Urinalysis Patient Result Form
Author: Penny Stevens
Review History
Review by
Heidi Hanes
Document Number:
Effective (or Post) Date:
Date of last review:
Reviewed by:
Review date
Pro68-06
5 May 2008
11 May 2010
Heidi Hanes
7 Feb 2012
SMILE Comments: This document is provided as an example only. It must be revised to accurately reflect your lab’s
specific processes and/or specific protocol requirements. Users are directed to countercheck facts when considering
their use in other applications. If you have any questions contact SMILE.
Manual Urinalysis by Bayer 10-SG Dipstick U01 v.1
Page 16 of 17
Effective: Date
Your Laboratory Name
Appendix IV - Patient Manual Urinalysis Result Report
Patient Information:
Sample Information:
Patient Name: _____________________________
Date Collected: ____________________________
___________________________________
Time Collected: ____________________________
ID#
Date of Birth: ______________________________
Ordering Physician & Clinic: _____________________
Patient Results
MultiStix Reagent Dipstick
Reference Range
Color
Yellow
Dk.Yellow
Straw
Amber
Other, Please indicate:
Yellow
Clarity
Clear
Slightly
Cloudy
Cloudy
Turbid
Other, Please indicate:
Clear
Glucose (mg/dL):
Negative
100
Bilirubin:
Negative
Small
Ketone (mg/dL):
Negative
Trace
Specific Gravity:
≤1.005
Blood:
Negative
pH:
5.0
5.5
6.0
250
Moderate
15
1.010
40
1.015
Trace
6.5
500
1.020
Small
7.0
1.025
≥1000
Negative
Large
Negative
≥80
Negative
≥1.030
1.005 to 1.030
Large
Negative
≥9.0
5.0 to 9.0
Moderate
7.5
8.0
8.5
Protein (mg/dL):
Negative
Trace
30
100
≥300
Negative
Urobilinogen (EU/dL):
0.2
1.0
2.0
4.0
≥8
0.2 - 1.0
Nitrite:
Negative
Leukocytes:
Negative
Positive
Trace
Small
Moderate
Negative
Large
Negative
Comments:
Tech Signature:
Supervisor review required for all
critical values.
Required?
Report Date/Time:
Yes / No
Signature:
Date:
Page 17 of 17
Effective: Date
Comments:
Manual Urinalysis by Bayer 10-SG Dipstick U01 v.1