Sample of requisition form for blood drwa

Requisition Completion, Specimen Labeling and Phlebotomy Guidelines

If a light blue top tube is drawn with a holder and butterfly needle, prime the tubing with a discard tube before filling the sodium citrate tube (light blue topped).
Specimens for Blood Bank require a specific patient identification and collection process. Refer to "Blood Center Services" additional information.

On in-patients compare the name and hospital number from the arm band to that on the requisition and labels and ask the patient to state their full name and date of birth.
If patient is an outpatient, ask them to state their full name and date of birth.
If patient is an infant or confused adult, check arm band or ask person accompanying the patient for identification.
See Patient Identifiers (University of Iowa Hospitals and Clinics Policy V.35).

For samples that MUST be collected from an arm with an active I.V., the best option is to collect the sample distal (below) the intravenous site. The infusion must be turned off for a MINIMUM of 2 minutes, before drawing the sample. If the only available site is proximal (above) to the I.V. site, turn off the I.V. for at least 2 minutes and draw from a vein other than the vein with the I.V. line. Record "drawn distal/proximal to I.V." in the patient's chart.
Follow the same procedure if a sample must be drawn during blood products transfusion. Best practice is to wait one hour after the transfusion is completed before drawing the sample.

TUBE TOP COLOR

LIGHT GREEN

LIGHT BLUE

The following forms are only used if Epic is unavailable or in select areas where Epic is not live.

Form/Requisition	Name	Processed Stores Order #
Form A-1a	Blood Center Request	922339
Form 0-9	Bone Marrow Examination Request	922993
Form A-1a	Clinical Microbiology Doctor's Order Form	923618
Form A-1a	Critical Care/Special Care Nurseries Laboratory	923779
Form H-2	Cytology Consult Report	922380
Form A-1a TDA	Doctor's Order Therapeutic Drug Assay	Not Available through Processed Stores
Form A-1a	Immunopathology Laboratory	922943
Form A-1a	Miscellaneous Request	922348
Form A-1a Lab	Pathology Doctor's Order-Lab Test	923533
Form A-1a Lab	Pathology Doctor's Order-Inpatient Service	923766
Form A-1a	Molecular Pathology/Diagnostics Laboratory	Not Available through Processed Stores
Form H-1	Surgical Pathology Consultation Request	922379

Form: A-1a General Lab (Pathology Doctor's Orders)
Form: A-1a Therapeutic Drug Assay (TDA) (Pathology Doctor's Orders)
Form: A-1a Clinical Microbiology Laboratory (Pathology Doctor's Orders)
Requires list of antibiotics patient is receiving.
Requires diagnosis, testing varies according to suspected clinical diagnosis.
Form: A-1a Immunopathology Laboratory (Pathology Doctor's Orders)
Form: A-1a Critical Care/Special Care Nurseries Laboratory (Pathology Doctor's Orders)
Form: A-1a Molecular Pathology/Diagnostics Laboratory (Pathology Doctor's Orders)
Form: Blood Center Request (Pathology Doctor's Orders)
(Please refer to the tables for complete forms listing).
- Information required on A-1a forms:
1. Label the form/requisition with an Epic label or print the full name (last, first, middle initial), medical record number, birthdate, and current date on the requisition.
2. Nursing station or clinic.
3. Ordering physician's name, code and signature. Clinic codes are unacceptable.