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Review of Lab Request and Samples
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* Indicates required question
Audit Date
*
MM
/
DD
/
YYYY
Lab No
*
Your answer
Request Type
*
Online OP request
Online IP Request
Hard Copy Request
Self Request
Completeness of the request
*
Yes
No
Not Legible/Incomplete
NA
Patient UHID
Patient Name
Age and Sex
Department/ Ward/BED
Tests
Doctors Name /seal
Doctors Signature
Clinical History
Consent
Yes
No
Not Legible/Incomplete
NA
Patient UHID
Patient Name
Age and Sex
Department/ Ward/BED
Tests
Doctors Name /seal
Doctors Signature
Clinical History
Consent
Sample Verification
*
Yes
No
NA
Appropriate Container
Insufficeint Volume
Excess Volume
Adequate Transport conditions
Tests identifiyable
Row 6
Yes
No
NA
Appropriate Container
Insufficeint Volume
Excess Volume
Adequate Transport conditions
Tests identifiyable
Row 6
Audited by Name and Emp ID
*
Your answer
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