Test Code ourtemplate <Type Reported Test Name Here to match the Epic test name>

Important Note

<Make Blank, and change color from Red to Ordering Note Color if this section is not needed. Type any notes that must appear at the top of the test code here (i.e. Special Instructions, test obsolete, time restrictions, sensitive or urgent notes to collectors)>

Profile Information

Test ID	Reporting Name	Available Separately	Always Performed

Specimen Requirements

Patient Preparation:	<Type any specific patient preparation information, such as fasting, and diet restrictions. Delete if not needed>
Container Type:	Optimal: <ie Gold Top <add a BD image of Tube Top here> Acceptable: <ie Mint Top, microtainer, capillary tube <add a BD image of Tube Top here>
Optimal Collection Volume:	<Total volume. ie 4.5mL whole blood>
Minimum Volume:	<Enter volume>
Collection Instructions:	<Fill sample vial to black notch on the outside of the container. Gently invert the sample 5-6 times after collection.>
Specimen Transport:	<Enter specimen transport conditions: room temp, refrigerated, frozen, etc>
Processing Instructions:	1. <Allow the sample to clot for 30 minutes.> 2. <Centrifuge specimen within 2 hours of collection.> 3. <Separate serum into a false bottom container.> 4. <Keep serum refrigerated until testing can be performed.>

Specimen Stability

Specimen Type	Temperature	Time
	Refrigerated	xx days
	Ambient	xx days
	Frozen	xx days

<Chemistry entries: note the stability differences between serum and plasma>

Specimen Rejection Criteria

Hemolysis	Mild OK; Moderate OK; Gross Reject
Lipemia	Mild OK; Moderate OK; Gross Reject
Icterus	Mild OK; Moderate OK; Gross Reject
Other	Quantity not sufficient

Useful For

<Enter information on clinical utility of testing. Can review procedures, Mayo website or Lab tests online for examples. If this test includes reflex testing, include information on reflex testing conditions here.>

Methodology

<Insert methodology (Instrument and method)>

Reference Ranges

<If only a single test, enter the reference range with reporting units. Then, delete the table below>

<If multiple tests, such as in a panel, enter reference ranges into the table below>

Test ID

Reference Range and Reporting Units

<Enter test c

ode>

<Only add "always performed" reference ranges and reporting units>

Interpretive

<When possible, paste Link from Mayo Clinical & Interpretive section>

Day(s) Performed

<Example: Enter 24/7 or Day through Day, i.e. Monday through Friday>

Expected TAT

<Enter Same day or range of days>

Performing Laboratory

<Bronson Laboratory, Department Name - Kalamazoo, Battle Creek, Paw Paw, South Haven (Remove sites that will not test)>

Sample Retention Time

<Enter time sample is kept in the laboratory. Example: 7 Days *Ensure this is standard for all 4 sites*>

CPT Code

<Add CPT code(s). For multiple CPTs, add a bullet point list with associated test component>

LOINC Code

<Enter LOINC code(s). If multiple LOINC, add a bullet point list with associated test component >