Methemoglobin
| 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. Methemoglobin | |
| 2. | |
| 3. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
METHB
Test Workstation :
MBG1
Specimen Type:
Blood
Tube Type:
Heparinized syringe, Green top (lithium heparin) macrotainer, or heparinized capillary tubes. NO GEL SEPARATOR TUBES OR MICROTAINERS.
Collection Volume:
0.5 mL syringe; (2) 125 uL capillary tubes; 4.0 mL whole blood green top (lithium heparin) tube.
Minimum Volume:
0.5 mL syringe; (2) 125 uL capillary tubes; 1.5 mL macrotainer.
Preferred Volume:
0.5 mL syringe; (2) 125 uL capillary tubes; 1.5 mL macrotainer.
Cause for Rejection:
Clotted, air bubbles, tubes with gel separator, microtainers.
Storage:
Room Temp
Availability:
Daily, 24 hours; STAT
Methodology:
Spectrophotometric measurement
Special Instructions:
Deliver immediately to laboratory at room temperature.
For Outpatients, test should only be drawn in outpatient locations within the Hospital at the Beeghly campus.
Lab/Phone:
330-746-9623
TAT:
30 minutes
Additional Info:
Reference range: 0.0 - 1.5 %
CPT Code:
83050
