Erythroblastosis Evaluation

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. Erythroblastosis Evaluation
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

ERYTH

Test Workstation :

BBANK

Specimen Type:

Blood

Tube Type:

Red top (no anticoagulant) tube, red micro tube( newborn patient only)

Collection Volume:

6 mL red top from biological mother of patient and 0.5 mL from Baby

Minimum Volume:

4.0 red top from biological mother of patient, 0.5 ml patient

Preferred Volume:

6 mL red top from biological mother of patient and 0.5 ml from patient

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. For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly)

Lab/Phone:

330-543-8723

TAT:

1 hour (STAT); 4 hours (Routine)

CPT Code:

86900

Synonyms:

Erythro Workup; Hemolytic Disease of the Newborn Workup

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Erythroblastosis Evaluation

Centralized Core Laboratory - : Blood Bank

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