Ucsf Microbiology Requisition Form

PROOF VERSION #2 04-18-16

COMPLETE ALL ITEMS IN THIS BOX

UCSF

Ordering Provider ______________________________________________________ Provider # ___ ___ ___ ___ ___

UCSF MICROBIOLOGY

L

(Required)

Attending

Resident/Fellow

Allied Health Practitioner

REQUISITION

Provider is a(n):

MRN

SPECIMEN COLLECTION

B

(attending info. req’d.)

(Incl. attending info. if req’d.)

Date: ___________ Time: ___________

S

UCSF

PT. NAME

Attending Physician _____________________________________________________ Provider # ___ ___ ___ ___ ___

VPO

HS

G

(Print Name)

(Required)

UCSF

Tech code: ___ ___ ___

BIRTHDATE

SEX

Copy to: _________________ _____________________________________________ _ Provider # ___ ___ ___ ___ ___

N

(Print Name)

(Required)

Rec’d: ___________ Enter: ______ ______

CLINIC

DOS

Authorizing Provider Signature: _________________ _____________________________________________ _

701-033Z (Rev. 08/12) WorkflowOne

(Required)

Phone #’s for stat/consult

BUDGET ACCOUNT NO.

CLINICAL FINDINGS:

Immunocompromised host

UCSF: 353-1268

specify:

After 2330 hrs.: 353-1667

Transplant (specify organ):

ICD-10 CODES (required on outpatients only):

Suspected pathogen(s):

Antibiotic Rx (specify):

1. ________ 2. _______ 3. _________ 4. _________ 5. _________

MEDICAL NECESSITY AND ICD-10 CODES (Required for outpatients only) Medicare (and, increasingly, other insurers) will only pay for services that are reasonable and necessary for the diagnosis and treatment of the patient. The physician

must specify an ICD-10 diagnostic code to indicate the medical necessity of each test requested. Medicare and other carriers may not pay for screening tests or tests that are not FDA-approved. If there is reason to believe that a carrier will not pay

for a test, the patient should be informed and asked to sign an Advanced Beneficiary Notice (ABN - Attach to requisition) indicating acceptance of responsibility for the cost of the test if the carrier denies payment. Write the ICD-10 diagnosis code(s)

for this patient in the numbered spaces above right, then check off the tests desired.

STEP 1: CHECK SPECIMEN SOURCE

STEP 2: CHECK TEST(S) REQUESTED

(1 PER FORM)

BACTERIAL:

VIRAL:

Clean catch midstream

URINE:

Rotavirus antigen

Screen only: omit I.D. and susceptibility

Clostridium difficile

HSV direct Ag (2 slides required)

First void (Chlamydia)

Bacterial vaginosis/Yeast Screen

VZV direct Ag (2 slides required)

Indwelling CATH collect with vacutainer (red top)

Rapid strep Group A

Straight (In & Out) CATH

Herpes simplex culture

Other: ________________________________________

Pertussis PCR

CMV culture (BAL, biopsies only)

C. trachomatis/N. gonorrhoeae RNA

(describe)

Influenza A/B & RSV PCR

RESPIRATORY:

Respiratory viral panel PCR

SPUTUM:

Expectorated

Induced

Trach aspirate

Culture includes Gram stain, anaerobic culture and susceptibility

test, where site and specimen appropriate.

THROAT

HSV PCR

Bacterial culture

NP Flocked swab

VZV PCR

Omit susceptibility testing

Omit full ID

BRONCHOALVEOLAR LAVAGE (BAL)

Mini-BAL

CF respiratory culture

ANTERIOR NARES

PARASITES:

Routine Ova and Parasite exam (submit in SAF)

(incl. S. aureus & B. cepacia)

OTHER: _______________________________________

Trichomonas RNA

Group A Strep culture

STERILE SITES:

Collected in surgery

(describe)

Microsporidia smear exam

Group B Strep culture

TISSUE

Giardia EIA

(type): ____________________________________________

Legionella culture

Legionella PCR

FNA

(site): _________________________________________________

Malaria exam

(Provide travel and Rx history above)

CSF

MRSA Screen (inpatients/anterior nares only)

OTHER

BODY FLUID

Staph. Aureus culture

(type): _______________________________________

MICRO TESTS:

BLOOD: (Must check source below)

AFB:

Culture (includes Nocardia)

requires consultation

Peripheral

Central Line

Differential Time to Positivity

Cultures of CSF, urine, stool, or swabs require consultation.

FUNGAL:

(Complete info below)

Line: __________ Draw time: __________

Peripheral draw time: ____________

Cryptococcal Antigen (CSF, serum only)

NON-STERILE SITES:

CSF Cocci Culture (serology more sensitive)

STOOL

Routine Fungal Culture

(NOT performed on

CERVIX

VAGINAL (site): _____________________

If unpreserved submit 0700 to 2330

CSF, swabs, stool, or urine. Includes KOH when

WOUND (site): _________________________________

appropriate).

ABSCESS (site): ________________________________

Yeast

(not on sputum or tracheal culture)

TUBE DRAINAGE

(site): __________________________________

Aspergillus

OTHER (site): __________________________________

(describe)