MFM - Glucose Challenge, 1 Hour

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. MFM - Glucose Challenge, 1 Hour
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SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

MFMGL MACH3

Specimen Type:

Blood

Tube Type:

Green top ( lithium heparin ) tube

Collection Volume:

1.5 mL

Storage:

Shipping: Send Refrigerated; Storage: Room Temp: 8 hours; Refrigerated: 72 hours; Frozen: 3 days

Availability:

Monday-Friday

Methodology:

Roche UV test

Special Instructions:

Prior to drawing patient, see Specimen Collection Procedure - Glucose Tolerance Testing. Outpatients must be scheduled in advance. Patients should eat their usual diet for 3-5 days and fast 8 hours prior to testing. Glucose dose will be orally administered and blood will be collected at the 1 hour interval post glucose ingestion. For Outpatients, test should only be drawn in outpatient locations within the Hospital at the Akron and Mahoning Valley campus.

Lab/Phone:

330-746-9623

TAT:

1 hour/draw

Additional Info:

Criteria for Diagnosis of Gestational Diabetes Mellitus(GDM) Effective 6/22/2011 50g, 1HR Glucose Challenge >130 mg/dl Detects 90% of those who will develop GDM >140 mg/dl Detects 80% of those who will develop GDM

CPT Code:

82950