Prothrombin Time

Laboratory : Hematology

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. Prothrombin Time
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

PT MACG1

Specimen Type:

Blood

Tube Type:

Blue top (sodium citrate) tube

Collection Volume:

2.7 mL (minimum 1.8 mL) Must use appropriated sodium citrate tube based on volume of blood drawn (1.8 mL or 2.7 ml tube)

Cause for Rejection:

Sample hemolyzed, clotted, diluted with IV fluid; contaminated with heparin; improperly filled; received > 1 hr. after drawn

Storage:

Ambient

Availability:

Daily, 24 hours; STAT

Methodology:

Optical Light Scatter Detection Clotting Assay

Special Instructions:

Indicate clearly if a specimen has been drawn from an arterial line or from a line that has been rinsed with heparin. This information is absolutely essential to the CCL personnel for the proper handling of the specimen and the reporting of results. Please indicate if the patient is currently receiving anticoagulant therapy. If collected at an offsite location, send by a STAT Courier to Beeghly Hospital lab.

Lab/Phone:

330-746-9623

TAT:

4 hours

Additional Info:

Reference range: 12-14 secs.

Recommended Therapeutic Range for Oral Anticoagulant Therapy: Prophylaxis of venous thrombosis, Treatment of venous thrombosis, Treatment of pulmonary embolism, Prevention of systemic, and Tissue heart valves- INR 2.0-3.0, Myocardial infarction ( to prevent systemic embolism), Valvular heart disease, Atrial fibrillation, Mechanical prosthetic valves - INR 2.0-3.0

CPT Code:

85610

Synonyms:

Protime; PT