Class Code:

0846L
Class No.: Date of Submission: 28/06/2020
Name:
MIRANDA, PEARL IANNE A. MLS 231 – Laboratory
Family Name First Name M.I.

ACTIVITY 3
Preparation of Laboratory Forms

PART 1: Laboratory Requisition Form, Laboratory Directory, and Template for Laboratory Report

1. Laboratory Requisition Form (using word processors or spreadsheets)

MIRACARE Mabini St. Baguio City

Contact: (63) 452345567
mericarelab@gmail.c
CLINICAL om

LABORATORY
Laboratory Requisition Form
(Outpatients)

BIOCHEMISTRY THERAPEUTIC DRUG MICROBIOLO

MONITORING

 

 GS

ENDOCRINOLOGY

VIROLOGY

HEMATOLOGY

IMMUNOLOGY

BLOOD

OTHER

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 2. Laboratory Directory (using word processors or spreadsheets)

MIRACARE
CLINICAL Mabini St. Baguio City
Contact: (63) 452345567
LABORATORY
GRAM STAIN
mericarelab@gmail.com

Order Test:
GS GS

Detect WBCs and presence and type of microorganisms in specimen

Specimen Required Urine
Collection Instructions Indicate midstream, indwelling cath, single cath, VB series,
cystoscopy, or suprapubic aspirate.
Container Type Sterile screw cap container
Minimum Volume 1 mL
Specimen Processing Refrigerate specimen if transport to laboratory will be greater
than 2 hours
Specimen Transport Transport specimen to the laboratory within 2 hours of
collection. Transport specimen with coolant pack if over 2 hours
Stability Unpreserved: Ambient: 2 hours; Refrigerated: 24 hours; Frozen:
Unacceptable
Boric Acid Tube: Ambient: 48 hours; Refrigerated: 48 hours;
Frozen: Unacceptable
Unacceptable Conditions Urine from catheter bag. Multiple (more than one in 24 hours),
24-hour, or pooled specimens. Foley catheter tips (syringe with
needle attached). Delayed transport of unpreserved urine
(greater than two hours at room temperature or greater than 24
hours refrigerated).
Department Microbiology
CPT Code 0060101
Test Schedule Sun-Sat
Turnaround time Within 24 hours
Within 2 hours of receipt (1 hour for stat specimens)
Methodology Stain/Microscopy
Clinical Information Identify presence of organisms in urine
Reference Ranges:

Negative: No organism seen

3. Template for Laboratory Report (using word processors or spreadsheets)

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 PART 2: Template for Laboratory Report (Insert pictures or screen shots of form generated using HospitalRun)

MIRACARE Mabini St. Baguio City

CLINICAL Contact: (63) 452345567
mericarelab@gmail.com
LABORATORY
MICROBIOLOGY
Patient Name: Age: 56y/o CN: Doctors Name:
Marcelo H. Del Pilar Sex: M P0002U Dr. Jose P. Rizal
Patient Id: P002
(mm/dd/yyy) (mm/dd/yyy)
Date Received: Date Reported:

GRAM STAIN
Specimen Midstream urine
Result NRMS
No recognizable microorganisms seen

______________________________ _______________________________
Name & Signature of Medical Name & Signature of Pathologist
Technologist

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