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

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

VCH Downtime &/or Code Requisition Diagnostic Laboratory 4605 TVC, Nashville, TN 37232 Month: Day: Year: Collection Time: Ordering Dept./Service: Collection Location: Allergies: _____a.m. _____p.m. Ordering Physician: Physician Beeper/Phone: Unit/Bed: STAT LAB Height: ______Weight______MAIN LAB ( Multiple Lab Tests Can Be Ordered) (Tubes: 109, 606, 801) ICD 10 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- CHL Cholesterol LGN TGL Triglycerides LGN PTT boplastin Time LB ABG Blood Gas, Arterial Lab Tube # CK-MB CK-MB CK Ratio LGN TRI Troponin I LGN Code Toxicology Color VBG Blood Gas, Venous Comp Metabolic Panel Full (BMP, TBIL,Alk Phos, PRO, Digoxin Dark CMP AST,ALT) LGN UAB Uric Acid LGN DIG Date/time last dose: DGN CAI Ionized Calcium Green Other: CRE LGN Other: DSA Drug Profile (U) UR Phenytoin (Dilantin) Other: GLU Glucose LGN Other: PYT Date/time last dose: DGN

Ancillary Departments: One (1) department/product per form Requested Order/s:______Reason/History/Diagnosis/ICD 10 Code ______

Peds Radiology Phone: 6-7155, Fax: 3-1841 Peds Nutrition (Phone3-9763 Fax 3-8810) Peds Respiratory (Phone 715-9014 Fax 6-4351)

*Non-MD Consult______Peds Echo (Phone 6-2481, Fax 3-1432) Social Work (beep SW)

Miscellaneous______Peds Pulmonary Function (Phone 6-2556, Fax 6-3665)

Other:

Collector's Collector's Collection Collector's Print Name: Signature: Date/Time: Vunet ID

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