Erythrocyte Sedimentation Rate
| 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. Erythrocyte Sedimentation Rate | |
| 2. | |
| 3. | |
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| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
ESRAT
Test Workstation :
MMCHM
Specimen Type:
Blood
Tube Type:
Purple top (EDTA) tube: Whole Blood
Collection Volume:
1.5 mL
Cause for Rejection:
Clotted specimen.
Specimens collected in microtainer tubes.
Storage:
Shipping: Send Refrigerated; Storage: Room Temp: 24 hours; Refrigerated: 24 hours
Availability:
Daily, 24 hours
Methodology:
Direct Measure of Aggregation of red blood cells (Westergren method)
Special Instructions:
Specimens must be collected by venipuncture in macro tubes with pierceable caps; multiple microtainer tubes are NOT acceptable.
Lab/Phone:
330-746-9623
TAT:
2 hours
Additional Info:
Reference Interval:
Newborn= 0-2 mm/hr
Newborn to puberty = 3-13 mm/hr
Male less than 50 years old = <15 mm/hr
Female less than 50 years old = <20 mm/hr
Male greater than 50 years old= <20 mm/hr
Female greater than 50 years old = <30 mm/hr
CPT Code:
85652
Synonyms:
Sedimentation Rate (Westergren);
ESR
