Form Permintaan Pemeriksaan Lab [PDF]

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RSIA MPM / F.LAB.001 / REV00



FORMULIR PERMINTAAN PEMERIKSAAN LABORATORIUM



No. Lab : ........................... Tgl.



: …………................



Penanggung Jawab : dr. Mimi Setio, Sp. PK Nama Pasien



: ..................................................................................



Dokter Pengirim



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No. RM. Registrasi



: ..................................................................................



Alamat



: ..................................................................................



Alamat



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No. Tlp



: ..................................................................................



Umur



: ............ Thn ............ Bln ........... Hari ........... Lk/Pr*



Tanggal



: ..................................................................................



Diagnosa



: .................................................................................. HEMATOLOGI KIMIA DARAH



O Hematologi Automatic (Hb, Leko, Hct, Trombosit) O Hematologi Lengkap (Hb, Leko, Hct, Trombosit, Diff, LED) O Hemoglobin O Leukosit O Hitung Jenis Leukosit O LED (Laju Endap Darah) O Trombosit O Hematokrit O Eritrosit O Eosinofil O Retikulosit O Apus Darah Tepi (ADT) O Apus Sumsum Tulang O Malaria O Sel LE O MCV O MCH O MCHC O Rumple Leede O Gol. Darah + Rhesus O Masa Pendarahan (BT) O Masa Pembekuan (CT) O PT (INR) O APTT O D-Dimer O G6PD O SI (Serum iron/Fe) O TIBC O Ferritin O Transferrin O Asam Folat O Coombs Test Direk O Coombs Test Indirek O Hb F O Hb Elektroforesa O CD4 KLINIK RUTIN O O O O O O



Urine Rutin Sedimen Glukosa Urine Protein Urine Protein Kuantitatif (ESBACH) # Protein Bence Jones



O Test Pack (Tes Kehamilan) O Beta HCG Kuantitatif Urine O O O O O O



Amphetamine Canabinoid Opiat Barbiturate Cocaine Benzodiazepine



O Faeces Rutine O Pencernaan O Darah Samar (Benzidine) KETERANGAN * Puasa dan dilarang merokok 10-12 jam (*) Persiapan pemeriksaan hubungi Laboratorium # Urine Tampung 24 Jam O Hasil dikirim ke dokter



O Hasil dikirim ke ruang : ....... O Hasil diserahkan ke penderita NAMA PETUGAS TGL JAM



O O O O O O O O



Glukosa Puasa* Glukosa 2 jam PP Glukosa Sewaktu Glukosa Toleransi Test* (GTT) HBA1C Insulin C-Peptide Fruktosamin



O O O O O O O O O O



Protein Total Albumin Globulin SGOT SGPT Gamma-GT Alkali Fosfatase Bilirubin Total Bilirubin Direk/Indirek Cholinesterase



O O O O O



Ureum / BUN Creatinin Asam Urat Estimasi GFR Cystatin C



O O O O O O O O O



Cholestrol Total Trigliserida HDL-Cholestrol LDL-Cholestrol LDL-Cholestrol (Direk) Total Lipid Lippo Protein A APO A1* APO B



O O O O O O O O



CK-MB CK-NAC LDH Troponin I Troponin T Myoglobin Alfa-HBDH Homocystein



O O O O O O O O O



Natrium Kalium Kalsium (Ca ion) Klorida Magnesium Fosfor Anorganik Bikarbonat Analisa Gas Darah Asam Laktat



IMUNOSEROLOGI DAN SEROLOGI O O O O O O O O O O O O



Anti HAV Total Anti HAV IgM HbsAg Rapid HbsAg (ELFA) Anti Hbs Rapid Anti Hbs (ELISA) HbeAg Anti Hbe Anti Hbc Anti Hbc IgM Anti HCV Anti HCV IgM



O O O O O O O O O O



CEA AFP Ca 125 Ca 15-3 Ca 19-9 Ca 72-4 PSA Total Free PSA NSE SCC



O O O O O O O O O O O O



Anti Toxoplasma Ig G Anti Toxoplasma Ig M Aviditas Anti Toxo Ig G Anti Rubella Ig G Anti Rubella Ig M Anti CMV Ig G Anti CMV Ig M Aviditas Anti CMV Ig G Anti HSV I Ig G Anti HSV I Ig M Anti HSV II Ig G Anti HSV II Ig M



O O O O O O O O O O O O O O O O



T3 T4 FT4 TSHs T3 Up Take FT-3 FT-4 Index LH FSH Prolaktin Testosteron Estradiol Progesterone Beta-HCG Kuantitatif Cortisol Growth Hormon



O O O O O O O O O O O O O



ASTO CRP Kuantitatif CRP Kualitatif RA/RF LE Test ANA Pola ANA Test Anti-ds DNA IgE ACA-IgG ACA-IgM C-3 Komplement C-4 Komplement



O Widal O Anti Salmonella Typhi IgM (Tubex TF) O Dengue Blot IgG & IgM O Dengue NS1 O ICT TB O TB Antigen O Seramoeba O Anti Helicobakter Pylori IgG O Anti Helicobacter Pylori IgM MIKROBIOLOGI O O O O O O O O O



Gram BTA Jamur Diphteri GO Trichomonas Candida Albicans BTA SPS BTA (Pagi I, II, III)



O O O O O O O O O



PEMERIKSAAN PENUNJANG YANG LAIN



Kultur Darah Kultur Urine Kultur Faeces Kultur Sputum / Dahak Kultur PUS Test Resistensi Kultur Empedu (Gal Kultur) Kultur & Test Resistensi BTA (MTB) ANALIS LAIN Analisa Cairan Acites (TransudatExudat) Analisa Liquor (LCS) Analisa Sperma (*) Analisa Batu Ginjal Analisa Batu Empedu Manthoux Test (PPD Test) PATOLOGI ANATOMI PAP Smear Sitologi Biopsi / Oprasi Vries cop / Potong Beku DOKTER YANG MEMERIKSA



O .............................................................................................................................. O .............................................................................................................................. O ..............................................................................................................................



(dr. ..........................................)



O O O O O O



O Anti HIV O TPHA O VDRL



O Amilase O Lipase



O O O O



PENGAMBILAN SPESIMEN / SAMPEL PENGAMBIL



PENGIRIM



PENERIMA