Gram Stain

Laboratory - : Microbiology

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. Gram Stain
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

GRAM

Test Workstation :

MMIC2

Specimen Type:

E-swab or smear from specimen for bacterial culture

Tube Type:

Specimen container, E-swab

Collection Volume:

1 swab or 0.5 mL liquid specimen

Cause for Rejection:

Specimen sent in nonsterile container. Specimen sent on dry swab.

Storage:

Ambient

Availability:

Daily

Methodology:

Microscopic examination

Special Instructions:

Gram stain slides may be prepared at the bedside by the physician except for sputum, tracheal aspirate, wound, CSF, body fluids, or urine. Smears on these specimen types will be prepared in the laboratory. An Eswab should be sent for gram stain for those specimens where a swab is appropriate for culture.

Lab/Phone:

330-746-9623

TAT:

2 hours CSF, all other stains read by day shift Microbiology staff

Additional Info:

NOTE: Gram stains are automatically added to all CSF, Wound, Sputum, and Tracheal aspirate cultures and do not need to be ordered separately.

CPT Code:

87205

Synonyms:

Bacterial Stain; Direct Stain for Bacteria

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Laboratory Services

Gram Stain

Laboratory - : Microbiology

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