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Lab Manual for UCSF Clinical Laboratories

Lab Manual for SFGH

Internal Resources

Ordering Lab Tests



  1. ORDER ENTRY


Lab tests can be ordered using the CHN Invision Electronic Order Entry System. With few exceptions, any laboratory tests orderable on a paper laboratory requisition form can be ordered via the Invision Laboratory Order Entry Modules. This order system consists of a series of cascading menu screens that allow the user to input information concerning the type of test. Tests can be ordered on a one-time-only basis or can automatically repeat within a 24 hour period. Results are automatically entered into the Invision System and are available from any network CHN work-station or Sunquest terminal.


For more information or to schedule training, contact an Information Systems Nurse Liaison at 206-6511 (Fern Ebeling) or 206-4897 (Carmel Gallagher).


  1. COMPLETING THE REQUISITION FORM


The information given below must be provided when submitting any specimen to the Clinical Laboratory. Refer also to the preceding section on Specimen Identification . For information regarding the appropriate form to use for a specific test, please refer to the section on Requisition Forms which follows this section, or to the ALPHABETICAL LIST OF TESTS .


For manual test ordering, a completely and correctly filled out laboratory requisition form is a legal requirement that must be satisfied for the request to qualify as a valid order.


A. REQUIREMENTS FOR REQUISITION COMPLETION:


All paper lab requisitions MUST be filled out completely and legibly. Each test must be clearly marked with an “X.” An imprinter with which the patient's card can be used to stamp the patient information onto the requisition slip is available on each ward and clinic. The following information MUST be provided on the laboratory request form:


  1. Requesting Physician’s name, ID code, and pager number.

  2. Patient’s first and last name.

  3. SFGH medical record number or other lab-approved unique number. Numbers must be legible.

  4. SFGH patient account number.

  5. Test (s) requested.

  6. Specimen source.

  7. Date and time of specimen collection.

  8. ICD-9 Code – establishes medical necessity.

  9. Patient’s birth date (needed for reference ranges and patient ID).

  10. Gender (needed for gender-specific reference ranges).

  11. Location (needed for critical results contact).


Report any malfunction of your unit’s card imprinter to the SFGHMC Electronic Data Processing Office, 206-5035. Sample requisitions follow this section.


  1. DIAGNOSTIC INFORMATION – ICD9 Code


All requisitions require an ICD9 Code, which establishes medical necessity for the test(s) requested. Serology specimens sent to the SF Department of Public Health, State Health Services or CDC Labs may require additionally that the date of onset, suspected diagnosis, significant clinical symptoms and signs, lab test results, and therapy given be noted on the requisition.


  1. PHYSICIAN NAME, ID CODE, AND PAGER NUMBER


Remember to include the requesting physician’s name, physician’s ID code, and pager number or extension on the requisition. Should any questions arise regarding the test(s) requested or an out of range value, the physician may need to be contacted.


  1. INCOMPLETE REQUISITIONS


  1. Any specimen not accompanied by a legible, correctly and completely filled out requisition will be retained by the Clinical Laboratory for up to 24 hours, but will not be processed. This will be recorded in the computer.

  2. For STAT specimens only, one attempt will be made to notify the requesting physician.

  3. Missing or incomplete required information must be provided by means of a new or faxed requisition. The Laboratory will not accept verbal information to complete a requisition.

  4. If still suitable for analysis, the specimen will be processed when the Laboratory receives the completed requisition. After 24 hours, all specimens without completed requisitions will be discarded.


  1. REQUISITION FORMS FOR LABORATORY SERVICES


  1. Be certain to use the proper laboratory requisition form for the test or service that is requested.

  2. Most tests are listed on the requisition form and can be checked off by the requesting physician.

  3. Some tests, generally those sent to reference labs, are not listed on the laboratory requisition and must be ordered by writing in the request under “Other Tests.”

  4. Test requests ordered on non-Clinical Laboratory requisitions will not be accepted. The request and the specimen will be returned to the originator via messenger service.

  5. Requisition forms are ordered through Materials Management. Fill out a Moore Order Form (generally used for all forms in the hospital) designating the desired Lab requisition form and submit it to Materials Management, telephone number 206-5315 for assistance. Allow up to a week for delivery.


  1. REQUISITION FORMS NOW IN USE


CLINICAL CHEMISTRY:

A. Main Laboratory (2M) Requisition - BLOOD/SERUM (Form # 5788146, F881D, Rev. 11/12)

B. Main Laboratory (2M) Requisition - URINE/FLUIDS (Form # 5788138, Rev. 08/13)


HEMATOLOGY:

A. Main Laboratory (2M) Requisition - BLOOD/SERUM (Form # 5788146, F881D, Rev. 11/12)

B. Main Laboratory (2M) Requisition - URINE/FLUIDS (Form # 5788138, Rev. 08/13)

C. Semen Analysis Requisition – (Form # 5781225, Rev. 08/06)


MICROBIOLOGY:

A. Microbiology Requisition (Form # 5788112, F881A, Rev 08/2013)

On the Microbiology Requisition form, check the appropriate boxes for source of specimen test(s) requested and supply essential clinical data. Use one requisition for each specimen. The requisition may be used for more than one type of culture per specimen. The form includes requests for culture for bacteria, fungi, AFB, viruses, and Chlamydia. It is also used for requests for parasitology, toxin assay, direct antigen detection and special antimicrobial tests. To ensure proper selection of media and techniques, designate suspected organisms and diagnoses whenever possible. All specimens, whether in collection container or inoculated to culture media, must be labeled with the patient's name and SFGH medical record number. Unlabeled specimens will be discarded.


SEROLOGY:

  1. Main Laboratory (2M) Requisition - BLOOD/SERUM (Form # 5788146, F881D, Rev. 11/12)


TRANSFUSION SERVICE (BLOOD BANK):

A. Blood Bank Transfusion Request and Diagnostic Studies (Form # 5788120, Rev. 6/10)

Blood Bank requisitions require the following information: Patient’s complete name, SFGH medical record and patient numbers (“B” and “A” numbers), birthdate, sex, ward or clinic, diagnosis, reason for transfusion, date to be transfused, number of units each of blood component being requested, name of requesting physician, signature of person who drew the blood specimen, date of request. Sample requisition is shown in Transfusion Service/Blood Bank Procedures section.


  1. ADDING TESTS TO PREVIOUSLY OBTAINED SPECIMEN

Physicians who wish to add an additional test to a previously obtained specimen must complete the following steps:

  • Added tests require a new requisition with all required information including when the original sample was collected and which test is to be added. (Added test from 0600 will be performed after 0900 only.)

  • The requisition may be tubed to station # 21 or delivered to Specimen Collection and Management.

  • For Microbiology tests, the requisition may be tubed to station # 21, delivered to Specimen Collection and Management, or faxed to (415) 206-3589.

  1. REQUEST TO CHANGE ROUTINE TESTS TO STAT TESTS

If a STAT test needs to be performed, it is the responsibility of the physician or ward staff to draw the sample and send it to the laboratory by messenger service, or by pneumatic tube to station # 21.

To change to STAT a routine that was not drawn by the phlebotomy team, physicians must:

  • Send a new requisition clearly labeled with the necessary information to tube station # 21, or hand deliver directly to Specimen Processing.


  1. CANCELLING TESTS

Physicians who wish to cancel tests should submit a new requisition stating which tests to cancel and when the blood was drawn.





BLOOD/SERUM MAIN LABORATORY (2M) REQUISITION

Sample Requisition (Form # 5788146, F881D, Rev. 11/12)



URINE/FLUIDS MAIN LABORATORY (2M) REQUISITION

Sample Requisition (Form # 5788138, Rev. 08/13)



SEMEN ANALYSIS REQUISITION

Sample Requisition (Form # 5781225, Rev. 08/06)



MICROBIOLOGY REQUISITION

Sample Requisition (Form # 5788112, F881A Rev. 08/2013)



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