PAGE : 1 (26) SP: 10 CHEMISTRY Lic. No.: CLIA #: SUB: 010 ROUTINE Receiving Date: _, TEST S/I Sample 1 Sample2 Sample3 Sample4 Sample5 157 WBG MG/DL DATE: SIGNATURES:
PAGE : 2 (26) SUB: 070 GENERAL Receiving Date:, 072 HEMATOLOGY CELL IDENTIFICATION Locate your identification in the Master List for GENERAL Transparencies and enter in the appropiate boxes the code. The list includes all identification that will be required. There is no provision to enter "Other, specify". TRANSPARENCIES NO. MASTER LIST TRANSPARENCIES CODE Sample 1 Sample 2 Sample 3 Sample 4 Sample 5 DATE: SIGNATURES:
PAGE : 3 (26) SUB: 070 GENERAL Receiving Date:, 372 Non Routine: HEMATOLOGY CELL IDENTIFICATION SAMPLE No. R E S U L T C O D E Sample 1 NR Sample 2 NR Sample 3 NR Sample 4 NR Sample 5 NR DATE: SIGNATURES:
PAGE : 4 (26) SUB: 070 GENERAL Receiving Date:, 172 DIFF-AT.5 PRO WBC S/I Sample 1 Sample 2 Sample 3 Sample 4 Sample 5 _ DATE: SIGNATURES:
PAGE : 5 (26) SUB: 070 GENERAL Receiving Date:, 472 Non Routine: DIFF. WHITE BLOOD CELL FOR 5 PARAM. INST SAMPLE No. R E S U L T C O D E Sample 1 NR Sample 2 NR Sample 3 NR Sample 4 NR Sample 5 NR DATE: SIGNATURES:
PAGE : 6 (26) SUB: 070 GENERAL Receiving Date: _, TEST M/S Sample1 Sample2 Sample3 Sample 4 Sample 5 075 RBC MILLION/UL 076 HCT 077 HGB G/DL 078 WBC THOUSAND/UL DATE: SIGNATURES:
PAGE : 7 (26) SUB: 070 GENERAL Receiving Date: _, TEST M/S Sample1 Sample2 Sample3 Sample4 Sample5 375 NR RBC MILLION/UL 376 NR HCT 377 NR HGB G/DL 378 NR WBC THOUSAND/UL DATE: SIGNATURES:
PAGE : 8 (26) SUB: 070 GENERAL Receiving Date: _, TEST M/S Sample1 Sample2 Sample3 Sample4 Sample5 079 PLATELET THOUSAND/UL DATE: SIGNATURES:
PAGE : 9 (26) SUB: 070 GENERAL Receiving Date: _, TEST M/S Sample1 Sample2 Sample3 Sample4 Sample5 379 NR PLATELT THOUSAND/UL DATE: SIGNATURES:
PAGE : 10 (26) SUB: 070 GENERAL Receiving Date: _, TEST M/S Sample1 Sample2 Sample3 Sample4 Sample5 149 RETICULOC. DATE: SIGNATURES:
PAGE : 11 (26) SUB: 070 GENERAL Receiving Date: _, TEST M/S Sample1 Sample2 Sample3 Sample4 Sample5 153 SED. RATE DATE: SIGNATURES:
PAGE : 12 (26) SUB: 070 GENERAL Receiving Date: _, TEST M/S REA Sample1 Sample2 Sample3 Sample4 Sample5 080 FIBRINOGEN _ MG/DL 081 PTT _ secs 082 PT _ DATE: SIGNATURES:
PAGE : 13 (26) SUB: 070 GENERAL Receiving Date: _, TEST M/S REA Sample1 Sample2 Sample3 Sample4 Sample5 380 NR FIBRINO _ MG/DL 381 NR PTT _ secs 382 Non Rou PT _ DATE: SIGNATURES:
PAGE : 14 (26) SUB: 075 BODY FLUID Receiving Date: _, TEST Sample1 Sample2 Sample3 Sample4 Sample5 159 BF RBC _ RBC/UL 160 BF WBC _ WBC/UL DATE: SIGNATURES:
PAGE : 15 (26) SUB: 075 BODY FLUID Receiving Date:, 161 BF DIFF. BFC Sample1 Sample2 Sample3 Sample4 Sample5 _ % _ % RESULT CODES DESCRIPTION: 01 MONONUCLEAR 02 POLYMORPHONUCLEAR DATE: SIGNATURES:
PAGE : 16 (26) SP: 30 IMMUNOHEMATOLOGY Lic. No.: CLIA #: SUB: 080 ABO-RH Receiving Date:, 150 ABO GROUP AND RH (D) TYPE BLOOD TYPING: Performed ABO grouping and Rh typing, in case of a negative Rh please performe Du. Centrifuge the sample to obtain plasma for the reverse grouping. SAMPLE No. DIRECT GROUP ANTI ANTI ANTI A B AB REVERSE GROUP CEL CEL CEL CEL A1 A2 B O TYPE - Rh ANTI Du D Du RESULT CODE ABO Rh Sample1 + + + 0 0 0 + + + + 0 0 0 0 + + 0 0 Sample2 + + + 0 0 0 + + + + 0 0 0 0 + + 0 0 Sample3 + + + 0 0 0 + + + + 0 0 0 0 + + 0 0 Sample4 + + + 0 0 0 + + + + 0 0 0 0 + + 0 0 Sample5 + + + 0 0 0 + + + + 0 0 0 0 + + 0 0 RESULTS CODE: ABO: 01. A 02. A1 03. A2 04. B 05. AB 06. A1B 07. A2B 08. O 999. NOT P. Rh: 01. Rh+ 02. Rh+ Du variant 03. Rh- Du not performed 04 Rh- 999. NOT P. DATE: SIGNATURES:
PAGE : 17 (26) SP: 30 IMMUNOHEMATOLOGY Lic. No.: CLIA #: SUB: 080 ABO-RH Receiving Date: _, TEST Sample1 Sample2 Sample3 Sample4 Sample5 383 NR ABO GRP _ 426 NR RH TYPE _ DATE: SIGNATURES:
PAGE : 18 (26) SP: 30 IMMUNOHEMATOLOGY Lic. No.: CLIA #: SUB: 090 COOMBS Receiving Date:, 084 UNEXPECTED ANTIBODY DETECTION-IND.COOMBS INDIRECT COOMBS: Please report in the appropiate site, using the strength of reaction from 0-4+ SAMPLE No. TEMPERATURE SALINE ALBUMIN COOMBS OTHER RESULTS CODE Sample1 1. 4 GRADE C _ 2. 20 GRADE C _ 3. 37 GRADE C _ Sample2 1. 4 GRADE C _ 2. 20 GRADE C _ 3. 37 GRADE C _ Sample3 1. 4 GRADE C _ 2. 20 GRADE C _ 3. 37 GRADE C _ Sample4 1. 4 GRADE C _ 2. 20 GRADE C _ 3. 37 GRADE C _ Sample5 1. 4 GRADE C _ 2. 20 GRADE C _ 3. 37 GRADE C _ B - RESULTS CODE: 01 - NEGATIVE 02 - POSITIVE C - PLEASE SPECIFY REAGENTS USED: DATE: SIGNATURES:
PAGE : 19 (26) SP: 30 IMMUNOHEMATOLOGY Lic. No.: CLIA #: SUB: 090 COOMBS Receiving Date: _, TEST Sample1 Sample2 Sample3 Sample4 Sample5 384 NR IND COO _ DATE: SIGNATURES:
PAGE : 20 (26) SP: 30 IMMUNOHEMATOLOGY Lic. No.: CLIA #: SUB: 090 COOMBS Receiving Date: _, TEST MET REA Sample1 Sample2 Sample3 Sample4 Sample5 179 Dir.COOMBS _ DATE: SIGNATURES:
PAGE : 21 (26) SP: 30 IMMUNOHEMATOLOGY Lic. No.: CLIA #: SUB: 100 COMPATIBILITY TESTING Receiving Date: _, 085 COMPATIBILITY TESTING Please performed antibodies screening, auto control and Mayor Side Cross-matching. If your lab. performes antibodies indentification, pelase identify it or them. CROSSMATCHING (Major side) SALINE 20-25C ALBUMIN 20-25C ALBUMIN 37C COOMBS OTHER INTERPRETATION Result Code CROSSMATCHING # Sample1 PATIENT PLASMA A-DONOR CELLS _ CROSSMATCHING # Sample2 PATIENT PLASMA A-DONOR CELLS _ CROSSMATCHING # Sample3 PATIENT PLASMA A-DONOR CELLS _ CROSSMATCHING # Sample4 PATIENT PLASMA A-DONOR CELLS _ CROSSMATCHING # Sample5 PATIENT PLASMA A-DONOR CELLS _ CROSSMATCHING INTERPRETATION CODE: 01 - COMPATIBLE 02 - INCOMPATIBLE 99 - TEST NOT PERFORMED DATE: SIGNATURES:
PAGE : 22 (26) SP: 30 IMMUNOHEMATOLOGY Lic. No.: CLIA #: SUB: 100 COMPATIBILITY TESTING Receiving Date: _, TEST Sample1 Sample2 Sample3 Sample4 Sample5 385 NR COMPA T _ DATE: SIGNATURES:
PAGE : 23 (26) SP: 30 IMMUNOHEMATOLOGY Lic. No.: CLIA #: SUB: 110 ANTIBODY IDENTIFICATION Receiving Date:, ANTIBODY IDENTIFICATION TESTING PATIENT PLASMA No. CODE DESCRIPTION Sample1 Sample2 Sample3 Sample4 Sample5 DATE: SIGNATURES:
PAGE : 24 (26) SP: 30 IMMUNOHEMATOLOGY Lic. No.: CLIA #: SUB: 110 ANTIBODY IDENTIFICATION Receiving Date:, 386 Non Routine: ANTIBODY IDENTIFICATION TESTING SAMPLE No. R E S U L T C O D E Sample1 Sample2 Sample3 Sample4 Sample5 DATE: SIGNATURES:
PAGE : 25 (26) SP: 40 IMMUNOLOGY Lic. No.: CLIA #: SUB: 120 GENERAL Receiving Date: _, TEST MET Sample1 Sample2 Sample3 Sample4 Sample5 093 HIV 096 HBsAG 097 antihbc 171 HCV Hep C 181 HAV Total 182 HBsAb 183 HAV IgM RESULT CODES DESCRIPTION: 01 - NEGATIVE OR NON REACTIVE 02 - POSITIVE OR REACTIVE DATE: SIGNATURES:
PAGE : 26 (26) SP: 40 IMMUNOLOGY Lic. No.: CLIA #: SUB: 120 GENERAL Receiving Date: _, TEST MET Sample1 Sample2 Sample3 Sample4 Sample5 393 NR HIV 396 NR HBsAG 397 NR antihbc DATE: SIGNATURES: