Download hemoFISH Gram (-) Panel - miacom diagnostics GmbH

Data Documentation Sheet
hemoFISH Gram (-) Panel
Please use one documentation sheet for each individual patient specimen.
ID of blood culture bottle:
_____________________________________________
Name of operator:
_____________________________________________
Date and time blood culture flagged “positive”: ________________________________________
Date and time blood culture was removed from incubator: _______________________________
Date of Birth and sex of patient:
☐ female
☐ male
DoB: _______________
Type of blood culture bottle
Results Gram stain:
Gram positive bacteria
Gram negative bacteria
Yeast cells visible in Gram stain
☐ aerobic
☐ anaerobic
☐ pediatric
☐ cocci
☐ cocci
☐ yes
☐ rods
☐ rods
☐ none
☐ none
☐ none
Date and time miacom test started:
_____________________________________________
Date and time miacom test finished:
_____________________________________________
Please fill out all boxes (positive signal “+”; no signal “/”)
Field
1
2
3
4
5
6
7
8
Red
Positive
control
Enterobacteriaceae
Escherichia
coli
Klebsiella
pneumoniae
Serratia
marcescens
Proteus
mirabilis
Proteus
vulgaris
Salmonella
spp.
+ or /
Yeast cells visible on miacom slide:
Green
Negative
control
Pseudomonas
aeruginosa
Acinetobacter
spp.
Stenotrophomonas
maltophilia
Haemophilus
influenzae
☐ yes
+ or /
Comments (optional)
☐ 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 130424-1