Type and Screen

Laboratory : Blood Bank

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. Type and Screen
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

T/S MBBNK

Specimen Type:

Blood

Tube Type:

Lavender(EDTA)tube

Collection Volume:

<4 months: 2 lavender (EDTA) microtainers; 4 months-6years: 1, 6mL lavender (EDTA)tube (5mL minimum); >6 years: 2, 6mL lavender (EDTA) tubes; sickle patient: 2-3, 6mL lavender top (EDTA)tubes

Cause for Rejection:

Improperly labeled specimen, gross hemolysis

Storage:

Refrigerated

Availability:

Daily, 24 hours

Methodology:

Tube Testing

Special Instructions:

Valid for only 3 days. Label the tube with a patient identification label (2 identifiers). Collector employee ID#, date and time must be added to the label at collection. All Blood Bank specimens must be accompanied by a completely filled out Blood Bank Requisition to include two signatures at the time of specimen collection. Mislabeled Blood Bank Specimens will not be processed, regardless of the situation. Specimens for Blood Bank testing with any type of mismatched or missing information must be redrawn.

Lab/Phone:

330-746-9623

CPT Code:

86900