Nitrazine Paper Vaginal Ph Patient And Qc Result Log - Bassett Healthcare Network
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1Bassett Healthcare Network
Point of Care
Nitrazine Paper Vaginal pH Patient and QC Result Log
Location: ______________________________________
pH 5.0 LOT #:_________________ Exp:_________ pH 7.0 LOT#:__________________ Exp:___________ pH Paper LOT#:_______________ Exp: _________
QC
QC
Patient result for
Patient result for
pH 7.0
pH 5.0
Initials of
Entered
POC
Date
Time
Patient Label/Information
ruptured membranes
bacterial vaginosis
Result
Result
Operator
into Epic
Review
Circle One
Circle One
pH 6.5 - 7.5
pH 4.5 - 5.5
Patient Information
pH = ____________
pH = ___________
Name:_______________ Loc:_______
pH<6.0=Negative
<4.5 excludes BV
MRN:__________ D.O.S.____________
Ordering Provider:_________________
pH>6.5=Positive
>4.5 c/w BV
or Place Patient Registration label here.
Patient Information
pH = ____________
pH = ___________
Name:_______________ Loc:_______
pH<6.0=Negative
<4.5 excludes BV
MRN:__________ D.O.S.____________
Ordering Provider:_________________
pH>6.5=Positive
>4.5 c/w BV
or Place Patient Registration label here.
Patient Information
pH = ____________
pH = ___________
Name:_______________ Loc:_______
pH<6.0=Negative
<4.5 excludes BV
MRN:__________ D.O.S.____________
Ordering Provider:_________________
pH>6.5=Positive
>4.5 c/w BV
or Place Patient Registration label here.
Patient Information
pH = ____________
pH = ___________
Name:_______________ Loc:_______
pH<6.0=Negative
<4.5 excludes BV
MRN:__________ D.O.S.____________
Ordering Provider:_________________
pH>6.5=Positive
>4.5 c/w BV
or Place Patient Registration label here.
Patient Information
pH = ____________
pH = ___________
Name:_______________ Loc:_______
pH<6.0=Negative
<4.5 excludes BV
MRN:__________ D.O.S.____________
Ordering Provider:_________________
pH>6.5=Positive
>4.5 c/w BV
or Place Patient Registration label here.
1) Patient Result Documentation is recorded as actual pH value - NOT POS/NEG
2) QC Result Documentation is recorded as actual pH value - NO CHECK MARKS OR +/- SIGNS
NOTE: All data is reviewed by the Point of Care technical staff during regularly scheduled site visits. The review encompasses information from the last review date to the
current review date. Staff performing tests are responsible to ensure that results are within acceptable range.
shares3\lab\POCT\FORMS-LOGS\Patient Result Log Nitrazine Paper Vaginal pH - 04/27/2015
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