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Transcript
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