Form Ch-0022 - Stat Requisition Form
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1STAT Requisition
Accession #
LABORATORY MEDICINE AND PATHOLOGY
Client Response Centre
780-407-7484
CAPITAL HEALTH REGION LABORATORIES
PHN / Healthcare Number
DynaLIFE
DIAGNOSTIC LABORATORY SERVICES
DX
D
Patient Legal Name (Last)
(First)
(Initial)
DD
MM
YY
M
Full Name & Location MUST BE PROVIDED
O
F
B
Copy to
Name ___________________________________
Address
City
Prov.
Postal Code
Physician Code ___________________________
Address _________________________________
Chart #
Patient Phone #
Lab #
________________________________________
Ordering Physician / Practitioner
Physician Code
Specimen Event Type
Bill Type CPL
Alberta Health Care
IA
AUXILIARY
CCO
Capital Health Company
IP
IN PT
OP
OUT PT
CO
Company
XX
Pre-paid
Ordering Address / Location
Report Location Code
AP
AMBUL
OT
Out of Prov
PB
Patient
Bill
HC
HMCARE
Co. name ____________________________________________
ST
STAFF
Report address if different
Address _____________________________________________
EN
ENVIRON
WCB
WORKER’S
Client # ______________________________________________
COMP
Date specimen collected
Col. Location
SPECIMEN TYPE
Urine / Feces
Random
24 h
HISTORY
DD
MM
YY
Blood
serum
plasma
Timed, other __________________
whole blood
Total volume ____________________
microcollection
TIME (24 h)
Collector
Start time / date __________________
Stop time / date __________________
Fasting
Other __________________________
# of hours
DIAGNOSIS:
HEMATOLOGY
GENERAL CHEMISTRY
TOXICOLOGY
THERAPEUTIC DRUG MONITORING
CBC
CBC (Hgb, Hct, RBC
GLUCF
glucose, fasting
Drug to be monitored
____________ __________
Reason for request _______________________________
Indices, Platelet & WBC)
Dose regimen / route
____________ __________
Current meds. ___________________________________
CBCD
CBC & differential
GLUCR
glucose, random
HB
hemoglobin
Time last dose STARTED
____________ __________
Drugs given in Emerg. ____________________________
HCT
hematocrit
COMPLETED
____________ __________
PLT
platelet count
QUANTITATIVE
WBC
WBC
Time of next dose
____________ __________
ACET
acetaminophen
NA
sodium
SAL
salicylate
K
potassium
How long on
ETOH
ethanol / alcohol
CL
chloride
this dose regimen
____________ __________
EGLY
ethylene glycol
CO2
CO2
ALC
isopropanol / acetone
PT
PT (INR)
CARB
carbamazepine
CRE
creatinine
ALC
methanol
PTT
PTT
Pt. wt. ______ kg
DIG
digoxin
FIB
fibrinogen
URE
urea
LI
lithium
QDDIM
quantitative D-dimer
PHB
phenobarbital
PTN
phenytoin
CA
calcium
THEO
theophylline
ALT
ALT
VA
valproate
TBIL
bilirubin, total
URINE RANDOM
NBIL
bilirubin, neonatal
UMA
urinalysis
USE ROUTINE REQUISITION
UOSM
osmolality
STOP
FOR ALL OTHER DRUG LEVELS
UNAR
sodium
CK
CK
UKR
potassium
TROP
troponin I
UCLR
chloride
OTHER STAT TESTS
OTHER PRIORITY TESTS
LPS
lipase
PREG
pregnancy test
(may be performed offsite and may require prior approval)
(may be performed offsite and may require prior approval)
MG
magnesium
OSM
osmolality
FLUIDS
SFGLU
CSF glucose
LACT
lactate
SFTP
CSF protein
SFCT
CSF cell count
FLCT
cell count
IMMUNOLOGY / SEROLOGY
Fluid type: __________________
RSV
RSV
MISCELLANEOUS
OB
occult blood
REQUESTS REQUIRED ROUTINE
ENDOCRINE
HCG
quant hcG
CH-0022
For tests which are not analysed on site turnaround time may be > 1 hour.
Sep 2008
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