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Specimen Container Label
Each specimen container must be identified with a gummed label. The label must contain the following information:
Patient's name
Medical record number and/or date of birth
Date/time of collection
Initials of person collecting the specimen
    • Blood Bank specimen need 2 initials
Note: Consult individual test requirements for special labeling requirements.
Laboratory Requisitions/Test Orders
Mandatory Information:
Patient's full name (last, first)
Patient's medical record number (if available)
Patient's location
Patient's date of birth and sex
Physician's full name
Test(s) requested: Check the box to the left of the test on the requisition. For tests not listed on the form legibly, print name of ordered test on the blank lines.
Diagnosis and/or ICD-9 code
Date and time of specimen collection
Supplemental Information
  • Note any special instructions (fasting, preoperative, etc)
  • Stat identification: Write "STAT" on requisition in red; or affix a STAT label to the requisition; or use a Blood Test Stat requisition
  • Microbiology requests must identify the type of specimen submitted and the anatomical site (source) of specimen collection. Antibiotics administered must also be indicated.
  • Cytogenetic study requests must be accompanied by a completed Patient History Form. Forms are available from Cytogenetics, ext 26298.
  • Drug levels must have time of blood draw
Laboratory Requisitions
Laboratory requisitions are used for outpatient test requests and inpatient test requests when order entry in PCIS (POE) is unavailable.  Laboratory requisitions are available through Laboratory Support Services (LSS) in Room 470 Jelke or by calling ext. 22378.  The following is a list of requisitions in use:
Your will need to view these files.

Form 4002........... Emergency Services
Form 4003........... Blood Tests Stats
Form 4004........... Blood Tests Routine
Form 4005........... Blood Gases
Form 4006........... Microbiology
Form 4007........... Microbiology/Immunology
Form 4008........... HLA Laboratory
Form 4009........... Blood Bank
Form 4010........... Specialty Tests
Form 4011........... Urine/Body Fluid Tests
Form 5709........... Transfusion Request
Each inpatient nursing station is stocked with laboratory requisitions by the Laboratory Liaison Technicians (LLT) assigned to the unit. Outpatient, physicians office, and client areas may obtain requisitions from LSS as stated above.