Healthcare Osmolality Report

Healthcare Osmolality Report

Report ID:     Laboratory Accession #:

Patient Information

Date of Birth:     Gender:

Phone:     Emergency Contact:     Emergency Phone:

Insurance and Billing

Policy Number:     Group Number:

Specimen Information

Specimen Type: Serum Plasma Urine CSF Other

Collection Date/Time:     Collected By:

Specimen Condition: Acceptable Hemolyzed Lipemic Clotted Insufficient

Osmolality Test Results

Measured Osmolality (mOsm/kg):     Calculated Osmolality (mOsm/kg):

Osmolal Gap (measured − calculated) (mOsm/kg):     Reference Range (serum): 275 − 295 mOsm/kg

Quality Control and Administrative Data

QC Run Date:     QC Level 1 Value:     QC Level 2 Value:

Reagent / Lot Number:     Analyst Initials:

Critical value identified

Ordering and Release

Clinician Phone:     Clinician License ID:

I authorize the laboratory to release these test results to the ordering clinician and to other healthcare providers involved in my care. I understand that results contained herein are based solely on the specimen provided and that clinical correlation by a qualified clinician is required.

This report contains protected health information. Retention, transmission, and disclosure of this report are subject to applicable privacy and confidentiality laws. The laboratory certifies that testing was performed in accordance with applicable procedural and quality control standards.

By signing below, I acknowledge receipt of this Osmolality Report, confirm the accuracy of the patient and specimen information provided to the best of my knowledge, and authorize release of these results as indicated above.

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