Download respiFISH HAP Gram (-) Panel

Data Documentation Sheet
respiFISH HAP Gram (-) Panel
Please use one documentation sheet for each individual patient specimen.
ID of specimen:
_____________________________________________
Name of operator:
_____________________________________________
Type of specimen:
☐ sputum
☐ BAL
☐ tracheal aspirates
☐ bronchial aspirates
Results Gram stain:
Gram positive bacteria
Quantity of bacteria in Gram stain
☐ cocci
☐ very low
☐ rods
☐ low
☐ none
☐ medium
☐ high
Gram negative bacteria
Quantity of bacteria in Gram stain
☐ cocci
☐ very low
☐ rods
☐ low
☐ none
☐ medium
☐ high
Yeast cells visible in Gram stain
☐ yes
☐ none
Date and time miacom test started:
_____________________________________________
Date and time miacom test finished:
_____________________________________________
For semi-quantification use numbers to indicate amount of bacteria on the respective field (e.g.
negative: “/”; very low amount: “1”; low amount: “2”; medium amount: “3”; high amount: “4”)
Field
Red
Positive
control
1
2
# or /
Enterobacteriaceae
3
4
5
6
7
8
Escherichia
coli
Klebsiella
pneumoniae
Klebsiella
oxytoca
Serratia
marcescens
Proteus
vulgaris
Proteus
mirabilis
Green
Negative
control
Pseudomonas
aeruginosa
Acinetobacter
spp.
Stenotrophomonas
maltophilia
Haemophilus
influenzae
Moraxella
catarrhalis
# or /
Comments (optional)
-
Yeast cells visible on miacom slide:
☐ yes
☐ no
Reference identification:
Date of testing:
Discrepant result:
Method of testing:
☐ yes
☐ no
Result:
☐ excluded
☐ included
Remarks:
Name:
Signature:
If you have any questions, please do not hesitate to contact us:
email:
[email protected]
phone:
+49-211-30155795
Version 130416-1