Rapid Respons Team Labs Order Form-For Paper orders
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Rapid Response Team Lab Orders Form General Labs: CBC CBC w/ Diff PT/INR aPTT Chem 7 LYTES Type & Screen Type & Hold U/A U/A + C&S Hematology: Bleeding Time Thormbin Time Fibrinogen D-Dimer Chemistries: Common Labs: Tox-32 Qual. Tox-32 Quant. VBG VBG w/ LYTES ABG Troponin T Troponin I Cardiac Panel Coags. Panel Cholesterol Panel Inflammatory Panel Histamine Panel Gulcose, Specific CMP CBMK Vitamin Panel Hgb A1C Other Labs: Blood Bank: Type & Cross (pRBC) for x_____Units Type & Cross (Platelets) for x_____Units Type & Cross (MTP) for MTP Pack #_____ Use Protocol:_________________ Patient Name:_____________ Patient MRN:___-____-____ Patient D.O.B.:___/___/___ Patient Sex:_________ Department:_____________ Room & Bed:_____________ Patient Label/ Orders Label Ca, ionized Protein, tot. Albumin Bilirubin Lactate Amy/Lip Uric Acid Ammonia Nitro. Anion Gap Osmolality CPK CPK MB C-Reactive Prot. Iorn Iorn Saturation Ferritin Folate Copper Zinc HCG-Quant. Serum HCG-Qual, Urine Cultures, Blood Cultures, Blood x2 Cultures, Swab Cultures, Sputum U/A Microscopy STAT (All Labs) STAT (Core Labs) Provider:______________ Provider ID #_______ Drawn By:______________ Drawn By ID #_______ Drawn Date:___/___/___ Drawn Time:___:___hrs Site:______ With:________ Notes:_________________ ______________________ ______________________ ______________________ ______________________ Rapid Response Team Lab Orders Form General Labs: CBC CBC w/ Diff PT/INR aPTT Chem 7 LYTES Type & Screen Type & Hold U/A U/A + C&S Hematology: Bleeding Time Thormbin Time Fibrinogen D-Dimer Chemistries: Ca, ionized Protein, tot. Albumin Bilirubin Lactate Amy/Lip Uric Acid Ammonia Nitro. Anion Gap Osmolality Common Labs: Tox-32 Qual. Tox-32 Quant. VBG VBG w/ LYTES ABG Troponin T Troponin I Cardiac Panel Coags. Panel Cholesterol Panel Inflammatory Panel Histamine Panel Gulcose, Specific CMP CBMK Vitamin Panel Hgb A1C Other Labs: Blood Bank: Type & Cross (pRBC) for x_____Units Type & Cross (Platelets) for x_____Units Type & Cross (MTP) for MTP Pack #_____ Use Protocol:_________________ Patient Name:_____________ Patient MRN:___-____-____ Patient D.O.B.:___/___/___ Patient Sex:_________ Department:_____________ Room & Bed:_____________ Patient Label/ Orders Label CPK CPK MB C-Reactive Prot. Iorn Iorn Saturation Ferritin Folate Copper Zinc HCG-Quant. Serum HCG-Qual, Urine Cultures, Blood Cultures, Blood x2 Cultures, Swab Cultures, Sputum U/A Microscopy STAT (All Labs) STAT (Core Labs) Provider:______________ Provider ID #_______ Drawn By:______________ Drawn By ID #_______ Drawn Date:___/___/___ Drawn Time:___:___hrs Site:______ With:________ Notes:_________________ ______________________ ______________________ ______________________ ______________________