Patient Name: MR #: CSN#: DOB: dd-mmm-yyy y Age: Sex: Date/time: dd-mmm-yyy y

Manually Complete or Attach Label with required Document Type Bar Code Here data

Vanderbilt University Medical Center Downtime &/or Code Requisition Diagnostic Laboratory 4605 TVC, Nashville, TN 37232 Month: Day: Year: Collection Time: Unit/Bed: Ordering Dept./Service: Collection Location: STAT LAB _____a.m. _____p.m. Ordering Physician: Physician Beeper/Phone: Height______Weight ______MAIN LAB ( Multiple Lab Tests Can Be Ordered) (Tubes: 109, 606, 801) ICD10 CODE: Lab Tube Lab Tube Lab Tube Lab Tube # # # # Code Chemistry Color Code Chemistry Color Code Hematology Color Code Body Fluids Color CSF Cell Count ABL Albumin LGN LDH LDH, Blood LGN CBP CBC/Platelets LV CSF (Body Fluid Container) CBC/Platelets/ CSF, AMY Amylase LGN MG Magnesium LGN CPD Diff LV SFG (Sterile Plastic LP Tube) CSF, Protein BMP (Elec, Glu, Bun, Crea, CA) LGN OSM Osmolality LGN HCT Hematocrit LV SFP (Sterile Plastic LP Tube) Phosphorus, Pregnancy Test, PLT Platelets LV UR BHC Beta HCG, Serum LGN PO4 Inorganic LGN UCG Urine Lab Tube # UR TBR , Total LGN K Potassium LGN Code Coagulation Color UA1 Urinalysis Protein Total, D-Dimer for DIC, CA Calcium LGN PRO Blood LGN DDI Quant LB OSU UR (ARUP # 0020228) CO2 Carbon Dioxide LGN ALT SGOT LGN FBG Fibrinogen LB Lab Tube Prothrombin Time # CL Chloride LGN NA Sodium LGN PT LB Code Other Color Partial Throm- Blood Gas, Arterial CHL Cholesterol LGN TGL Triglycerides LGN PTT boplastin Time LB ABG Lab Tube # Blood Gas, Venous CK-MB CK-MB CK Ratio LGN TRI Troponin I LGN Code Toxicology Color VBG Comp Metabolic Panel (BMP, TBIL,Alk Phos, PRO, Digoxin Full Dark Green CMP AST,ALT) LGN UAB Uric Acid LGN DIG Date/time last dose: DGN CAI Ionized Calcium Other: Other: CRE LGN DSA Drug Profile (U) UR Other: Phenytoin (Dilantin) Other: GLU Glucose LGN PYT Date/time last dose: DGN

Ancillary Departments: One (1) department/product per form Requested Order/s:______Reason/History/Diagnosis/ICD10 Code ______

Adult Pulmonary Function Neurology TVC (Phone 6-0060, Fax 3-2008) Radiology (Phone 3-3310, (Phone 2-0626; Fax 2-6637) Neurology PRB (Phone 2-7246, Fax 6-7147) (Pulmonary Function & Fax 2-8997) (Tube 104) MS, OHO (Phone 3-1176, Fax 3-1219) Cardio/pulmonary Stress) Cardiology (Phone 2-2318, *Nutrition (Phone 3-9761, Fax 3-8810) (Tube 607) Fax 3-2450 EKG & Heart Monitors) Rehabilitation (Phone 2-0100) Reason not required for diet orders. (Adult Echo Fax 6-0840) Respiratory (Phone 480-2766, *Consult (Not MD)______Vasular Lab (Phone 3-9205 or 3-3455 Fax 3-3762) Fax 3-0684)

Miscellaneous______Social Work (beep SW)

Collector's Collector's Collector's

Print Name: Signature: Date/Time: Vunet ID:

MC 0246F 1 (8/2016)