Pro6.4-E-04 App 2 Body Fluid Worksheet - pSMILE



LAB NAME

Address

Pro6.4-E-04 Appendix 2 - BODY FLUID WORKSHEET

TIME RECEIVED: ________________

TECH: __________________________

1. SPECIMEN TYPE: CSF Pleural (chest/lungs) Peritoneal (abdomen/ascites)

Synovial (joint) Pericardial (heart) Other: _________________

2. SPECIMEN RECEIVED:

Hematology Tube: Tube #________ Clotted or Not Clotted

If clotted, the cell count and differential will not be performed only the cytospin preparation will be reviewed for malignancy.

Specimen Type: Heparin EDTA No anticoagulant

Volume: _______________ Color & Appearance: ___________________________________

Chemistry Tube (If yes, attach LIS results): YES or NO

Microbiology Tube (If yes, attach LIS results): YES or NO

3. HEMATOLOGY TESTS ORDERED and RESULTS

Cell Count (worksheet attached): RBC count: _____________ WBC count: _________________

Manual Diff (cytospin prep) -

100 cells counted? If not, total # counted__________. Convert to percentages:

Neutrophils: _____________________Monocytes: ________________________________________

Lymphocytes: __________________ Other cells (indicate type & quantity):___________________

Other Tests - not applicable to CSF:

Specific gravity (1.015=exudate): SG:________________________

Crystal Exam: Positive or Negative Type:______________________

4. PATH COMMENTS: _____________________________________________________________

_________________________________________________________________________________________________

PATH SIGNATURE: ____________________________________________DATE: __________

CELL COUNT WORKSHEET

[pic]

(W) WBC Square Volume = 0.1uL or mm2 (R) RBC Square Volume = 0.004uL or mm2

5. FORMULA: (Avg Cells Counted) x (Dilution) = Cells/mm3

(Squares counted) x (Volume of 1 square)

6. CELL COUNT:

6.1. Dilution: Yes or No Dilution Factor: ____________

WBC Count:

RBC Count:

7. COMMENTS: _________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Do not exceed a cell count of 150 cells on one (1) side of the hemocytometer (9 square area). Either perform a dilution or reduce the number of squares counted to maintain a manageable cell count. Counts in excess of 150 cells results in spurious results due to fluid evaporation. Also, cell counts cannot be less than 25 cells on (1) side of the hemocytometer (9 square area) except on undiluted specimens. If diluted counts are less than 25 cells, perform the cell count on an undiluted specimen. Count all nine squares on both sides of the hemocytometer for best results. Refer to the CSF and Bodyfluid SOPS for more information.

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Place LIS

label here

(side 1) + (side 2) = _______ Avg WBC

2

(WBC Avg) x (dil.factor) = ______________WBC/ mm3

(Sq. Counted) x (Square Vol)

(side 1) + (side 2) = _______ Avg RBC

2

(RBC Avg) x (dil.factor) = _______________RBC/ mm3

(Sq. Counted) x (Square Vol)

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