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LAB REQUEST FORM – SAVE THE CHILDREN – KERRY TOWN EBOLA TREATMENT CENTRE DATE: ____ / ____ / 2014 DD / MM / YYYY PATIENT ID #: KT– – KT-­‐2 = Triage; KT-­‐3 = Confirmed; KT-­‐4 = morgue BASIC PATIENT INFORMATION Ward #: ______ Bed #:______ Name: Surname_____________________ Given names_____________________ Sex: ☐ Male ☐ Female Age: _____ ¨ YEARS or ¨ MONTHS (for children under 1 year) PRESCRIBER INFORMATION Requested by (print your name): _________________________________ Title: ________________________________________________________ LAB TESTS (PHE) ¨ New admission (Malaria RDT + Ebola PCR) ¨ Repeat Ebola PCR LAB TESTS (MoD) ¨ Full Blood Count (purple) Amylyte 1 3 Metlac 1
2 Sodium Sodium ¨ Coagulation screen (blue) Potassium Potassium Urea Urea Creatinine Creatinine ¨ Amylyte 13 (green) Glucose Glucose OR Calcium Calcium Albumin ¨ Metlac 12 (green) Albumin Total Bilirubin Chloride Special request ALT Magnesium AST ¨ D-­‐Dimer Phosphate CK Bicarbinate ¨ HIV Amylase Lactate CRP ¨ Blood culture ¨ Dengue R equest F orm 2.0 Lab Save the Children – KERRY TOWN TREATMENT CENTRE Page 1 of 1 LAB REQUEST FORM – SAVE THE CHILDREN – KERRY TOWN EBOLA TREATMENT CENTRE DATE: ____ / ____ / 2014 DD / MM / YYYY PATIENT ID #: KT– – KT-­‐2 = Triage; KT-­‐3 = Confirmed; KT-­‐4 = morgue 2014-­‐11-­‐15 Created by Shefali Oza (shefalita@gmail.com) The latest version of this form can be found at https://wiki.openmrs.org/display/projects/Paper+forms+for+SCI+ETC Lab Request Form 2.0 Save the Children – KERRY TOWN TREATMENT CENTRE Page 1 of 1