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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