Download Instructions for Off Base Doctors: A B

Instructions for Off Base Doctors:
How to Complete a Defence Pathology Request Form
A. Patient details - Complete all fields
B. P.M. Keys Number
A
B
C
PaTIENT LaST NamE
GIVEN NamES
Pm KEYS No.
GENDER
TEL (HomE & moBILE)
DaTE oF BIRTH
C. Unit/barracks and address
D. Tests Requested - Please list
required tests here
TEL (BUS)
aDF UNIT/SHIP NamE aND LoCaTIoN
PoSTCoDE
E.Fasting - The patient’s fasting status
TESTS REQUESTED
E
D
F. Clinical Notes (if required)
Is patient:
Fasting
■
Non Fasting
■
If drug level required:
LaST DoSE
TImE ....................................
DaTE .......... /.......... /...........
LABORATORY COPY
CLINICaL NoTES
Urgent
Clinically High Risk/Significant
YES
BILL CoDE
No
BY TImE: ..................................... REaSoN: ......................................................................................
I
CoPY REPoRTS To:
REQUESTING DoCToR aND DaTE oF REQUEST
H
H. Duty Medical Officer Code - This
code is for Path-Way. Add further
‘Copy To’ report doctors as required
COPY CODE INFORMATION
To ensure that the defence facility
receives a copy report, please add
the appropriate copy code here.
Please see table below for codes.
F
G
G.Urgency - Whether a sample is
urgent or not
PRINTED NamE ......................................................................................... LaV. DR CoDE ..........................
SIGNaTURE ............................................................................................... DaTE .......... / ............ /.............
REFERRING FaCILITY
I. Requesting Doctor Details The requesting doctor’s name and
Laverty doctor code are required.
HoSPITaL/WaRD:
PERSoN DRaWING BLooD
I certify that the blood specimen(s) accompanying this request was drawn from the patient named above.
established the identify of this patient by direct inquiry and/or inspection of wrist band and immediately
upon the blood being drawn I labelled the specimen(s). I have also signed the sample tube.
LAB USE
Name: ........................................................................ Signature: .............................................................
Collect Date
Coll. Time
Received Date
Rec. Time
Collector
B/C
DFF
aCC
Specimens
EDTA
SST
CIT
Flox
K2
Others
Sign
Collected
Received
Specialist Diagnostic Services Pty Ltd (ABN 84 007 190 043) t/a Laverty Pathology APA No.000042
ACT
Base
Medical Centre
Copy Code
Duntroon
Duntroon Health Centre
4DUNH
HMAS Harman
Harman Clinic
4HMNC
Russell Offices
Russell Health Centre
4RUSH
Weston
Weston Clinic
4WESC