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SPECIMEN

COLLECTION AND
TEST CATALOG

http://shands.org/professionals/labs/default.asp
ABOUT OUR LABORATORIES

Shands at UF Medical Laboratories are privileged to serve you and your patients. Our team is composed of
nationally recognized pathologists in a wide spectrum of subspecialties and laboratory staff licensed in the State
of Florida. We strive to provide the highest quality patient care using state-of-the-art technology, with quick,
accurate, and professional attention to each patient case in the accredited laboratory environment.

Shands at UF Medical Laboratories are accredited by:

n The HealthCare Financing Agency of the U.S. Department of Health and Human Services under
the Statutes of the Clinical Laboratory Improvements Act. Our CLIA Numbers are 10D0997531,
10D0665884, and 10D0726675, and

n The College of American Pathologists Commission on Laboratory Accreditation. Our CAP laboratory
numbers are 7178590, 1482301, and 1482314.

Shands at UF Medical Laboratories are licensed by the State of Florida Agency for Health Care Administration
with license numbers 800000315, 80017098, and 800004146. Our licensed specialties are: Histocompatibility,
Virology, General Immunology, Routine Chemistry, Urinalysis, Endocrinology, Toxicology, Hematology,
Histopathology, Immunohematology, Cytology, Parasitology, Bacteriology, Mycology, Mycobacteriology, and
Molecular Pathology.
TABLE OF CONTENTS

Contact Information................................................................................................................................1

Locations of Draw Stations and Laboratories.......................................................................................3

Patient and Specimen Information.........................................................................................................5

Test Catalog...........................................................................................................................................13

Core Laboratories..................................................................................................................................15

Microbiology and Virology Laboratories..............................................................................................17

Transfusion Service (Blood Bank).........................................................................................................25


Cytology Laboratory..............................................................................................................................27

Surgical Pathology................................................................................................................................33

Hematopathology Laboratory...............................................................................................................39

Transplant Laboratory...........................................................................................................................43

Order Forms

PS42510: Medical Laboratory Request..........................................................................................16

PS86250: Cytology Non-GYN Request..........................................................................................30

PS40994: Cytology GYN Request (2 pages)............................................................................ 31-32

PS44626: Surgical Pathology Request (for outpatients) (2 pages)........................................... 35-36

15-9020-0: Surgical Pathology Request (for inpatients).................................................................37

Surgical Pathology Request for Muscle and Nerve Biopsies.........................................................38

PS105674: Hematopathology Request Form.................................................................................41

UF PathLabs Oncology Cytogenetic Testing Requisition Form...................................................42

Contact Customer Service at (352) 265-0522 with questions about above request forms.
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CONTACT INFORMATION

We are open 24 hours a day, seven days a week for emergency laboratory testing. Please feel free to contact us:

Customer Service............................................................................................ (352) 265-0522

Chairman, Department of Pathology, Immunology and Laboratory Medicine


Michael Clare-Salzler, MD.................................................................................. (352) 392-6840

Laboratory Medical Director


Kenneth Rand, MD............................................................................................ (352) 265-0680, x4-4875
........................................................................................................................... (888) 543-1806 pager
........................................................................................................................... (352) 265-0680, x5-0447 fax

Anatomic Pathology Medical Director


Anthony Yachnis, MD......................................................................................... (352) 265-0680, x4-4951
........................................................................................................................... (352) 413-7518 pager

Administrative Director
Jannet Ward....................................................................................................... (352) 265-0037

Pathology Resident On-call........................................................................................... (352) 413-6266


(Frozen Sections 5 pm 8 am, weeknights/weekends/holidays,
clinical problems 24/7, STAT autopsies weeknights)

Point of Care................................................................................................................. (352) 265-0037


Abby Estilong and Arvid Olson.......................................................................... (352) 413-6736 pager

Quality Assurance, Safety, and Compliance................................................................. (352) 265-0172


Agnieszka Avizinis.............................................................................................. (352) 413-2445 pager

Each Laboratory Specialty............................................................................................ See Table of Contents

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DEPARTMENT OF PATHOLOGY

Medical Director Department Telephone* Pager Fax

Clinical Pathology,
Dr. Kenneth Rand Microbiology, and x4-4875 (888) 543-1806 (352) 265-0447
Virology

Dr. Neil Harris Core Lab, POC x4-4717 (888) 553-6799 (352) 265-0437

Dr. Lindsay Bazydlo Core Lab x5-0037 (888) 980-4022 (352) 265-0437
(352) 265-0680
Dr. Martha Burt Autopsy (352) 273-5891 (352) 491-3360
x6-1923
Dr. Ying Li Hematopathology x7-2052 (352) 413-7468 (352) 265-1063

Dr. John Reith Surgical Pathology x4-4961 (352) 413-7504 (352) 265-0437

Anatomic Pathology
Dr. Anthony Yachnis x4-4951 (352) 413-7518 (352) 265-0437
and Neuropathology

Dr. Juan Scornik (interim) Blood Bank x7-2030 (352) 413-7508 (352) 265-9901

Dr. Larry J. Fowler Cytology x4-4959 (352) 413-1620 (352) 265-0437

Dr. Juan Scornik Transplant x7-2030 (352) 413-7508 (352) 265-9901

Dr. John Reith Histology x4-4961 (352) 413-7504 (352) 265-0437

*Main telephone number for all extensions is (352) 265-0680.

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Phlebotomy Services
Pam Core, Manager
office: (352) 265-0172 ext. 72204
Draw Stations cell: (352) 682-3471

Shands Vista 441


75 Shands Rehab Hospital
Magnolia 24 Gainesville
Parke
Regional Airport
222 39TH AVENUE 39TH AVENUE
Exit #390

NW 13TH STREET
23RD AVENUE 16TH BLV
D 16TH AVENUE

43RD ST

34TH ST

D
OA
Exit #387

OR
LD
26 NE
8TH AVENUE

WA
MAIN STREET
WB Park Avenue UF Shands Eastside
Tower Hill ER Community Practice
Internal Oaks RY R
OA
SW

Mall D
Medicine
26
62N

UNIVERSITY AVENUE UNIVERSITY AVENUE


A
D ST

Family UF Orthopaedics
75TH STREET (TOWER ROAD)

Shands Florida
Medicine
Surg. Ctr. and Sports SW 2ND AVE 20
at Hampton SW 6 Medicine
2 N
Oaks Institute HA
D BLVD

WT
HOR
16TH AVENUE NE
SW 20TH AVENUE RO
AD
Shands Shands at UF

ET
(North Tower)

TRE
Shands Cancer
D Hospital D
OA Medical IN S Ayers
RR at UF Family
91ST STREET

Plaza
MA
E Medical Plaza
CH 121 (South Practice
Haile AR and Surgery
C
91ST TERRACE

Plantation Rocky
Tower) Medical
331 Group Center
Exit #384 Point
VD) AD
E
SW 13TH STREET

AILE BL B RO
46TH BLVD (H
ON
75 I ST Shands
24 ILL Endoscopy
W
OA
D Center
RR
Exit #382
C HE
AR
121
441

Map not to scale.

Tower Hill Internal Medicine Shands at UF Outpatient Laboratory*


A 7540 W. University Ave.
D First Floor of Shands at UF (Room 1021.1)
Gainesville, FL 32607 1600 SW Archer Rd.
352.265.0370 Gainesville, FL 32610
Open 8:00 am 4:30 pm, Monday Friday 352.265.0484
Closed 12:30 pm 1:30 pm for lunch Open 7:00 am 5:00 pm, Monday Friday

Shands at Rocky Point Ayers Diagnostic Lab


B 4800 SW 35th Dr.
E 720 SW 2nd Ave.
Gainesville, FL 32608 Gainesville, FL 32601
352.265.0522 352.733.0070
NEW HOURS: Open 7:00 am 4:30 pm, Monday Friday Open 7:30 am 4:00 pm, Monday Friday

Shands Medical Plaza* Shands Medical Group at


C 2000 SW Archer Rd.
F Magnolia Parke Lab
Gainesville, FL 32609 4740 SW 39th Pl., Suite B
352.265.0111, x 87175 Gainesville, FL 32608
Open 7:30 am 5:30 pm, Monday Friday 352.265.5230
*$4 parking fee at these locations.
Open 7:30 am 5 pm, Monday Friday

Rev. 2/15/11 3 PS43541


LOCATIONS OF SUF MEDICAL LABORATORIES

1. Shands at UF Hospital 2. Shands Medical Plaza


Cancer Center Lab
NORTH TOWER
2000 SW Archer Rd.
1600 SW Archer Road
Gainesville, FL 32609
PO Box 100344
352.265.0680, x50772
Gainesville, FL 32610-0344
352.265.0734 fax
352.265.0037
352.338.9889 fax

3. Rocky Point Medical Laboratories


SOUTH TOWER
4800 SW 35th Drive
1515 SW Archer Road
Gainesville, FL 32608
PO Box 100344
352.265.0172
Gainesville, FL 32608
352.265.0585 fax
352.733.0900
352.733.0812 fax

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PATIENT AND SPECIMEN INFORMATION
GENERAL REQUIREMENTS

Proper patient preparation, timing of specimen collection, selection of specimen container type including
preservatives and anticoagulants, specimen transportation, and relevant patient clinical data are critical for
successful testing, timely reporting of laboratory results, and proper diagnosis.

BEFORE COLLECTION

1. Patients
Patient should be instructed about particular requirements of fasting, special dietary consumption, or
other requirements timely before collection, especially prior to arrival at a draw station.

Each patient must be identified positively, using active communication techniques, by means of two
patient identifiers before collecting a specimen for clinical testing. The patients identity should be verified
by asking the patient to identify him or herself whenever it is practical. Room number or physical location
can not be used as an identifier.

Inpatients: Use full name and Shands medical record number.

Inpatients, ED patients, or outpatients having an operative or invasive procedure: Compare the two
identifiers on the identification band to another document such as order to confirm you have the
correct patient.

Outpatients: Ask the patient their full name and date of birth. Compare the two identifiers to another
document such as lab order form.

2. Supplies
Collectors of specimens are responsible to assure that collection supplies are stored according to
manufacturers requirements and used only before expiration date.

COLLECTION OF SPECIMENS

1. Peripheral Blood

Safety Note: Please carefully consider the need for laboratory tests, avoiding unnecessary repetition of tests,
and use of standing orders in efforts to minimize unnecessarily large blood draw volumes. Blood losses
from phlebotomy, particularly in pediatric patients and those with many venipunctures may be a cause of
iatrogenic anemia and increased transfusion needs. Among adverse consequences of excess venipunctures
are complications during collection for patients and health-care workers, hazards from subsequent
transfusions, and increased amounts of hazardous waste.

Venipuncture Procedure

Method: Percutaneous Venipuncture


Steps:
Identify self to patient.
Properly identify the patient using two unique identifiers. Acceptable identifiers are patient first and
last name and one of the following: date of birth, medical record number, or drivers license number.
Verify diet restrictions.
Position patient lying on back with face up or sitting with the appropriate site exposed.

(continued on next page)

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Method: Percutaneous Venipuncture
Steps: (cont.)
Wash hands thoroughly and apply clean gloves.
Select venipuncture site.
DO NOT USE an extremity with an A-V shunt or status/post mastectomy.
DO NOT USE a site with extensive scarring.
DO NOT USE a site with a hematoma.
DO NOT USE a site with an IV.
Prep overlying skin with alcohol using a circular motion. Chloraprep may be used if patient is allergic
to alcohol.
Before using, tap all tubes that contain additives to ensure that the entire additive is dislodged from
the stopper and the wall of the tube.
Make sure patients arm or other venipuncture site is in a downward position to prevent reflux.
Apply tourniquet to extremity 2 inches proximal to desired site.
Identify target vein with palpation and visualization.
Use thumb to apply tension downward distal to insertion site.
Verbally state to patient that the venipuncture is starting and insert the needle at a 15-30 angle and
to inches below the intended entry into the vein.

Venipuncture procedure when evacuated tubes are used:


Insert blood collection tube into holder and onto needle up to the recessed guideline on the
Vacutainer adapter.
Position the needle with the bevel up and the shaft parallel to the path of the vein.
Insert needle through skin at 15-30 angle and to inches below intended entry into vein.
Grasp the flange of the needle adapter and push the collecting tube forward until the needle punctures
the stopper. Observe for flow of blood into stopper. Maintain tube below the needle.
Remove tourniquet as soon as possible once blood flow is established.
Keep constant, slight forward pressure on the end of the tube to prevent release of shut-off valve and
stop of blood flow.
Fill the tube until the vacuum is exhausted and blood flow ceases.
When blood flow ceases, remove the tube from the holder. The shut-off valve recovers the point,
stopping blood flow until the next tube is inserted.
Tubes containing additives should be mixed immediately upon draw by inverting 5-10 times. To avoid
hemolysis, do not mix vigorously.
To obtain additional specimens, insert the next tube into the holder and repeat steps 7-9.

Venipuncture procedure when using needle and syringe:


Position the needle with the bevel up and the shaft parallel to the path of the vein.
Insert sterile needle or butterfly through the skin at a 15-30 angle to inches below the intended
entry into the vein.
Pull back on plunger or syringe slowly until sufficient volume of sample is achieved.
Release tourniquet.
Withdraw needle and syringe.
Apply pressure to site with gauze pad.
Pierce stopper of collection tube with needle; the evacuated tube will fill to the correct amount of
blood.
Immediately activate the safety feature according to manufacturer instructions and discard without
assembly into a sharps container.
Check patients arm to ensure bleeding has stopped.
Apply gauze pad secured lightly with tape to the puncture site.
Instruct patient to leave bandage in place for at least 15 minutes.
Label all blood tubes at patients time of draw.
Place labeled specimens in biohazard bag.
Discard gloves and wash hands.
Place specimen at courier pickup station for processing.

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Venipuncture procedure when multiple specimens are collected:
Obtain blood specimen using the following order of draw.
Blood culture tubes or vials
Non-additive (e.g., PLAIN RED)
Coagulation tube (e.g., BLUE)
Serum tube with or without clot activator, with or without gel (e.g., RED, GOLD, or SPECKLE)
Heparin tube with or without gel plasma separator (e.g., GREEN)
EDTA (e.g., LAVENDER, PINK or PEARL)
Glycolytic inhibitor (e.g., GRAY)
NOTE: Plastic serum tubes containing a clot activator may cause interference in coagulation
testing. Glass non-additive serum tubes may be drawn before the coagulation tube.
When using a winged blood collection set (butterflies) for venipuncture and a coagulation tube is
the first tube to be drawn, a discard tube should be drawn first. The discard tube must be
used to fill the blood collection tubing dead space and to assure maintenance of the proper
anticoagulant/blood ratio and need not be completely filled. The discard tube should be a
non-additive tube.
Release the tourniquet as soon as possible after the blood begins to flow.
Fill lab tubes with appropriate volume.
Apply pressure to site with gauze pad.
Apply bandage or gauze pad secured lightly with tape to puncture site.
Immediately activate the safety feature according to manufacturer instructions and discard without
assembly into a sharps container.
Label tubes at patients draw station.
Place labeled lab specimen in biohazard bag.
Discard gloves and wash hands.
Send specimens to courier pick up station for processing.
Follow with section called Whole Blood, Serum, Plasma collection including the tube guide.

Capillary Puncture
Capillary puncture may be used for obtaining specimens in infants or in adults where venipunture is difficult.
Specimens from infants under the age of 6 months are usually collected by heelstick. Above 6 months,
fingerstick collection is usually used. Microtainers are available for collection and are color-coded similar to
vacuum tubes red for serum specimens and lavender for EDTA whole blood or plasma. A translucent brown
microtainer is available for bilirubin analysis.

The capillary puncture should be made with a sterile lancet according to current nursing or laboratory
capillary collection procedure. The first drop of blood containing tissue and tissue fluid should be wiped
away, and the blood collected from the clean flow of blood from the wound. Care should be taken not to
squeeze the finger or leg excessively in order to avoid sample hemolysis. After collection, the collection
tube should be capped and inverted several times to mix the anticoagulant. Do NOT shake. Label each tube
before sending.

WHOLE BLOOD, SERUM or PLASMA COLLECTION

The most common sample of laboratory testing is whole blood serum or plasma. The preferred collection method
for adults is venipuncture using vacuum collection tubes. The method of collection is similar for whole blood,
serum or plasma except for the anticoagulant used. The color of the stopper of the collection tube specifies the
anticoagulant content.

Blood should be obtained from a freely flowing venipuncture performed according to current nursing or
laboratory venipuncture procedure. (See previous pages for venipuncture procedure.) Tubes should be
collected in the following stopper color order red, blue, other. All tubes, except red top tubes, should be
inverted gently several times in order to mix the anticoagulant. Adequate volume should be collected for the
number and types of tests requested. Minimum blood volumes are determined for each test. If insufficient
volume is collected, call the laboratory before sending.

Safety Note: Glass vacutainers are not acceptable.

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SHANDS AT UF SHANDS
SPECIMEN
at UF COLLECTION TUBE TUBE
SPECIMEN COLLECTION GUIDE
GUIDE

Contact Tests to Perform Tube Type Standard Tube Pediatric Bullet


Information (Additive) Minimum Volume Minimum Volume
Mixing Requirement Mixing Requirement
Urgent orRenal
Metabolic, STATandonly
Hepatic LIGHT GREEN Min. vol. 2 mls
Contact Lab Metabolic,
panels, Renal and
or Cardiac Hepatic
Markers (Lithium heparin) Mix 8 times
for minimum panels, or Cardiac Markers Min. vol. 400ul Mix 10 times
volume on Routineprotein
Chemistry tests GOLD Clot
multiple test Lithium, electrophoresis,
including above
folate, PTH, panels,
serum viral
free light activator
order! GOLD Min. vol. 2 mls
serology, lithium, protein
chains, mycophenolic acid,
(with gel separator)
(with in
clots gel30separator)
min Mix 5 times
electrophoresis,
and cadaveric viralfolate, PTH,ASO
testing, OR
ASO titer, serum free light Min. vol. 400 ul Mix 5 times
RED clots in 1hr
chains, mycophenolic acid, and (w/o gel)
cadaveric viral testing
Vit D., tacrolimus, cyclosporin,
Sirolimus, intraoperative PTH, LAVENDER Min. vol. 2 mls
Core Labs ammonia testing , (K2EDTA ) Mix 8 times
Min. vol. 400ul Mix 10 times
and also
complete blood count,
352.265.0412
differential and reticulocyte
or determinations.
352.265.9961 Glucose determination GRAY is preferred
(OGTT or other timed glucose (potassium Min. vol. 2 mls
analysis) oxalate/ sodium Mix 8 times
fluoride )

Joint crystal determination


Min. vol. 3 mls
(crystal synovial fluid) DARK GREEN
Mix 8 times
(Sodium heparin)
Coagulation
PT, PTT, INR,determination
and 2.7ml size tube
platelet function testing LIGHT BLUE
must be filled to
(3.2 % sodium 2.7ml size bbbbb
the top line.
citrate)
Mix 3 or 4 times.
Transplant HLA phenotyping, YELLOW
352.265.0072 DNA testing, and *HLA (Citrate Dextrose Min. vol. 5 mls
crossmatch (donor's cells) solution A or Mix 8 times
* both donor's cells and recipient's ACD-A)
serum required for crossmatch

HLA antibody, and *HLA GOLD


GOLD
crossmatch (recipient's serum) (with gel separator)
(with gel separator) Min. vol. 3 mls
*both donor's cells and recipient's Clot activator Mix 5 times
serum required for crossmatch clots in 30 minutes
Hemato- Immunophenotyping by
pathology flowcytometry LAVENDER NO min. vol.
352.265.0071 (K2EDTA) Mix 8 times
Send outs evaluation
Cytogenic - cytogenetics
DARK GREEN NO min. vol.
(Sodium Heparin) Mix 8 times

Blood Bank Blood bank testing. Samples must


352.265.0377 be accompanied with a Transfusion PINK (K2EDTA) Min. vol. 2 mls
Services Time Out Verification Form. Mix 8 times

Virology CMV and BKV DNA PCR WHITE = PEARL


Min. vol. 2 mls
352.265.0978 testing (with gel separator)
(K2EDTA) Mix 8 times

Infectious disease testing GOLD


GOLD
(with gel separator)
(with gel separator) Min. vol. 2-3 mls
Clot activator Mix 5 times
clots in 30 minutes
EBV PCR testing
LAVENDER Min. vol. 1 ml
(K2EDTA) Mix 8 times

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The following general procedures should be observed when collecting the following samples:

The volume requirements of blue top tubes for coagulation tests such as PT or
Blue Top tubes PTT are very specific. The tube should be filled precisely to the required volume
with a free flowing sample.

Betadine or other non-alcoholic solution should be used for disinfecting the arm
Ethanol (Alcohol) testing
prior to sampling. Do NOT use alcohol preps.

Blood culture
For each request for blood cultures when a time or location is not specified by the doctor, two sets of
two bottles will be drawn. Each set of aerobic and anaerobic blood culture bottles will be obtained from
two different sites. Samples will NOT be taken from an arterial line, heparin lock or a subclavian IV unless
specifically ordered by the attending physician. After selecting a good phlebotomy site, the tourniquet will be
released and the site disinfected. The site will be cleansed first with chloraprep using a concentric spiral
motion moving from the site outward. Prep the site using an iodine prep. using the same motion working
from the site outward. Allow the iodine to dry before drawing specimen.
Safety Note: If the patient is allergic to iodine, another topical disinfectant may be used. Any deviation
from routine collection should be noted on the request form or sample bottles.
Perform the venipuncture and draw the sample according to procedure. Sample should flow freely. Carefully
change syringe needle and blood transfer device and place of blood into each vial using aseptic technique.
Required Volumes: Adult/Aerobic & Anaerobic bottles: 8-10 mls EACH bottle and Pediatric/Lytic Bottle:
1-3mls. Be sure not to contaminate bottle tops before entering bottle with needle. Label and send to lab
as soon as possible. Treat patient according to current post-phlebotomy procedures. (See venipuncture
methods lists on previous pages.)

2. Urine
Random Urines
Unless otherwise specified, random urine collection should be the first morning urine collected using clean
catch mid stream technique. If a catheter is used for collection, the collection should be made from the free
flow in the tube, not the bag. The specimen cup should be capped and properly labeled before transporting
to the lab. The outside of the container should be clean and dry. Samples for urine culture should be
collected in a sterile container. If another test is requested on the culture sample, an aliquot should be
poured off into a new container, labeled and sent with a separate request slip.

Random urines should be sent to the laboratory as soon as possible after collection or else refrigerated
unless otherwise indicated.

Timed Urines
Timed urines are usually collected during a 2 or 24 hour time period. The normal amount of urine collected
over a 24-hour period ranges from 800 to 2000mL. The laboratory supplies the containers to be used for the
collections with the appropriate preservative added. The requesting location should send a message or a
request slip to the laboratory with the name of the patient, the patient location and the test requested to the
laboratory so that a 24-hour urine container can be prepared. Containers containing caustic or dangerous
preservatives will be labeled with warning stickers and patients should be cautioned not to urinate directly
into the container.

The time that the initial sample was discarded (beginning time) and the time of the last sample collected
(ending time) should be noted on the label and the requisition. All volumes of urine between these two times
should be added to the sample. If an aliquot has been lost or need to be used for another purpose and the
total volume of all lost aliquots represent less than 10% of the collection, the amount of the lost volume
should be noted on the label and the collection may be continued. If the volume of the submitted sample
is less than 200mL the laboratory will suggest a recollection unless the patients physician feels that the
submitted volume is appropriate.

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Urine Preservation
Preservatives are used to keep the substance to be measured in the urine sample stable during the collection
period. The preservative is required to be added to the sample collection container before the collection of
the specimen begins.

Safety Note: Some preservatives are caustic and the sample containers will be labeled as such. Collect each
sample in another container and pour into collection container.

Urine Preservatives
Keep urine refrigerated or on wet ice during collection. Send to lab as soon as possible after
ON ICE
completion of collection.
Collect urine in a container in which 4 grams of dry boric acid has been added either as a
BORIC ACID
powder or in a table form before collection.
Collect urine in a container in which 30mL of 6 N hydrochloric acid has been added to
HCL
container before collection.

3. Stool
Fecal specimens for analysis should be collected in a plastic or water-impermeable stool container. If the
sample cannot be sent to the laboratory right away, preservative containers supplied by the laboratory may
be used for O&P and culture samples. Contamination of stool samples by urine, laxatives and barium should
be avoided. Diaper samples are not suitable for cultures. Call lab for instructions in collecting stool samples
for ova and parasites.

4. Sputum
Sputum collection should be made by deep cough. If a culture is requested on a sample that does not demonstrate
alveolar dust cells or contains large amounts of epithelial cells, the laboratory will request a recollection.

5. Bone Marrow
Bone marrow is collected by a clinician or a pathologist in an aseptic environment. Specimens may be
submitted for microbiology, cytology, flow cytometry, or hematological evaluations. Specimens may consist of:
a core biopsy
an aspirate or
prepared glass smear

Safety Note: Do not send a syringe with a needle. The sample will be rejected.

6. Body Fluids
A variety of diagnostic tests may be performed on various fluids that are present in the body. Collect by
sterile screw capped tube or syringe, depending upon volume obtained, by physician. Indicate the source of
the fluid on the label of the specimen. Specimens for body fluid analysis may include:
Spinal fluid
Safety Note to Patient Care Providers: When Creutzfeldt-Jacob disease or any prior disease is
suspected, laboratory must be contacted prior to sending spinal fluid specimen. Special transporta-
ation, communication and testing protocols must be followed for the safety of all handling the specimen.
Contact the specific laboratory section to which specimen is to be sent for specific instructions.
Ascitic fluid
Pericardial fluid Peritoneal fluid Pleural fluid Thoracentesis fluid Amniotic fluid
Synovial fluid Abdominal fluid Paracentesis fluid Bile fluid
Safety Note: Do not send a syringe with a needle. The sample will be rejected.

7. Tissue
Tissue specimens are typically collected via a needle biopsy. The specimen is thin and fragile. Paraffin block
is also acceptable, if not more than 1 or 2 cuts have been made for slides.

Refer to the Test Catalog (on page 13) for test-specific collection and transportation
requirements!

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LABELING

Each primary specimen container, innermost container that actually holds the specimen, must be labeled at
the time of specimen collection in patients presence with at least two identifiers.
patients first and last name
a second form of identification (date of birth, medical record number, drivers license number, account
number, or accession number )
samples for transfusion compatibility testing require a 3rd identifier in the form of a Blood Bank ID#
derived from Blood Bank ID band
date and time of collection
initials of a collector, and
exact anatomical site description for body fluid and tissue specimens

Blood Bank Note: For type and cross or type and screen tests performed in the blood bank, the specimen
must be sent with a completed Time Out Verification Form (100030156) to be accepted for testing.

All specimen labels must match patient identity. Patient name and medical record number on the label must
be compared with the name and medical record number on the the patients identification band.

The specimen containers must be labeled in the presence of the patient during the collection time.

The computer-generated labels are recommended. If preprinted labels are not available, complete patient
information can be handwritten on the label, but it must be legible.

Every specimen tube or container must be labeled regardless of size. Labels for additional tests that do not fit
onto the specimen container should be placed into the specimen transport bag along with the labeled specimen.

Date and time must be recorded on each specimen label after the specimen has been obtained. Dates on
labels printed on days prior to the actual collection may need to be corrected. Accurate collection date and
time are vital to physicians to correlate the results with any changes in the patients condition.

Patient information on the specimen container and the requisition (either hard copy form or electronic) must
match. If discrepancies can not be resolved with the collector, specimen must be recollected.

Routine blood and urine specimens that are not properly labeled or unsuitable should be voided and the
ordering physicians notified/unit notified with request to recollect. In certain rare cases when a specimen can
not be recollected due to either the site it is obtained from (e.g., cerebrospinal fluid), or timing of collection,
laboratory medical director in consultation with the ordering physician may authorize testing.

The following items are necessary on a Laboratory order form:


Two patient identifiers: name and date of birth or Shands Patient Medical Record,
Attending name, ID number, and address,
Qualified signature (by the ordering physician, or PA, or ARNP, or Resident),
Diagnosis or ICD9 codes for each test ordered, and
Specimen collection date and time

TRANSPORTATION

All diagnostic specimens should be submitted in a closed container, properly labeled, and in a biohazard bag.

All diagnostic specimens shall be transported in a manner to prevent contamination of workers, patients, or
environment. Samples should be transported in approved, inherently safe, leakproof containers. Samples
transported by couriers should be triple packaged. The original container must be leak-tight and inserted into
a secondary bag with preferably absorbing material to absorb accidental spill. The outer packaging (cooler)
must be designated and labeled for biohazards only and secured against the movement during transport.
The operator of motor vehicles that transport specimens must be trained as to the hazards they transport.

Safety Note: Specimens with needles will be rejected.

11
Patient Safety and Quality Note: SUF laboratories reserve the right to reject any specimen not
meeting safety, labeling, collection, transportation, minimum volume, or other requirements as
defined in this manual and the test catalog.

Examples of unacceptable specimens:


a specimen tube/container with no label
two or three tubes with one label going over all tubes
unlabeled specimens with loose labels in the specimen bag
a container with 2 different patient labels
tube with a wrong patient label
specimen for ammonia not transported on ice
specimen for vitamin E, A, K, B1, B6 test not protected from light during transportation
specimen in a syringe with a needle
specimen with insufficient volume

12
TEST CATALOG FOR SHANDS AT UF MEDICAL LABORATORIES

Click here to view Test Catalog for Medical Laboratories

It includes all tests and evaluations


performed by Shands at UF and selected
reference laboratories.

Tests can be searched by name/


test code, Shands at UF Laboratory
department, or reference laboratory
included.

It includes test-specific information,


such as collection and transportation
requirements, turnaround time, reflex
tests, CPT codes, critical result criteria,
etc.

13
14
CORE LABORATORIES
Manager: Nisha Patel Medical Director: Neil Harris, MD
(352) 265-0680 ext. 44876 Pager: 888-553-6799

Medical Director: Lindsay Bazydlo, PhD


Pager: 888-980-4022

Resident on call: (352) 413-6266

Scope of Service: Shands Medical Core Laboratories provide full service testing in Clinical Chemistry,
Special Chemistry, Hematology, Coagulation, and Urinalysis. To better serve the Shands Healthcare entity
and a wide range of patients there are multiple laboratory and phlebotomy station locations. All facilities are
equipped with state of the art analyzers which are selected to produce accurate result testing and improve
turnaround time and throughput.

Core Laboratory at SUF Hospital


Hours of operation: 24 hours/7 days a week
Phone # (352) 265-0412, Fax # (352) 265-0328

The majority of tests performed on-site at Shands UF are non-esoteric tests which require a routine
turnaround time of 4 hours or less. Stat results are available within one hour of receipt in the lab. The STAT
Lab, located on the 2nd floor at North Tower services the North Tower operating rooms. The limited stat test
menu includes blood gas testing, microhematocrit and whole blood testing for glucose, ionized calcium,
lactic acid, potassium and sodium. The STAT lab also provides quick access to blood products through the
management of a blood dispensing station.

Cancer Center Laboratory at Shands Medical Plaza


Hours of operation: M F, 6:30 AM 6:30 PM
Phone # (352) 265-0680 ext. 50722, Fax # (352) 265-0734

The Core laboratory is referred to as the Cancer Center Lab. It provides a limitedbasic chemistry and
hematologytest menu for Cancer and Infusion Center patients.

Core Laboratory at Rocky Point


Hours of operation: M F, 3 AM 11:30 PM; Weekends 3 AM 12 Noon
Phone # (352) 265-9961, Fax #: (352) 265-9909

Rocky Point Laboratory provides both routine and specialized chemistry testing for inpatient and
outpatients. The test menu includes general chemistries, metabolic and hepatic profiles, therapeutic and
immunosuppressant drug levels, sweat testing for cystic fibrosis, protein and hemoglobin electrophoresis,
infectious disease testing, protein and hemoglobin electrophoresis, anemia tests, hormone testing and tumor
markers.

Non-essential esoteric testing is primarily referred to ARUP Laboratories, Inc. with results generally available
within 2-3 days of collection. (Refer to www.aruplab.com for a detailed test menu.) Additional reference labs
are used as needed with approval by the medical director. Shands Core Labs, under the guidance of the
medical director, are continually investigating new tests in order to better serve the patient population.

SEE OUTPATIENT REQUEST FORM (PS42510) ON THE NEXT PAGE.

15
Encounter/Account # ________________________________
Send h Shands Medical Laboratories at Rocky Point

*OO0001*
To: 4800 SW 35th Drive Gainesville, FL 32608
Phone: (352) 265-0522 Fax (352) 265-9910
h Shands at the University of Florida
OO0001 1600 SW Archer Road PO Box 100344 Gainesville, FL 32610-0344
Page 1 of 1 Phone: (352) 265-0412 Fax (352) 265-0328
CLIENT INFORMATION REFERRING PHYSICIAN (PLEASE PRINT IN BLACK INK) PATIENT INFORMATION
PT LAST NAME FIRST MI

MEDICAL
RECORD #
ADDRESS BIRTHDATE SEX: h M h F

CITY PT SSN

STATE ZIP HOME PHONE


ATTENDING PHYSICIAN NAME WITH #

EMPLOYER WORK PHONE


REFERRING PHYSICIAN SIGNATURE
WORK ADDRESS CITY STATE ZIP
INSURANCE BILLING INFORMATION (PLEASE PRINT IN BLACK INK)
PRIMARY: h Medicare h Medicaid h Other Ins. h Self h Spouse h Dependent PT LOCATION / CLINIC
SUBSCRIBER FIRST MI
LAST NAME
BENEFICIARY/ GROUP # COLLECTION REPORTING INFORMATION
MEMBER # h FAX results to COPY to
CLAIMS ADDRESS CITY STATE ZIP
h CALL results to
Date Collected h Non-Fasting Time Collected h AM h PM
SECONDARY: h Medicare h Medicaid h Other Ins. h Self h Spouse h Dependent
h Fasting (8hrs)
SUBSCRIBER FIRST MI
For Lab Use Only Place
LAST NAME
BENEFICIARY/ GROUP # h Signed ABN Obtained h STAT
MEMBER # h Venipuncture Draw Fee Label
CLAIMS ADDRESS CITY STATE ZIP
Phlebotomist Initials Here
PHYSICIAN When ordering tests, the physician is required to make an independent medical necessity decision with regard to each test the laboratory will bill. The physician also understands he or she is required
NOTICE to (1) submit ICD-9 diagnosis supported in the patients medical record as documentation of the medical necessity or (2) explain and have the patient sign an ABN.

ICD-9 Code(s) Diagnosis: 1) _____________________ 2) _____________________ 3) _____________________ 4) _____________________ 5) _____________________ 6) _____________________


SIGNS AND SYMPTOMS:
ORGAN / DISEASE PANELS GENERAL LABORATORY GENERAL LABORATORY MICROBIOLOGY
Basic Metabolic Panel ANA (titer if indicated) Protein, Electrophoresis, Serum (SPEP) Culture, Grp. B Strep Vag Rectal
(Na, K, Cl, CO2, Gluc, BUN, Creat, Ca) Bilirubin, Direct PSA Screening (see Medicare Screening Box) Culture, Herpes
Comp. Metabolic Panel Bilirubin, Neonatal PSA, Diagnostic (84153) Culture, Sputum w/ gram stain
(Na, K, Cl, CO2, Gluc, BUN, Creat, Ca, Bilirubin, Total PT/INR (85610) Culture, Sputum w/ gram stain, CF Patient
Alb, TBili, APhos, TP, AST, ALT) BNP (B-type Natriuetic Peptide) (83880) PTH Level (83970) Culture, Stool
Electrolyte Panel CA 125 (86304) PTT (85730) (w/Campy, Sal/Shig, E. Coli, and Yersinia)
(Na, K, Cl, CO2) CA 19-9 (86301) Retic Count Beta-Strep Screen, Throat
Hepatic Function Panel CA 27-29 (86300) Rheumatoid Arthritis (RA), quant. Culture, Urine (87086 & 87088)
(Alb, TBili, DBili, APhos, TP, AST, ALT) Calcium (82310) RPR (w/confirmation if indicated) (86592) Clean Catch Cath
Lipid Panel (80061) Carbamazepine (Tegretol) Sed Rate (ESR) (85652) Culture, Wound (87070)
(Chol, Trig, HDL , calc. LDL) Carbon Dioxide (CO2) Sickle Cell HGB Electrophoresis Culture, Anaerobic w/gram
Acute Hepatitis Panel (80074) CBC (w/PLT & Differential) (85025) T3, Total (84479) Source / Site ___________________
(HAAb (IGM), HBcAB (IGM), HBsAG, HCAb) CBC (Hemogram w/o Differential) (85027) T4, Free (Free Thyroxine) (84439)
CCP Antibody Chlamydia Probe
Renal Function Panel Transferrin (84466) Chlamydia / GC Probe
CEA (82378) Triglycerides (84478)
(Na, K, Cl, CO2, Gluc, BUN, Creat, Ca, Alb, PO4) Source / Site ___________________
Cholesterol (82465) TSH (Ultrasensitive) (84443)
Obstetric Panel (CBC a/plt & diff. CK (CPK) Gram Stain (only)
85025, HBSAg 87340, Rubella, RPR 86592, Uric Acid
CRP (High Sensitivity) Valproic Acid STOOL (FECAL)
Blood Type, Antibody screen) Digoxin (Lanoxin) (80162) Vitamin B12 C-Difficile
MEDICARE SCREENING (ABN REQUIRED) Dilantin (Phenytoin)
Ferritin (82728) Vitamin D (82306) Giardia Ag
Cardiovascular Screen Folate, Serum MICROBIOLOGY H. Pylori Ag
(Includes: Cholesterol, Triglycerides and GGT (82977) Ova & Parasite
HDL Freq., Covered every 5 years (ABN Glucose, Serum (82947) (Culture ID & Sensitivity if indicated) ROTAG
Required) Glucose Tolerance ______ hrs Lactoferrin
H. Pylori Ab, IgG (Serum) Collection Date _______ Time _______ Shiga Toxin
Dx Requires one (1) of the Dx listed below:
V81.0 Screening for Ischemic Heart Disease HCG, Qual. Culture, AFB sputum w/smear
HCG, Quant. (84702) Culture, AFB other w/smear URINE
V81.1 Screening for Hypertension
V81.2 Screening for Unspecified Cardio. Conditions HDL (83718) Culture, Body Fluid w/gram stain Creatinine Clearance
Hepatitis A Virus, IGM Ab Microalbumin, Urine (Check one below)
Diabetic Screen (Check one below) Hepatitis B Core Ab
Fasting glucose and 2hr post-glucose Source / Site ______________________ Random w/creat. ratio
Hepatitis B Surface Ab (86706) Culture, Fungus UR 24 hour
Glucose Tol. Test (3 spec. incl. fasting) Hepatitis B Surface Ag (w/conf. if positive) (87340)
Freq. Individ. w/pre-diabetes Twice yearly; Culture, GC Vag Cervix Protein, Total Quant.
Hepatitis C Antibody (w/conf. if positive) (86803) Urinalysis (w/microscopic)
Individ. w/o diag. pre-diabetes Once yearly Hgb A1C (glycohemaglobin) (83036) Culture, Genital Vag Cervix
Dx V77.1 Screening for Diabetes Mellitus HIV-1/HIV-2 Ab (w/conf.) (86703**) MISCELLANEOUS TESTS
Occult Blood Screen (1-3 specimens) Homocystine (Serum) (83090)
Freq. Covered Annually (ABN Required) Insulin
Dx No Specific Diagnosis Requirement Iron (83540)
Iron TIBC% (83540, 84466)
PSA Screen (G0103) LDL, Direct
Freq. Covered Annually (ABN Required) Lipase
Dx V76.44 Scrn. for Malig. Neoplas., Prostate) Luteinizing Hormone (LH)
GENERAL LABORATORY Magnesium (83735)
Mono Test
ABO & Rh Occult Blood Screen (see medicare screening box)
AFP (Alpha Fetoprotein) (82105) Occult Blood Diagnostic (82272)
AFP Quad Screen Phosphorus (84100)
Amylase Potassium 16
Rev. 2/10/11 **HIV Consent Required PS42510
MICROBIOLOGY AND VIROLOGY LABORATORIES
Shands at UF, North Tower

Microbiology Section: Room 3164 Virology Section: Room 3101


Hours: 24 hours/7days Hours: MonFri, 6:30 AM 5 PM
Phone: (352) 265-0165 Weekends & Holidays: 8:30 AM 12:30 PM
FAX: (352) 265-0204 (Off-hours, call Microbiology Section)
Phone: (352) 265-0978
Fax: (352) 265-0979

Manager: Patricia Giglio Medical Director: Kenneth H. Rand, MD


Office phone: (352) 265-0165 Office phone: (352) 265-0680, x44875
Pager: (888) 543-1806

Scope of Service: The Microbiology/Virology Laboratories provides full-service Bacteriology, Mycology,


Mycobacteriology, Parasitology, Serology, and Virology testing for Shands at UF hospital and multiple
outpatient facilities. Specimens of blood, body fluids, CSF, surgical biopsies, tissues, wounds, respiratory,
feces, and urine are processed for isolation/identification of potential pathogenic infectious agents.
Antimicrobial susceptibility testing is performed for appropriate organisms/sources.

SEE OUTPATIENT REQUEST FORM (PS42510) ON THE PRECEDING PAGE.

Collection Guidelines

Each specimen should be considered potentially infectious; handle using Standard Precautions.
Extra precautions must be taken for CSF with suspected CJ Disease/please contact the Micro
Lab.

Each specimen requires collection in a STERILE and tightly capped/sealed container to avoid
leakage, and possible rejection of specimen due to contaminated exterior of container.

Specimens requested for Anaerobic Culture should optimally be collected in the Anaerobic
Transport tubes.

BLOOD CULTURES for bacteria consist of one (1) Silver labeled AEROBIC bottle and one(1)
Purple labeled LYTIC bottle, with recommended blood volume of 8-10mls each.
PEDIATRIC draws (1-3 mls) can be inoculated into a Pink-labeled PEDS PLUS (aerobic) bottle.

When ordering microbiology test(s) and test(s) for other Lab sections (e.g., Cytology), whenever
feasible (e.g., urine specimen), please provide 2 separate containers one designated for
microbiology testing (i.e., urine culture), and the other for the additional tests. Affix appropriate
labels on each container.

Tissue samples for bacterial culturing MUST NOT be placed into formalin fixative. Send the
samples in a dry sterile container or with 1-5 ml of sterile saline solution in a sterile container to
the Microbiology Laboratory directly.

17
Instructions for Microbiology Specimen Collection and Transport
Specimen Collection Equipment Transport Instructions (Comments)
Anaerobe Optimum recovery of anaerobes Do not refrigerate. Use 1. Avoid all 02 exposure.
occurs with tissue or curetting, anaerobe transport 2. Use Ana transport tubes or expel air
which can be placed into the tube or syringe without from syringe.
anaerobic collection container. needle. 3. DO NOT submit needle-syringe;
Aspirates collected in syringe syringe with cap only.
(submitted without needles) are 4. Label properly.
the next best specimen. Swabs 5. Send two tubes if STAT gram stain is
are the least likely to yield requested.
clinically relevant results. 6. Deliver promptly to lab.
Blood/ Bactec Blood culture collection Aer F & Ana Lytic F 1. Decontaminate puncture site -
Bone kit. Needle & syringe. bottles require 8-10 mL Hibistat.
Marrow blood/bottle. May use 2. Do not palpate disinfected site.
minimum of 3 mL. [all 3. Decontaminate bottle stopper with
resinated] Peds Plus /F Hibistat.
bottles used for short 4. Label properly.
draws (1-3mLs) Do NOT 5. Deliver promptly to lab.
REFRIGERATE.
CSF Surgical prep & collection by Transport in CSF 1. Surgical prep of puncture site
physician. collection tube. DO NOT refrigerate.
2. Obtain 4-5 mL (optimal for adults) 0.5-
1.0 mL for children
3. Handle as EMERGENCY specimen;
hand carry to laboratory.
4. One tube only, send to bacteriology
first. Second and/or third, routinely to
bacteriology
5. Label properly.
6. Deliver promptly to lab.
Ear Aspirate from Transport medium 1. Clean external ear surface.
tympanocentesis. Swab of 2. CAREFULLY culture representative
drainage. area.
3. Label properly.
4. Deliver promptly to lab.
Eye Swab (small) for each eye Transport medium 1. Do not touch external skin.
Corneal scrapping (by 2. Obtain maximum material.
physician). 3. Label properly.
Feces Clean or sterile collection cup. Refrigerate if not 1. Best specimen is diarrhea stool.
Swab (only if necessary) May processed within 1 hour 2. Swab is satisfactory in acute
use clean vial of 2-vial kit for cases but not necessary for routine
Parasitology. 1 specimen/day specimens.
No culture accepted after 3rd 3. Insert swab beyond anal sphincter.
hospital day. Swab must show feces.
4. Label properly.
5. Deliver promptly to lab.
Feces for Clean vial; no preservative 1. Label properly.
Lactoferrin (5grams) 2. Deliver promptly to lab.
Genital Swab. 1. Collect culture with a swab inserted
through a speculum.
2. Avoid touching swab to uninfected
surfaces.
3. Clean external urethra before taking
urethra specimen.
4. For GC, inoculate TM at bedside, if
possible.
5. Label properly.
6. Deliver promptly to lab.

18
Instructions for Microbiology Specimen Collection and Transport (cont.)
Specimen Collection Equipment Transport Instructions (Comments)
Nasopharynx Calcium alginate swab Do not refrigerate 1. Nasal speculum helpful.
Transport medium. 2. Pass through the nose into nasopharynx.
3. Allow to remain for a few seconds.
4. Carefully withdraw.
5. Label properly.
6. Deliver promptly to lab
Nose Swab Transport medium. 1. Swab anterior nares only.
2. Culture quickly.
3. Label properly
4. Deliver promptly to lab
Sinus Swab (small) Transport medium 1. Insert and removequickly.
2. Label properly
3. Deliver promptly to lab.
Sputum Sterile cup (Minimum 5mL) Refrigerate if needed. 1. Carefully instruct pt. to cough deeply
Transport in collection (not to spit)
cup. 2. First morning specimen is best. (no 24hr
collection)
3. Transport immediately: seal container
tightly.
4. Consider sputum contaminated with TB.
5. Label properly
6. Deliver promptly to lab.
Throat Swab Transport medium if 1. Use tongue blade.
more than 2hr delay 2. Sample only back of throat between &
around tonsil area thoroughly.
3. Avoid cheeks, teeth etc.
4. Label properly
Urine Sterile screw cap cup or Transport in collection 1. Give patient clear & detailed instructions.
transport tube/media/vial container. Refrigerate 2. Clean with soap, not disinfectant.
(Minimum 10 mL) quickly. 3. Refrigerate no longer than 24 hrs. prior
to culture.
4. Seal container tightly.
5. Label properly
6. Deliver promptly to lab.
Superficial Sterile container, swab/ Transport to lab quickly. 1. Disinfect surface with Hibistat.
Wound syringe 2. Aspirate deepest portion of lesion.
3. Swab affected area. Crush ampule of
culturette.
4. Send to lab immediately.
Burn Sterile container; swab Transport to lab quickly. 1. Disinfect surface with Hibistat.
Wound 2. Swab area - crush ampule of culturette.
Send to lab.
3. Use dermal punch. Obtain 3-4mm punch
bx. No Formalin. Deliver promptly to lab.

Serology specimens

TEST ACCEPTABLE SPECIMEN UNACCEPTABLE SPECIMEN


Cryptococcal Antigen Serum or CSF (1mL)

Legionella Antigen Urine (10mL) 24 hr urine


Test
Mono Serum (1mL) hemolyzed,
markedly lipemic, contaminated serum

19
GC and Chlamydia by DNA Testing Collection Procedure
The BDProbeTec ET System is designed to detect the presence of Chlamydia trachomatis and Neisseria gonorrhoeae in
endocervical swabs, male urethral swabs and male and female urine specimens using the appropriate collection method.
Endocervical
Collection Endocervical Specimen Collection:
Use the BD ProbeTec Cleaning - Collection and Transport System
Remove excess mucus from the cervical os with the large-tipped cleaning swab provided in the
BD ProbeTec Cleaning-Collection and Transport System and discard.
Insert the BD ProbeTec collection swab into the cervical canal and rotate for 15 - 30 sec.
Withdraw the swab carefully. Avoid contact with the vaginal mucosa.
Immediately place the cap/swab into the transport tube. Make sure the cap is tightly secured to
the tube.
Label the tube with patient information and date/time collected.

Urethral
Collection Male Urethral Specimen Collection:
Use the Mini-Tip BD ProbeTec Collection and Transport System
Insert the Mini-Tip BD ProbeTec swab 2 - 4 cm into the urethra and rotate for 3 - 5 sec.
Withdraw the swab and place the cap/swab into the transport tube. Make sure the cap is tightly
secured to the tube.
Label the tube with patient information and date/time collected.

Urine
Collection Urine Specimen Collection:
The patient should not have urinated for at least 1 h prior to specimen collection.
Collect specimen in a sterile, plastic, preservative-free specimen collection cup.
The patient should collect the first 15 - 20 mL of voided urine (the first part of the stream - not
midstream).
NOTE: During the clinical evaluation, testing urine volumes up to 60 mL was included in the
performance estimates.
Label with patient identification and date/time collected.

Specimen The BD ProbeTec collection swab and the Mini-Tip BD ProbeTec collection swab must be
Transport transported to the laboratory within 4-6 days of collection if stored and transported at 2-27C.
If specimens are refrigerated at 2-8C after collection and during transport, then they can be
submitted up to 10 days after collection. Urine specimens can be stored and transported to
the test site at 2-30C within 24 hours. Otherwise all urine specimens should be stored and
transported at 2-8C.
Shipping The BD ProbeTec collection swab, the Mini-Tip BD ProbeTec collection swab, and urine
Instruction specimens must be shipped in an insulated container on ice (cold packs) by either an overnight
or 2-day delivery vendor.
Specimen
Rejection Specimens will be rejected for any of the following reasons.
Swabs or tissue not submitted in correct collection container.
Specimens not labeled with the patients correct name and medical record number.
Specimens from a patient on any type of isolation, which are not properly bagged and labeled with
the isolation precautions.
Specimens that are leaking out of their containers.

20
BD ProbeTec Cleaning - Collection and Transport System

Mini-Tip BD ProbeTec Collection and Transport System

21
Sterile Urine Container

Collection and Handling of Specimen for Virus Isolation

All specimens must be delivered to the specimen accession window, room 3164 or to the Diagnostic
Virology Lab, room 3101, within thirty minutes. All specimens for culture are to be put on ice or
refrigerated immediately. Specimens must be labeled with the patients name and medical record number
and must be accompanied by order labels and/or a completed Order Request form. Physicians or nurse
should collect all specimens using aseptic technique and the following specifications (on the next page):

22
Sterile containers, clean-catch mid-stream, or catheterized specimens only.
Urine
Order test: vcur

Obtain specimen with flocked swab contained in the Viral Transport pack. After
specimen collection, insert the swab into the liquid Viral Transport medium and
then break off the end carefully. Cap the vial securely to avoid leakage. When
swabbing a lesion, it is best to scrape the base of a fresh lesion after lancing,
using sterile techniques.
NP and
Lesion
Order test RVPCRB for NP, NP WASH, NP Aspirates, BAL, and Throat
specimens; VCLES for lesions; VCEYE for eye swab; or VCGEN for genital
specimens.

If any specimen is to be tested for Herpes only, order VCHSV.

Submit in a sterile container (no additive) or obtain specimen with flocked swab
contained in the Viral Transport pack. Partially insert swab into transport medium
and break off the end, trying not to contaminate the part of the swab going into
the media. Replace the cap tightly to avoid leakage.
Stool
If unable to obtain stool, using Viral Transport media and a swab as above,
collect rectal swab with visible amount of stool.

Order vcst

(CSF, Pleural, etc...) 1 .0 to 5 .0 mL in a sterile tube


Sterile
Fluids
Order test vccsf for CSF and vcasp for other source of body fluids

Place in Viral Transport Media


Tissues
Order vcbx

Collect bone marrow in green top (heparin) tube and mix well. Hold at room
Bone Marrow temperature and deliver to Virology lab immediately upon collection. Only available
(Buffy coat- from 8:00 am to
WBC culture) 2:00 pm, Monday through Friday.

Order vcbm

23
Viral Transport Media (Star Swab)

Viral
Transport Viral Transport packs are available from Owens and Minor or CDC (Hospital Store
Media #1300910) and should be available at all inpatient nursing units.

Specimens will be rejected for any of the following reasons.

Specimen Cultures left unrefrigerated for more than 2 - 3 hours.


Rejection Swabs or tissue not submitted in viral transport media.
Specimens not labeled with the patients correct name and medical record number.
Specimens that are leaking out of their containers.

For submission of requests for Varicella zoster and


Herpes simplex tests by direct fluorescent assay
(DFA), 2 slides should submitted for each test. The
procedure for preparing slides is as follows:

Lance lesion using sterile procedures and use a sterile


swab to obtain cellular material from the base of the
lesion, then make dime-sized smears on the slides.

The slides should be labeled with the patient


information and placed back-to-back in a sterile urine
container before transporting to the laboratory.

24
TRANSFUSION SERVICE (BLOOD BANK)
Shands at UF, South Tower

Hours of Operation: 24 hours/7 days


Telephone: (352) 733-0900
Fax: (352) 733-0812
Blood Bank Supervisor-on-Call: (352) 260-3358

Manager: Belinda Manukian (Interim) Medical Director: Juan Scornik, MD


Cell # (352) 260-8806 Pager: (352) 413-7508

Scope of Service: The blood bank department provides a wide span of immunohematology services using
the most advanced technology to assist the physician in obtaining quality test results as well as quality blood
products for the patient. Numerous blood products are available to the ordering physician in order to manage
the diversified group of patients that are encountered here at Shands Cancer Hospital at the University of
Florida.

Services offered:

Blood Bank Laboratory Tests


Blood Products
Pathology Consultations

Related Service:
Autologous/Directed Donations

Additional Requirements:

Samples for transfusion compatibility testing require a 3rd identifier in the form of a Blood Bank ID#
derived from Blood Bank ID band.

For type and cross or type and screen tests performed in the Blood Bank, the specimen must be sent
with a completed Time Out Verification Form (100030156) to be accepted for testing.

Samples with any errors or missing information on the specimen label or verification form will be
rejected.

SEE TIME OUT VERIFICATION FORM (100030156) ON THE NEXT PAGE.

25
Transfusion Services Time Out Verification Form
Instructions: Each person participating in the Time-Out Verification process shall place their initials in the appropriate
boxes as the collector or the verifier, and print and sign their name, along with their Employee ID #. Each persons initials
and signatures attests that they have stopped together at the patient bedside to complete each step of the Time-Out
Verification process.

Correct labeling examples:


Initial Specimen

Subsequent Samples

h Initial Blood Band Application h Subsequent Blood Bank Specimen

Steps MUST BE DONE AT BEDSIDE Collector Initials Verifier Initials


A. Patient identified with Name and MRN
(compare Patient ID band with the preprinted patient
label placed on this form)
B. Blood Band name and MRN match Patient ID band
exactly

C. Label on Specimen tube matches Name and MRN

D. Blood Band ID number (alpha-numeric yellow sticker)


on specimen tube matches patients Blood Band ID

E. Date / Time / Initials on Specimen

Blood Bank ID# __________________________________ Patient Location

I verify this patients identification ______________________________________________________________ Clinical Care Provider


(Print / Signature / Employee ID # [SUF Only])

I am the second verifier of this patients identification


(Print / Signature / Employee ID # [SUF Only]) (Clinical Care Provider)

Date / Time __________________ / __________________

Patient Name: Patient Identification #:

*LA0002* LA0002
Approved 2/25/08
Transfusion Services Time Out Verification Form - CP 02.051 Revised 8/17/11
Distribution: White With specimen to Transfusion Services; Yellow Patient Chart 100030156
26
CYTOLOGY LABORATORY
Hours of Operation:
Laboratory at Rocky Point M F 8:00 AM 4:30 PM

Telephone: (352) 265-0172 ext. 7-2120


Fax: (352) 265-6935
FNA at SUF North Tower 8:30 AM 3:30 PM; pager (352) 413-6834
FNA at SUF South Tower 8:30 AM 3:30 PM; pager (352) 413-5351
After-hours: Page Resident-on-Call (352) 413-6266

Manager: Mary Reeves Medical Director: Larry J. Fowler, MD


Cell # (352) 318-9110 Pager: (352) 413-1620

Scope of Service: The function of the Cytology Laboratory is to evaluate exfoliated cells for abnormalities.
These abnormalities include the presence of cancer, precancerous conditions, infection due to fungus,
virus, parasites, bacteria, etc. The cytology services include processing, evaluating, and performing
diagnostic interpretation on the specimens submitted. All specimens are examined and interpreted by the
cytotechnologists and given to the pathologist for review and final diagnosis. The cytology laboratory staff
assists in Fine Needle Aspirate (FNA) procedures in various areas stationed only in Shands at UF and only
during regular hours. Residents are available for questions but do not assist with FNA slide preparation and
assessment of adequacy.

STAT specimens are processed between 7 am and 3 pm. Contact Lab Customer Service at (352) 265-0522
for rush pick-up and delivery to Rocky Point. After hours, contact resident on-call at (352) 413-6266.

Collection Guidelines (other than Fine Needle Aspiration)


1) Contact laboratory before obtaining CSF specimen on patient suspected to have CJ disease.
2) All specimens must be capped/sealed tightly.
3) When ordering cytologic evaluation and tests for other labs, whenever feasible, please provide
a separate specimen for Cytology Laboratory. If one specimen is to be shared between two
laboratories, please indicate so.
4) Refrigerate specimens that cannot be sent immediately.

Breast Secretions: Secretion from the nipple can be obtained in up to 70% of women who have borne children.
There are two procedures that are acceptable for handling of the breast cytology specimen. They are as follows:

1. Six slide technique: Secretion from the nipple is expressed on six slides, labeled with the patients
last name. As the drop of secretion appears, the first slide is gently brought to the drop and the
secretion is smeared on the slide using a slide push technique as employed in Hematology. In this
technique, a second slide is simply brought up to the drop, the drop is permitted to spread across
the joining edges of the slide and, at that point, the forwarding slide is pushed across the surface
smearing the sample. The sample is immediately placed into 95% alcohol or sprayed using an
appropriate fixative, being certain the spraying nozzle is at least 12 inches away from the sample.
2. Breast secretion employing the cytocentrifuge technique: Collection of the sample employing
these technologies requires that the sample preferably be collected fresh in a clean covered
container and submitted directly to the section of Cytopathology. In these cases at least 2
mL of sample is generally required to perform cytologic evaluation. If the sample cannot be
submitted directly to Cytopathology, the sample must be refrigerated until it can be delivered
to Cytopathology. The sample should be submitted to the section of Cytopathology with the
appropriate requisition form.
3. Fine needle aspiration may also be used for breast masses.

Corneal (eye): Samples are collected by the ophthalmology clinicians and submitted as air-dried smears
often requesting GMS (silver) stains. The slide, which must have the patients name written on the frosted
end, is given an accession number and submitted to Histology for a Gomori methanamine silver stain (when
requested) and evaluated for the presence of fungi.
(continued on next page)
27
(CORNEAL (EYE): (cont.)

If the request states Rule out acanthamoeba the protocol established for this laboratory by the medical
director is that the submitted slide should be stained with Gomori methanamine silver stain fungal
stain with a light green counterstain to detect both acanthamoeba and fungal organisms. (Ref: Medical
Microbiology p 1178)

Fluid samples from the eye should be transported immediately to the Cytopathology lab for process or, if
delayed, refrigerated.

Effusions-Ascites, Pleural OR Pericardial: If a specimen can be transported promptly to the lab, we prefer
the fresh fluid. If it cannot be brought immediately, add 3 units of heparin per mL of fluid as precaution
against clotting, and place in refrigerator until it can be delivered. We prefer at least 30 mL of sample or more
if possible.

Female Genital Tract Cervical Vaginal Conventional Cytology: The patients last name MUST be printed
in pencil on the frosted end of the slide BEFORE the smear is taken and spread. An endocervical brush
aspirate is recommended unless the patient is pregnant. The endocervical sample should be obtained and
placed on the slide before the cervical scrape is made with the spatula, or placed on a separate slide. Obtain
the cervical scraping from the complete transformation zone by rotating the spatula 360 degrees around
the cervix at least twice. Spread the material obtained in a rotating clockwise fashion, with the spatula, on
the clear end of the slide and place immediately in 95% ethanol or spray IMMEDIATELY with an appropriate
fixative, keeping the spray nozzle 12 inches from the slide surface. DO NOT ALLOW SMEAR TO AIR DRY!!
Please supply pertinent clinical information, especially patients age and menstrual history. A vaginal pool
sample is rarely of value in screening for cervical carcinoma.

ThinPrep Paps: Obtain an adequate sample. (See ThinPrep or SurePath Pap kits for detailed collection
information.) Rinse spatula/broom in preservative solution and discard collection device. Tighten the cap
on vial and label with the patients name before placing in transport bag. HPV, GC and CT testing is now
available.

Gastrointestinal Tract: Brushing or aspirated material may be smeared directly on slides, which should
have the patients last name printed in pencil on one end. The smears should be fixed IMMEDIATELY in 95%
ethanol and the slides brought to Cytopathology. The brush used in the procedure may be submitted in a
small (10 ml) amount of saline or ThinPrep/SurePath preservative fluid provided by lab for processing with
prepared slides.

Respiratory Tract: Sputum - Instruct the patient to cough deeply (from the diaphragm) to expectorate a
deep cough specimen and not saliva. We prefer a fresh unfixed sample or the specimen may be refrigerated
until it can be delivered to the Cytopathology lab. For best results, a series of early morning specimens
should be submitted each morning for 3 consecutive days.

Bronchial: Send fresh bronchial secretions or washings to lab immediately or refrigerate until specimen can
be delivered to Cytopathology for processing.

NOTE: Bronchoalveolar lavage is preferred for detection of Pneumocystis carinii.

If slides are made, print the patients name with pencil on one end of all-frosted slides, smear brushing or
aspirated material and fix the slide immediately in 95% ethanol. DO NOT ALLOW SMEAR TO AIR DRY!! The
brush may also be placed in saline and submitted. Do not forget to send three post-bronchoscopy sputum
specimens to the lab, obtained over the next 3 days. These are rich in exfoliated cells from the bronchial
epithelium and are of great diagnostic value.

Spinal Fluid: Bring the fresh specimen PROMPTLY to the Lab for processing. A sample size of at least
1-3 mL is needed. If a lymphoproliferative disorder is suspected, submit the CSF to Hematopathology for
analysis.

28
Urinary Tract: For Cancer Detection - Send fresh urine or bladder washing immediately to the Cytopathology
Lab, please indicate whether specimen is voided or catheterized urine or bladder washing. If specimen
cannot be brought immediately to the lab, it MUST be refrigerated.

For Cytomegalic Inclusion Disease (CMV) Detection Fresh urine should be sent IMMEDIATELY to the
Cytopathology Lab after collection. A 5 mL minimum volume is required.

For Polyoma (BK virus) cytologic changes Follow procedure for urines above.

Virology Testing Note: PCR testing in Virology is the preferred method of detection for BKV and CMV. BKV
and CMV are performed on plasma specimens, and BKV is also done on urine specimens.

Wound or Lesion Scrapes: Print patients last name with pencil on one end of all-frosted slide, scrape the
wound with moistened tongue blade and place the material directly on slides. Place the slides IMMEDIATELY
in 95% ethanol, or spray with an appropriate fixative, keeping the spray nozzle 12 inches away from the slide
surface. If the wound is hard and crusted it should be soaked with warm saline prior to obtaining the scrape.

Virology Testing Note: Tzanck smears for viral changes are unreliable and non-specific. Virology testing is
recommended.

Guideline for Fine Needle Aspiration

Purpose: The purpose of Fine Needle Aspiration is to obtain diagnostic cells from a designated site without
using open biopsy techniques.

Principle: Tissue is obtained from a specific anatomic site with or without the aid of radiological assistance.
The tissue is evaluated at the site to ensure that diagnostic tissue has been obtained.

Specimen: Fine needle aspiration of masses for cytological examination.

Safety Note: All speciments must be submitted in closed containers, properly labeled, and transported in
biohazard bags!

Smears: When submitting non-Gyn smears it is important to indicate which are spray-fixed and which are air-
dried, as these are handled differently.

Sputum: In cases where a sample is to be shared between Cytology and Microbiology, a cytology request
form should accompany the specimen to the lab.

EACH SPECIMEN IS TO BE SUBMITTED WITH AN APPROPRIATE ORDER FORM:

CYTOLOGY NON-GYN REQUEST FORM (PS86250) (SEE PAGES 30), OR


CYTOLOGY GYN REQUEST FORM (PS40994) (SEE PAGES 31 AND 32)

29
Page 1 of 1
Send To:
Cytology h Shands Medical Laboratories at Rocky Point h Shands at the University of Florida
Non-GYN 4800 SW 35th Drive Gainesville, FL 32608 1600 SW Archer Road PO Box 100344 Gainesville, FL 32610-0344
Request Phone: (352) 265-0522 Fax (352) 265-9910 Phone: (352) 265-0412 Fax (352) 265-0328
CLIENT INFORMATION REFERRING PHYSICIAN (PLEASE PRINT IN BLACK INK) PATIENT INFORMATION
PT LAST NAME FIRST MI

MEDICAL ACCOUNT #
RECORD #
ADDRESS BIRTHDATE SEX: h M h F

CITY PT SSN

STATE ZIP HOME PHONE

EMPLOYER WORK PHONE


REFERRING PHYSICIAN SIGNATURE
WORK ADDRESS CITY STATE ZIP
INSURANCE BILLING INFORMATION (PLEASE PRINT IN BLACK INK)
PRIMARY: h Medicare h Medicaid h Other Ins. h Self h Spouse h Dependent PT LOCATION / CLINIC
SUBSCRIBER FIRST MI
LAST NAME
BENEFICIARY/ GROUP # COLLECTION REPORTING INFORMATION
MEMBER #
CLAIMS ADDRESS CITY STATE ZIP h FAX results to COPY to

SECONDARY: h Medicare h Medicaid h Other Ins. h Self h Spouse h Dependent h CALL results to
SUBSCRIBER
LAST NAME
FIRST MI Date Collected Time Collected
BENEFICIARY/ GROUP #
MEMBER # h AM h PM
CLAIMS ADDRESS CITY STATE ZIP
h STAT
NON-GYN CYTOLOGY: Label specimen container with the patients name, MRN# or DOB, and site of specimen.
Specimen / Exact Anatomical Source(s): (FNA Fine Needle Aspirates)
Body Cavity Fluid: (type) _______________________________________________ Abdominal
CSF: __________________________________________________________________ Breast
Eye / Corneal Scrape: __________________________________________________ Comon Bile Duct
Respiratory: (type) _____________________________________________________ Liver
Other: (specify) ________________________________________________________ Lung
Lymph Node
Urine Specimens:
Neck
Source: Voided Catheterized Bladder Wash
Pancreas
Other: _____________________________________________
Pelvic
Cytology Only
Thyroid
Cytology with Reflex to Bladder Cancer Testing by UroVysion FISHTM if
Other: (specify) ___________________________________________________
indicated (if atypical, dysplastic and suspicious)
Bladder Cancer Testing by UroVysion FISHTM
Additional Status:
- CMV - Fe - Oil Red O - PCP - Fungus - Other:

Clinical History (to be completed by Physician, ARNP, or other provider):

Radiology Findings:

PHYSICIAN When ordering tests, the physician is required to make an independent medical necessity decision with regard to each test the laboratory will bill. The physician also understands he or she is required
NOTICE to (1) submit ICD-9 diagnosis supported in the patients medical record as documentation of the medical necessity or (2) explain and have the patient sign an ABN.

ICD-9 Code(s) Diagnosis: 1) _____________________ 2) _____________________ 3) _____________________ 4) _____________________ 5) _____________________ 6) _____________________

SIGNS AND SYMPTOMS:

*The patient must sign a waiver that states he or she understands that Medicare will deny payment for this / these laboratory test(s)
unless the diagnosis code(s) is / are federally acceptable as medically necessary. See Advance Beneficiary Notice.

I hereby authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries
or carriers any information needed for this or a related Medicare / Medicaid claim. I permit a copy of this authorization to be used in place
of the original and request payment of medical insurance benefits to the party who accepts assignment.

X Patient Signature ____________________________________________________________________________________________________________


Rev. 10/27/09 PS86250
30
Page 1 of 2

Send To:
Cytology h Shands Medical Laboratories at Rocky Point h Shands at the University of Florida
GYN 4800 SW 35th Drive Gainesville, FL 32608 1600 SW Archer Road PO Box 100344 Gainesville, FL 32610-0344
Request Phone: (352) 265-0522 Fax (352) 265-9910 Phone: (352) 265-0208 Fax (352) 338-9889
CLIENT INFORMATION REFERRING PHYSICIAN (PLEASE PRINT IN BLACK INK) PATIENT INFORMATION
PT LAST NAME FIRST MI

MEDICAL ACCOUNT #
RECORD #
ADDRESS BIRTHDATE SEX: h M h F

CITY PT SSN

STATE ZIP HOME PHONE

EMPLOYER WORK PHONE


REFERRING PHYSICIAN SIGNATURE
WORK ADDRESS CITY STATE ZIP
INSURANCE BILLING INFORMATION (PLEASE PRINT IN BLACK INK)
PRIMARY: h Medicare h Medicaid h Other Ins. h Self h Spouse h Dependent
SUBSCRIBER FIRST MI COLLECTION REPORTING INFORMATION
LAST NAME h FAX results to h COPY to
BENEFICIARY/ GROUP #
MEMBER #
CLAIMS ADDRESS CITY STATE ZIP
h CALL results to
SECONDARY: h Medicare h Medicaid h Other Ins. h Self h Spouse h Dependent Date Collected Time Collected h AM h PM
SUBSCRIBER FIRST MI
LAST NAME

h STAT
BENEFICIARY/ GROUP #
MEMBER #
CLAIMS ADDRESS CITY STATE ZIP

GYN SPECIMEN GYN REQUIRED MEDICAL NECESSITY INFORMATION


(1) Specimen Preparation (Please select only one): SCREENING PAP
Slide from spatula and/or brush Thin Prep V76.2 Routine cervical PAP smear without gyn exam **
V72.31 Annual/Routine PAP smear with gyn exam **
Sure Path V72.32 Follow-up of normal PAP with history of previous abnormal
V76.47 Routine PAP smear-vagina (patient w/out cervix) **
V22.1 Supervision of normal pregnancy, other
(2) HPV Testing (Please select only one): V22.0 Supervision of normal first pregnancy
HPV Only V22.2 Pregnancy, incidental, NOS
HPV reflex for ASC-US age 20 and over V73.81 Screening exam for HPV
V73.88 Screening exam for Chlamydia disease
HPV concurrent age 30 and over V74.5 Screening sexually transmitted disease (NG)
HPV concurrent under the age of 30 (insurance may not cover)*** **Must obtain Advance Beneficiary Notice for Medicare patients
HPV declined DIAGNOSTIC PAP
*** Advanced Beneficiary Notice suggested. 622.10 Unspecified dysplasia of cervix
622.11 Mild dysplasia of cervix
622.12 Moderate dysplasia of cervix, CIN 2
(3) Anatomical Source(s): Cervix/Endocervix 233.1 Severe dysplasia, carcinoma in-situ, CIN 3
Vagina Vaginal cuff Anal Other ____________________________________________ 623.0 Dysplasia of vagina, VAIN 1 & 2
569.44 Dysplasia of anus, AIN 1 & 2
230.6 Severe dysplasia of anus, carcinoma in-situ, AIN 3
(4) Reason for Pap Smear (Please select only one): 616.10 Vaginitis & vulvovaginitis, unspecified
Routine Screening Follow-up of abnormal PAP Test (Diagnostic) 616.0 Cervicitis and endocervicitis
627.3 Postmenopausal atrophic vaginitis
Previous PAP Showing: 626.8 Other disorders of menstruation and other abnormal bleeding
ASCUS Low Grade SIL Reactive/reparative 627.1 Postmenopausal bleeding
626.6 Metrorrhagia
Carcinoma High Grade SIL History of AGUS
626.2 Excessive or frequent bleeding

(5) Clinical History: Last Pap _______________________ LMP __________________________ Previous nonspecific abnormal test
Abnormal glandular cells, (AGC-NOS)
Clinical Hx: Pregnant Clinical Procedures 795.00 Cervix 795.10 Vaginal 796.70 Anal
Abnormal bleeding Previous radiation Biopsy Low grade intraepithelial lesion (LSIL)
795.03 Cervix 795.13 Vaginal 796.73 Anal
Bilat tubal ligation Other Chemotherapy
Atypical squamous cells (ASC-US)
High risk Colposcopy 795.01 Cervix 795.11 Vaginal 796.71 Anal
Hysterectomy Drugs/Hormones Conization High grade intraepithelial lesion (HSIL)
795.04 Cervix 795.14 Vaginal 796.74 Anal
IUD Birth Control Pills Cryosurgery Aytpical squamous cells not excluding high grade sq. intraepi. lesion (ASC-H)
Oophorectomy Estrogen Laser treatment 795.02 Cervix 795.12 Vaginal 796.72 Anal
Post / menopausal Progesterone LEEP High risk HPV DNA positive
795.05 Cervix 795.15 Vaginal 796.75 Anal
Post menopausal bleeding Depo Provera Radiation Therapy Atypical squamous cells & low risk HPV pos
Postpartum Other: ________________ Other: ______________________ 795.09 Cervix 795.19 Vaginal 796.79 Anal
Cytologic evidence of malignancy
795.06 Cervix 795.16 Vaginal 796.76 Anal
(6) Infectious Disease Testing (Select if applicable):
N. Gonorrhea (NAT) Nucleic Acid Test Previous Malignant Neoplasm: See reverse side for additional codes:
180.9 Malignant neoplasm of cervix _______ Other (fill in ICD-9 code)
Chlamydia Trachomatis (NAT) Nucleic Acid Test 183.0 Malignant neoplasm of ovary
184.4 Malignant neoplasm of vulva
182.0 Malignant neoplasm of uterus, corpus uteri
Source:
Liquid base PAP Urine
NOTE: Please refer to Journal of Lower Genital Tract Disease 2007; 11(4):201-222 OR AJOG 2007; 348-355; for guidelines on testing for HPV. HPV testing is not recommended if the test is ASCUS favor high-
grade squamous lesion (ASC-H), LSIL, HSIL, AGC-US, or carcinoma. You may also visit www.asccp.org for additional information.
Label specimen container with patients name, MRN# or DOB, and site of specimen.
PHYSICIAN When ordering tests, the physician is required to make an independent medical necessity decision with regard to each test the laboratory will bill. The physician also understands he or she is required
NOTICE to (1) submit ICD-9 diagnosis supported in the patients medical record as documentation of the medical necessity or (2) explain and have the patient sign an ABN.
ICD-9 Code(s) Diagnosis: 1) _____________________ 2) _____________________ 3) _____________________ 4) _____________________ 5) _____________________ 6) _____________________

SIGNS AND SYMPTOMS:


Rev. 12/22/09 PS40994
31
Page 2 of 2

*The patient must sign a waiver that states he or she understands that Medicare will deny payment for this / these laboratory test(s)
unless the diagnosis code(s) is / are federally acceptable as medically necessary. See Advance Beneficiary Notice.

I hereby authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries
or carriers any information needed for this or a related Medicare / Medicaid claim. I permit a copy of this authorization to be used in place
of the original and request payment of medical insurance benefits to the party who accepts assignment.

X Patient Signature ____________________________________________________________________________________________________________

*This is not an exclusive list of Diagnosis Codes for GYN specimens. Write the appropriate code(s) on the front of the form under Other selection.

ADDITIONAL CODES 621.30 Endometrial hyperplasia, unspecified 795.09 Other abnormal PAP smear of cervix and cervical HPV
042 Human Immunodeficiency virus (HIV) infection 621.32 Complex endometrial hyperplasia without atypia 795.1 Abnormal PAP smear of other side (not cervix)
158.9 Malignant neoplasm of peritoneum, unspecified 623.5 Noninflammatory disorder of vagina, leukorrhea 995.50 Child abuse, unspecified
180.0 Malignant neoplasm of endocervix 625.0 Pain and other symptoms assoc. with female 955.53 Child abuse, sexual
180.1 Malignant neoplasm of exocervix genital organs, dyspareunia 955.54 Child abuse, physical
180.8 Malignant neoplasm of other specified sites of 625.3 Pain and other symptoms assoc. with female 955.59 Other child abuse and neglect
cervix genital organs, dysmenorrhea V01.6 Contact with or exposure to venereal disease
183.2 Malignant neoplasm of fallopian tube 625.9 Pain and other symptoms assoc. with female V07.4 Hormone replacement therapy (postmenopausal)
183.8 Malignant neoplasm of other specified sites of genital organs, unspecified V08 Asymptomatic human immunodeficiency virus
uterine adnexa 626.0 Absence of menstruation (HIV) infection status
184.0 Malignant neoplasm of vagina 626.4 Irregular menstrual cycle V20.2 Routine infant or child health check
184.8 Malignant neoplasm of other specified sites of 627.2 Symptomatic menopausal of female climactic V25.09 Encounter for contraceptive management, general
female genital organs states counseling and advice, other
218.9 Leiomyoma of uterus, unspecified 789.00 Other symptoms involving abdomen and pelvis, V25.3 Encounter for contraceptive management,
221.2 Benign neoplasm of vulva abdominal pain, unspecified menstrual regulation
233.30 Carcinoma in situ of other and unspecified female 789.01 Other symptoms involving abdomen and pelvis, V25.9 Unspecified contractive management
genital organs abdominal pain, right upper quadrant V67.01 Follow-up vaginal PAP smear
233.31 Carcinoma in situ of vagina 789.02 Other symptoms involving abdomen and pelvis, V70.0 Routine general medical exam at a health care facility
233.32 Carcinoma in situ of vulva abdominal pain, left upper quadrant V74.5 Special screening exam for bacterial and
595.0 Acute cystitis 789.03 Other symptoms involving abdomen and pelvis, spirochetal diseases, venereal diseases
616.81 Mucositis (Ulcerative) of cervix, vagina, and vulva abdominal pain, right lower quadrant V76.49 Special screening for malignant neoplasms, other
616.89 Other inflammatory diseases of cervix, vagina 789.04 Other symptoms involving abdomen and pelvis, sites (not cervix or vagina)
and vulva abdominal pain, left lower quadrant V88.01 Acquired absence of both cervix and uterus
620.2 Noninflammatory disorders of unspecified ovarian 789.30 Abdominal or pelvic swelling, mass, or lump, V88.02 Acquired absence of uterus with remaining
cyst unspecified site cervical stump
V88.03 Acquired absence of cervix with remaining uterus

32
SURGICAL PATHOLOGY
Shands at UF, North Tower

Hours of Operation: M F 7:30 AM 5:00 PM

Telephone: (352) 265-0208


Fax: (352) 265-1110
After-hours: Page Resident-on-Call (352) 413-6266

Manager: Mary Reeves Medical Director: John Reith, M.D.


Cell # (352) 318-9110 Pager: (352) 413-7504

Scope of Service: Surgical Pathology processes surgical specimens from inpatients, outpatients, and
autopsies for a wide variety of tests on tissue sections for demonstration of organisms, substances, and
structures. The tests include the demonstration of bacteria, fungi, protozoans, and inclusion bodies;
pigments and minerals; carbohydrates and mucoproteins; fats and lipids; nerve cells and fibers; hematologic
and nuclear elements; cytoplasmic granules and connective tissue elements, and enzymes. Preparations are
made for light microscopy, fluorescent antibody tests and immunoperoxidase techniques using paraffin and
frozen section techniques, respectively.

Specimen Submission Guideline

SEE ORDER FORMS ON THE FOLLOWING PAGES:


SURGICAL PATHOLOGY REQUISITION (INPATIENT FORM) (PS44626)
SURGICAL PATHOLOGY REQUEST (OUTPATIENT FORM) (15-9020-0)
SURGICAL PATHOLOGY REQUEST FOR MUSCLE AND NERVE BIOPSIES

Each form is to include: patients first and last name, gender, DOB, SUF medical record number,
pertinent clinical history, submitting physicians name (legible) and signature, date of collection/
service, exact anatomic source of specimen, service/department/clinic/OR#. If patient does
not have an SUF medical record number, provide patients address, insurance information, and
social security number.

Specimen must be labeled with patients full name, MR#, or DOB, and exact anatomical
specimen source (e.g., left breast biopsy).

Deliver specimens with appropriate forms:


Regular hours: Monday Friday, 8 am 5 pm, to either North or South Tower gross room
After hours: Monday Friday, 5 pm 8 am and weekends/holidays, to core lab window at
North Tower. Contact resident on-call at (352) 413-6266 about STAT specimens after hours.

Tissue samples for bacterial culturing MUST NOT be placed into formalin fixative. Send the
samples in a dry sterile container or with 1-5 ml of sterile saline solution in a sterile container to
the Microbiology Laboratory directly.

Fresh tissue (kidney, heart, or skin) specimens for Immunofluorescence Testing and muscle
biopsies deliver on saline-soaked gauze to SUF North Tower gross room, Room # 2225.

Specimens for routine Light Microscopy: place tissue in 10% zinc formalin 20 times tissue
volume in a leak proof container that is properly labeled and deliver to gross room either at
North Tower, Room # 2225 or South Tower, Room # 2325.

Surgical Pathology Consults: submit slides, a copy of the corresponding Pathology Report from
the referring location, and a completed outpatient Shands Surgical Pathology request. Deliver to
Surgical Pathology office at SUF Hospital North Tower, Room # 3109.

Outpatient muscle biopsies: contact Histology laboratory at Rocky Point facility before obtaining
a specimen. Call 1-352-265-0680 ext.7-2117.

33
34
Surgical Pathology Request
h Shands Medical Laboratories at Rocky Point h Shands at the University of Florida
Send 4800 SW 35th Drive Gainesville, FL 32608 1600 SW Archer Road PO Box 100344 Gainesville, FL 32610-0344
Page 1 of 2 To: Phone: (352) 265-0111 x 72118 Fax (352) 265-6935 Phone: (352) 265-0208 Fax (352) 338-9889
CLIENT INFORMATION REFERRING PHYSICIAN (PLEASE PRINT IN BLACK INK) PATIENT INFORMATION
PT LAST NAME FIRST MI

ADDRESS BIRTHDATE SEX: h M h F

CITY PT SSN

STATE ZIP HOME PHONE

REFERRING PHYSICIAN EMPLOYER WORK PHONE

INSURANCE BILLING INFORMATION REFERRING PHYSICIAN (PLEASE PRINT IN BLACK INK)


PRIMARY: h Medicare h Medicaid h Other Ins. h Self h Spouse h Dependent WORK ADDRESS CITY STATE ZIP
SUBSCRIBER LAST NAME FIRST MI

COLLECTION REPORTING INFORMATION


BENEFICIARY/MEMBER # GROUP #
h FAX results to h COPY to

CLAIMS ADDRESS CITY STATE ZIP


h CALL results to

SECONDARY: h Medicare h Medicaid h Other Ins. h Self h Spouse h Dependent


SUBSCRIBER LAST NAME FIRST MI Date Collected Time Collected h AM h PM

h STAT
BENEFICIARY/MEMBER # GROUP #

CLAIMS ADDRESS CITY STATE ZIP

PHYSICIAN When ordering tests, the physician is required to make an independent medical necessity decision with regard to each test the laboratory will bill. The physician also understands he or she is required
NOTICE to (1) submit ICD-9 diagnosis supported in the patients medical record as documentation of the medical necessity or (2) explain and have the patient sign an ABN.

ICD-9 Code(s) Diagnosis: 1) ________________________ 2) ________________________ 3) ________________________ 4) ________________________ 5) ________________________ 6) ________________________


I hereby authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare / Medicaid
claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to the party who accepts assignment.

X Patient Signature
Pertinent Clinical Hx:

Pre-Operative / Operative Dx (May use ICD-9 Codes):

PLEASE FILL
Specimen / Exact anatomical source: *Label specimen with patient name, MR# or DOB and specimen / site

THIS
A. M.

B. N.

C. O.

D. P.

E. Q.

SECTION OUT
F. R.

G. S.

H. T.

I. U.

J. V.

K. W.

L. X.
35
Rev. 11/20/09 PS44626
Page 2 of 2

PROCEDURE FOR SENDING MUSCLE AND NERVE BIOPSIES


(SHANDS MEDICAL LABORATORIES AT ROCKY POINT)
Packing and Shipping for Muscles:
1) Immediately upon receipt of tissue; examine for orientation (under dissecting microscope).
2) Excise, with new razor or scalpel blade, 2-6 small pieces (1 mm greatest dimension each), from area(s) of the biopsy
which (is) are not crushed or torn, and immerse these in EM fixative for transportation.
3) Wrap the majority of the (unfixed) specimen (1 cm or greater best) in sterile saline-dampened (not soggy) sponge and place
in a sealed plastic container on crushed ice (not dry ice). Specimen size of 1 cm or greater is best.
4) The entire specimen (ie. both parts) must be shipped in a larger protective container accompanied by the
following information:
Patients name, age and sex and pertinent history
Hospital and pathologist name and telephone number
Name and telephone number of doctor ordering the biopsy
Location and number of muscle biopsies

Packing and Shipping for Nerves:


1) Immediately upon receipt of tissue (ideally with suture tied near proximal end by the surgeon); gently pull the specimen (by
the suture) onto a thin cardboard strip and allow to sit for about 60 seconds.
2) Excise, with new razor or scalpel blade, 1/3 of the (proximal) nerve segment and place in a sealed container of 10% neutral
buffered formalin.
3) Immerse remaining 2/3 portion of nerve segment on (by now adherent) cardboard strip to a container of EM fixative for
transportation.
4) The entire specimen (ie. both parts) must be shipped in a larger protective container accompanied by the
following information:
Patients name, age and sex and pertinent history
Hospital and pathologist name and telephone number
Name and telephone number of doctor ordering the biopsy
Location and number of muscle biopsies

IMPORTANT
1) The following Shands Hospital staff should be notified that a muscle or nerve biopsy is being sent:
Histology (352) 265-0111, ext. 72117.
2) Outside of package MUST be labeled with one of the following:
Perishable or Muscle Bx or Surgical Specimen or Nerve Biopsy
3) The shipment must be arranged prior to shipping. The specimen must arrive no later than 24 hours after the biopsy (no
Friday biopsies), between the hours of 9:00 a.m. and 4:00 p.m., Monday through Friday and should be delivered to:
Shands Medical Laboratories at Rocky Point
Attn: Elaine Dooley/Charles Fletcher
Histology, Room 1130
4800 SW 35th Drive
Gainesville, FL 32608
Telephone: (352) 265-0111, ext. 72117

36
Page 1 of 1

Name M.R. #

Sex Age/DOB

Date of Collection: REQUIRED FOR REQUEST PROCESSING:

Preoperative Diagnosis: Physician performing procedure


Postoperative Diagnosis:
Service/Dept./Clinic/OR#
ICD-9-CM Code(s)
Primary attending physician*

Service/Dept./Clinic/OR#
* Physician who will be responsible for treating the patient on
the basis of pathology results

Copies to:
Clinical History (supplied by physician, ARNP, or other provider):

Specimen/Exact Anatomical Source(s)


Label specimen with patients name, M.R. #, and specimen/site.

A. K.

B. L.

C. M.

D. N.

E. O.

F. P.

G. Q.

H. R.

I. S.

J. T.
Attending Surgeon signature confirming I have reviewed the surgical pathology form to be correct and accurate.

Physicians Signature: MD#: Date: Time:


Patient Name: Patient Identification #:

*LA0014* LA0014
Surgical Pathology Requisition
Surgical Pathology Department
PO Box 100344 Gainesville, FL 32610-0344 Rev. 4/7/11
(352) 265-0208 Fax (352) 265-1110
37
15-9020-0 37
Page 1 of 1
Shands Medical Laboratories at Rocky Point Telephone (352) 265-0111 x72117
4800 SW 35th Drive Fax (352) 265-6935
Gainesville, FL 32608
Surgical Pathology Request for Muscle and Nerve Biopsies
Please read all instructions prior to collecting specimen.
MUSCLE BIOPSY NERVE BIOPSY
Packing and Shipping: Packing and Shipping:
1. Please read all instructions before sending a muscle biopsy. The 1. Please read all instructions before sending a nerve biopsy. Majority of
majority of the specimen should be sent on saline dampened gauze. A specimen should be divided into formalin and EM fixative.
tiny portion should be sent in EM fixative. 2. Immediately upon receipt of tissue, (ideally with suture tied by the
2. Immediately upon receipt of tissue, examine for orientation (under surgeon near proximal end), gently pull the specimen by the suture
dissecting microscope). onto a thin cardboard strip and allow to sit for approximately 60
3. Excise, with new razor or scalpel blade, 2-6 small pieces (1mm in seconds.
greatest dimension each), from area(s) of the biopsy which is/are not 3. Excise, with new razor or scalpel blade, approximately 1/2 of the
crushed or torn, and immerse these in EM fixative for transportation. proximal nerve segment and place in a sealed container of 10%
4. Wrap the majority of the (unfixed) specimen in sterile saline- neutral buffered formalin.
dampened (not soggy) gauze and place in a sealed plastic container 4. Immerse the remaining 1/2 of specimen (on cardboard strip) in a
on crushed ice (not dry ice). A specimen size of 1 cm or greater is container of EM fixative for transportation.
best. 5. The entire specimen (both parts) must be shipped in a larger
5. The entire specimen (both parts) must be shipped in a larger protective container accompanied by the following information:
protective container accompanied by the following information: a. patients name, age, sex, and pertinent history
a. patients name, age, sex, and pertinent history b. hospital and pathologists name and telephone number
b. hospital and pathologists name and telephone number c. name and telephone number of the attending (not the surgeon)
c. name and telephone number of the attending (not the surgeon) ordering the biopsy
ordering the biopsy d. location of nerve biopsy
d. location and number of muscle biopsies

1. The following Shands Hospital staff should be notified that a muscle or nerve biopsy is being sent: Elaine or Charles (Histology)- (352) 265-0111 x72117
2. Outside of package MUST be labeled with the following: perishable and muscle bx, or nerve bx.
3. The shipment must be arranged prior to sending and the specimen must arrive no later than 24 hours after the biopsy. Laboratory accepts specimens
between the hours of 9:00 am and 4:00 pm, Monday through Friday (not on weekends; ie: no Friday biopsies) and should be delivered to:
Shands Medical Laboratories at Rocky Point
Attn: Elaine Dooley/Charles Fletcher
Histology Room 1130
th
4800 SW 35 Drive
Gainesville, Fl 32608
Client Information-Referring Physician Patient Information - Inpatient Outpatient
Last Name First Name

Address Birthdate Sex M F

City SSN

Referring Physician_____________________________ State Zip Home Phone

Insurance Billing Information Please attach face sheet


Primary Medicare Medicaid Other Ins Self Spouse Dependent Secondary Medicare Medicaid Other Ins Self Spouse Dependent
Subscriber Last Name First Subscriber Last Name First

Beneficiary/Member # Group # Beneficiary/Member # Group #

Claims Address City State Zip Claims Address City State Zip

Physician Notice: When ordering tests the physician is required to Collection Reporting Information
make an independent medical necessity decision with regard to each test the FAX Results To _________________________________________
laboratory will bill. The physician also understands he or she is required to (1) CALL Results To ________________________________________
submit ICD-9 diagnosis supported in the patients medical record as COPY To _____________________________________________
documentation of the medical necessity or (2) explain and have the patient Date Collected: ___/___/_____
sign an ABN.
ICD-9 Codes(s) Diagnosis
1)________________2)________________3)___________________4)________________5)_________________6)_______________
Specimen/Exact Anatomical Source: *Label specimen with patient name, Preoperative/Operative Diagnosis (may use ICD-9 codes):
MR#, or DOB and specimen source/site
A.______________________ C._______________________
B. _____________________ D._______________________

Pertinent Clinical Hx Should Include the Following:


Does the patient have Proximal or Distal muscle weakness?
What is the CPK?
What are the results of the EMG?
What is the Clinical Differential Diagnosis?
Additional Information:
38
HEMATOPATHOLOGY LABORATORY
Rocky Point

Hours of Operation:
M F 7:30 AM 9:30 PM
Saturday 8:00 AM 4:00 PM

Telephone: (352) 265-0071


Fax: (352) 265-1063
After-hours: Page Resident-on-Call (352) 413-6266

Manager: Mary Reeves Medical Director: Ying Li, M.D.


Cell # (352) 318-9110 Pager: (352) 413-7468

Scope of Service: Hematopathology department provides a comprehensive diagnostic testing for


hematologic malignancies using state-of-the-art technology such as conventional microscopy,
immunohistochemistry, flow cytometry, molecular genetic testing, cytogenetics, and fluorescence in situ
hybridization (FISH).

Consultations Offered
1. Comprehensive leukemia myelodysplasia or cytopenia evaluation
2. Comprehensive lymphoma/lymphoproliferative evaluation
3. Comprehensive plasma cell disorder evaluation
4. Disease Monitoring
5. Consultation on pathologic materials (slides)
6. Performance of specialized hematologic laboratory tests on blood, bone marrow, or other fluids
7. CD34(+) stem/progenitor cell quantitation
8. Immunophenotyping

Expert pathologists are available 24 hours/7 days a week for a personalized service and consultation. Special
arrangements must be made for off hours and Sunday specimens.

Diagnoses of diseases that require prompt management are routinely reported via telephone by one of the
consulting physicians. Reports are faxed and original reports are sent by regular mail.

STAT Requests:
During regular hours Call laboratory at (352) 265-0071 and Customer Service at (352) 265-0522 for
rush pick-up and delivery to Rocky Point.
After hours Page resident on-call at (352) 413-6266.

EACH SPECIMEN IS TO BE ACCOMPANIED BY A HEMATOPATHOLOGY REQUEST FORM


(PS105674; SEE PAGE 41).

IF CYTOGENETIC EVALUATIONS ARE TO BE REQUESTED, REFER TO:


CYTOGENETIC ANALYSIS ONCOLOGY FORM (SEE PAGE 42)
CYTOGENETIC SPECIMEN REQUIREMENTS (CLICK HERE)

Cytogenetics laboratory can be contacted at (352) 265-9900.

Specimen Guidelines: See next page.

39
Hematopathology Specimen Submission Guideline

Notify Laboratory staff when sending a rush specimen.


Special arrangements must be made for specimen arriving during off hours.

Sample Type Sample Requirements Instructions

Cytogenetic analysis: Tube type is green top (sodium heparin). Room temperature.
Peripheral blood, Children and adults: 5-7 mls of blood or
bone marrow aspirate, or 1-2 mls of bone marrow or fresh, unfixed biopsy If shipped, use cold pack
fresh bone marrow biopsy. core, collected aseptically, in RPMI or similar culture or wet ice. No dry ice.
medium, or saline.

Infants: 2 mls of blood or 0.5-1 ml of bone marrow.

Peripheral blood 1-2 tubes in EDTA (lavender top) and freshly prepared Cold pack or wet ice.
smear. No dry ice.

Provide WBC and differential count results or


order those tests.

Bone marrow aspirate 3-5 ml in EDTA (lavender top) and freshly prepared Cold pack or wet ice.
smear. No dry ice.

Provide WBC and differential count results or


order those tests.

Bone marrow biopsy Fresh, unfixed biopsy core in RPMI, similar culture Cold pack or wet ice.
medium or saline. No dry ice.

Fine needle aspirate Collect in RPMI or similar culture medium and freshly Cold pack or wet ice.
prepared smear or cytology evaluation. No dry ice.

Fluids Spin large volume and send cell pellet in RPMI or Cold pack or wet ice.
(CSF, pleural, etc.) similar culture medium. No dry ice.

Do not use anticoagulant unless grossly contaminated


with blood.

Fresh tissue (unfixed) Keep moist in saline at all times (immerse in saline or Cold pack or wet ice.
wrap in medium soaked gauze). No dry ice.

Send a control: a representative portion of the biopsy


fixed in formalin, if available.

Histology slides for Place slides in unbreakable container. Room temperature


consult
Submit corresponding paraffin blocks.

Immunophenotyping 3-5 mls in EDTA (lavender top) Room temperature

Provide WBC and differential count results from


within 24-hr period or order those tests.

40
Page 1 of 1
Shands Medical Laboratories at Rocky Point (352) 265-0071
Hematopathology Laboratory Room 1112 FAX: (352) 265-1063
4800 SW 35th Drive
Gainesville, FL 32608
Patient Name ______________________________________________ DOB _____________________ Sex: M F
MRN# ____________________________ Service / Dept. / Clinic / OR#
Ordering Physician (Print and Sign)
Collected By _____________________________ Phone ______________________ Fax
Clinical History / Previous Relevant Therapy (Check all that apply)
Anemia Leukopenia Splenomegaly
Thrombocytopenia Leukocytosis Lymphadenopathy
Lymphocytosis Abnormal Cells on Smear Hepatomegaly

Most current CBC: RBC _______ HGB _______ HCT _______ WBC _______ PLT _______ MCV _______

Additional information:

Test / Stain Request (Check all that apply)


Outside Slide Review / Consultation:

BM Asp (purple/EDTA): Flow _______ Iron _______ Other _________________________________________


Right / Left / Bilateral Date and Time collected _______________________________________________
BM Asp (green/heparin): Cytogenetics ______ Molecular ______
Right / Left Date and time collected _______________________________________________
BM core biopsy:
Fresh Flow _____ Cytogenetics _____ Other _________________________________________
Right / Left / Bilateral Date and Time collected _______________________________________________
Fixed Iron _____ Reticulin _____ Congo Red _____ Other ____________________________
Right / Left / Bilateral Date and Time collected _______________________________________________
Clot Section:
Fresh Flow _____ Cytogenetics _____ Other _________________________________________
Right / Left / Bilateral Date and Time collected _______________________________________________
Fixed Iron _____ Reticulin _____ Congo Red _____ Other ____________________________
Right / Left / Bilateral Date and Time collected _______________________________________________

Other specimen (please circle specimen type below):


Peripheral Blood or Body Fluid (type) ___________________________ or Tissue (site) _______________________________
Test required: Flow _____ Cytogenetics ______ Other _________________________________________

*Please submit other pertinent diagnostic materials (H&E slides, frozen sections, smears, etc.). These are very important materials that are necessary for quality control.
*Additional tests may be performed and billed by the laboratory if deemed medically necessary by the pathologist. This reflex testing is an extension of the requesting
physicians original order and signing this requisition, the requesting physician authorizes these additional tests, as necessary. *A recent CBC or WBC result is required
clinical information. This may be provided by the requesting physician, or a CBC/WBC will be performed by this laboratory and billed separately.

For Lab Use Only: BONE MARROW BIOPSY:


Number of containers ______ Fixed: Time ___________ Date ___________ Decal: Time ___________ Date ___________
Patient Name: Patient Identification #:

*LA0014* LA0014

Hematopathology Request Form 2/9/11


(page 1 of 1) 41
PS105674
41
Page 1 of 1
ONCOLOGY CYTOGENETIC Telephone: (352) 265-9900
Toll Free: 1-888-375-5227
TESTING REQUISITION FORM FAX: (352) 265-9920
UF Cytogenetics Laboratory (please use the Standard or Prenatal Cytogenetic Request forms for all other studies) http://www.pathlabs.ufl.edu/
th
4800 SW 35 Drive
Gainesville, FL 32608

Patient Demographic Information Requesting Physician Information

Name: ___________________________________________ Name:______________________________ NPI #:____________

Medical Record No.: ________________________________ Location/Institution: _____________________________________

Age or D.O.B.: ____________________________________ Signature:______________________________________________

Sex/Gender: Male Female Unknown Send additional reports to: ____________________________

Clinical Indication or Reason for Cytogenetic Testing Specimen Information

CML AML APL (M3) precursor B-ALL Bone marrow aspirate


T-ALL B-ALL ALL, nos Mixed lineage leukemia Bone marrow core biopsy
Acute leukemia, nos MPD - Subtype: ____________________________ Peripheral blood Lymphatic tissue
MDS - Subtype: __________________________________________________ Solid tumor (NO PARAFFIN BLOCKS)
Multiple myeloma Lymphoma - Subtype: _______________________ Other ________________________
Solid tumor type: ______________________________________________________ Date Collected: ____________________

Other: _______________________________________________________________ Time Collected: ____________________

Cytogenetic Testing Requested (must be completed to avoid delays in processing) Post-therapy Post-transplant
UNFIXED TISSUES ONLY - NO PARAFFIN BLOCKS OR FORMALIN PRESERVED Remission Relapse
Conventional G-banded Chromosome Analyses (aka karyotyping) Immunophenotyping by FLOW:

FISH Analyses - (all primary studies should include a conventional chromosome study) has been ordered has not been ordered
Rows 1-5 reflect commonly grouped "panels"
1 - MDS/MPD; 2 - MM/PCL; 3 - CLL/SLL; 4 - AML; 5 - ALL For Lab Use Only
BCR/ABL1 PML/RARA X/Y sex mis-matched transplant
1
5q - del/mono 7q - del/mono Trisomy 8 20q - deletion
2
del(13q) IGH (14q32) TP53 (17p13) IGH fusions (if positive*)
3
del(13q) IGH (14q32) TP53 (17p13) Trisomy 12 ATM (11q22)

4
MLL (11q23) CBFB (16q22) RUNX1/RUNX1T1
5
BCR/ABL1 ETV6/RUNX1 MLL (11q23) 4/10/17 (B-ALL)
MYC (8q24) BCL2 (18q21) BCL6 (3q27) IGH/MYC IGH/BCL2 Lab No.:______________________________

ETV6 (12p13) IGH/CCND1* IGH/MAF* IGH/FGFR3* ALK (2p23)


Specimen Descriptor: ___________________

FOXO1 EWSR1
(13q14) SS18
(22q12) (18q11.2)
# Containers: _______ Quantity (ml): ______

Sodium Heparin Tube


INQUIRE FOR AVAILABILTY - OTHER:
Other:
_____________________________________
Insurance/Billing Information (must be completed prior to sample processing)
Additional Test Codes: __________________
Insurance Provider: ______________________________________________________


_____________________________________
Pre-Authorization Required: YES NO
If Yes, Please provide Authorization Number: __________________________________ Tech Login ID.:___________

Ver.0172010 PHOTOCOPY42
AS NEEDED Oncology Request.doc
42
TRANSPLANT LABORATORY
Rocky Point

Hours of Operation: M F 7:30 AM 10:30 PM

Telephone: (352) 265-0072


Fax: (352) 265-0626
After-hours: Page Technologist-on-Call (352) 413-0194

Manager: Mary Reeves Medical Director: Juan Scornik, MD


Cell # (352) 318-9110 Pager: (352) 413-7508

Scope of Service: The Transplant Laboratory performs compatibility tests, transplant monitoring for bone
marrow, kidney, pancreas, heart, lung, liver transplantation, and other immunological testing using the
following methodologies: molecular, flowcytometric, serologic, and ELISA. The tests offered are utilized
according to the clinical application.

Services Provided:
1. Solid Organ Transplant Evaluation for:
Heart, Liver, Kidney, Lung, Pancreas
2. Bone Marrow Transplant Evaluation
3. Other Immunological Evaluation
Disease association (B27, DR15, etc.)
HLA typing for platelet transfusions

STAT Requests:
During regular hours Call laboratory at (352) 265-0072 and Customer Service at (352) 265-0522 for
rush pick-up and delivery to Rocky Point.
After hours Page technologist on-call at (352) 413-6266.

Shands Transplant Programs request all transplant-related testing.


Please contact individual transplant program for any questions.

Type of patient Sample requirements

Deceased Donor Workups 4 ACD-A tubes

HLA Typing 3 ACD-A tubes

HLA antibody testing 1 red top tube

Living Renal or Liver Donor evaluation 5 ACD-A tubes

Crossmatch 1 red top tube

HLA typing for platelets 3 ACD-A tubes


Disease Association 1 ACD-A tube

Identity Confirmation or HLA typing Confirmation 1 ACD-A tube

1 ACD-A tube
Post BMT Engraftment
(PBL or BM)

43
8/1/11 PS108542

44

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