

Preferred Volume:

1.0 ml

Cause for Rejection:

Improperly identified specimen, gross hemolysis

Storage:

Room Temperature Transport

Availability:

Daily, 24 hours

Methodology:

Tube Testing

Special Instructions:

Label the tube with a patient identification label (2 identifiers). Collector employee ID#, date, and time must be added to the label at collection. All Blood Bank specimens must be accompanied by a completely filled out Blood Bank Requisition to include two signatures at the time of specimen collection. Mislabeled Blood Bank Specimens will not be processed, regardless of the situation. Specimens for Blood Bank testing with any type of mismatched or missing information must be redrawn.

Lab/Phone:

330-543-8723

TAT:

30 minutes

CPT Code:

86880

Synonyms:

Antiglobulin Test; Direct; DAT; Direct Coombs