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Test Code ourtemplate <Type Reported Test Name Here to match the Epic test name/MA1>

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)>

Additional Codes

Epic Order Code: LABXXX
Sunquest Order Code: XXXX

Specimen Required

Patient Preparation:

<Type any specific patient preparation information, such as

fasting, 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>
Collection Instructions:

<Fill sample vial to black notch on outside of container. Gently invert sample 5-6 times after collection.>
Processing Instructions: 

1. <Allow sample to clot for 30 minutes.>

2. <Centrifuge specimen within 2 hours of collection.>

3. <Separate serum into a false bottom container.>

3. <Keep serum refrigerated until testing can be performed.>

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, be sure to include information on reflex testing conditions here.>

Profile Information

Test ID   Reporting Name Available Separately Always Performed
       
       

Method Name

<Insert methodology>

Stability Information

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

Rejection Due To

Hemolysis Mild OK; Moderate OK; Gross Reject
Lipemia Mild OK; Moderate OK; Gross Reject
Icterus Mild OK; Moderate OK; Gross Reject
Other N/A

 

Post Processing Specimen Type

<Enter Post Processing Specimen Type as preferred and alternate>

Preferred:

Alternate:

Specimen Minimum Volume

Collecting minimum volumes can result in a need for sample recollection, and/or a delay in results. Minimum volumes are subjective and cannot account for all aspects of specimen and testing needs. Refer to the Specimen Required section for optimal volumes for laboratory specimens. Contact the Bronson Laboratory if complex collection exceptions occur that require more information.

 

Minimum Volume: <enter as pre and post processed volume (ex: 0.5mL whole blood, 0.25mL serum>
Neonate Volume: <enter as pre and post processed volume (ex: 0.5mL whole blood, 0.25mL serum>

Performing Laboratory

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

Day(s) and Time(s) Performed

<Example: Monday through Friday XX-XX or 24/7>

Reference Values

 Test ID   Reference Range    Units      
  <Only add "always performed" test ranges>  
     

LOINC Code Information

<If only single LOINC, delete table below> 

Test ID Test Order Name Order LOINC Value
     

CPT Code Information

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

Sample Retention Time

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