Platelet Function Test
| 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. Platelet Function Test | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
PFT
Test Workstation :
MNCOG
Specimen Type:
Blood
Tube Type:
Blue top (sodium citrate) tube
Collection Volume:
2.7 mL
Cause for Rejection:
Sample hemolyzed, clotted, diluted with IV fluid; contaminated with heparin; improperly filled; received on ice; received > 4 hrs after drawn
Storage:
Ambient
Availability:
Daily, 24 hours
Methodology:
Test Cartridge System Simulating Platelet Adhesion and Aggregation
Special Instructions:
Specimens should be sent to the lab immediately. Specimens should NOT be sent on ice. Whole Blood Do Not Spin
If collected at an offsite location, specimen is stable only 4 hours. Call a STAT Courier
Lab/Phone:
330-543-8416
TAT:
1 hour
Additional Info:
Reference range:
COL/EPI = 80-184 sec
COL/ADP = 56-102 sec
NOTE: Platelet counts less than 50,000 will not give accurate results and may be rejected.
CPT Code:
85576
Panel Includes:
Collagen/Epinephrine, Collagen/ADP
