Combination Quality Control Log Sheet
Combination Quality Control Log Sheet
Urine Chemistry & Urine Pregnancy
Health Department: _____________________ Site ______________
Test Name: Urine Chemistry Dipstick
Manufacturer: _________________________________ Month: __________ Year _______
| | | | |
|Dipstick Lot Number | |Positive Control: Lot number: | |
| | |Expiration Date: | |
| | |Negative Control: Lot Number: | |
|Dipstick Expiration Date | |Expiration Date: | |
| | | | | | | |
|Test |Test not |Observed |Expected |Observed Negative|Expected Negative |Pass / Fail |
| |performed |Positive |Positive | | | |
| | | | | | | |
|Glucose | | | | |neg |Pass Fail |
| | | | | | | |
|Bilirubin | | | | |neg |Pass Fail |
| | | | | | | |
|Ketone | | | | |neg |Pass Fail |
| | | | | | | |
|Specific Gravity | | | | |1.0__ |Pass Fail |
| | | | | | | |
|Blood | | | | |neg |Pass Fail |
| | | | | | | |
|pH | | | | |6.5-7.5 |Pass Fail |
| | | | | | | |
|Protein | | | | |neg |Pass Fail |
| | | | | | | |
|Urobilinogen | | | | |Normal (0.2–1.0) |Pass Fail |
| | | | | | | |
|Nitrite | | | | |neg |Pass Fail |
| | | | | | | |
|Leukocytes | | | | |neg |Pass Fail |
| | | | | | |
| | | | |Date: |Initials: |
Test Name: Urine Pregnancy Internal Control Expected Result: Control Bar Present
Yes = control bar present No = control bar not present
Manufacturer: _________________ Please note: When bar is not present a “Failed Test Form”
must be completed. All other QC errors require a
Continuous Quality Improvement Form” to be completed.
| | | | | | |
| |Lot Number |Expiration Date |Control Bar Observed |Observed Result |Acceptability |
| | | | | | |
|Positive Control | | | | |Pass Fail |
| | | | | | |
|Negative Control | | | | |Pass Fail |
| | | | | | |
|Test Kit | | |na |Date: |Initials: |
Corrective action: (use reverse side if needed)
| | |
|Date |Corrective Action: |
| | |
| | |
_________________________ ___/___/___ _________________________ ___/___/___
Site Coordinator Date Laboratory Director/Technical Consultant Date
RLF-42
Rev. 6/9/2006
................
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