Requisiton and Labeling Instructions

Requisition, Labeling, Storage and Transportation Instructions

Choose Which Requisition to use

Please choose the appropriate requisition for the test that you need to order. There are two requisitions available: Tissue Request and Cytology

For Surgical Specimens, the yellow Tissue Request should be used.

For Non-Gyn Cytology or Gyn-Cytology, the green-blue Cytology Requisition is appropriate. There are additional special tests that are listed on the Cytology Requisition that can be ordered.

The above underlined and bolded links will provide you with a copy of the respective requisition. The Tissue Request is in Black and White to be printer friendly, but the hard copies provided by the lab are yellow. The Cytology Requisition PDF is also user fillable and printable.

Filling out the requisition

Enter the patient's first and last name as designated on the requisition.
Enter the patient's Date of Birth, sex, address, phone number, insurance, and SSN if available.
Enter the Ordering Physician's Name, location, and contact information.
For EHR reporting, please include the patient ID, chart#, MRN, Visit Number, Encounter #, and/or sample ID as it pertains to your specific EHR needs.
Enter the Test Orders.

For Tissue Request:

Enter the specimen type and source as labeled on the container.
Number each separate specimen Ex. (1. skin bx neck 2. skin bx chest)
Write in any pertinent orientation information or additional test order information, paying attention to what collection media is appropriate for the test being ordered. Please see our Container Guide.
Enter any relevant clinical history or differential diagnosis, including ICD10s, when available.

For Cytology Request:

Check a Source, or write in the source Ex. (Other: urethral)
For Pap Tests, please fill out LMP field (Last Menstrual Period)
Choose which tests you would like to order, paying attention to what tests are available for which collection types (in bold). Please see our Container Guide as an aid.
Enter/check all clinical history, including ICD10s that indicate necessity for the test. Please see our list of ICD10s that may be appropriate. Please note that if appropriate ICD10 or clinical indicators are not provided, insurance may reject the lab test claim.
For EHR reporting, please include the patient ID, chart#, MRN, Visit Number, Encounter #, and/or sample ID as it pertains to your specific EHR needs.
If this is a Medicare patient, the patient is required to fill out the Advanced Beneficiary Notice form on the back of the Cytology requisition.

Labeling Containers

Write the patient's first and last name on the label.

Write the specimen type/source on the label.

Ordering physician last name and date is also recommended.

Make sure that the fixative/medium is written on the container or label.

Specimen Storage and Courier Transportation

Please make sure that the proper storage temperature is maintained between 15-30 degrees Celsius (room temperature), for most specimens in collection medium.
If fresh tissue for P.O.C. karyotyping/genetic studies or tissue in RPMI, this should be sent with the courier on the same day, and kept refrigerated at 2-8 degrees Celsius until the courier picks up the specimen.
Using a CPA biohazard transport bag, insert the requisition into the outside pocket of the biohazard transport bag, and place the specimen(s) in the main zipper pouch of the bag.
Write the specimen information on the specimen inventory log for tracking of the specimen. Alternatively, features of the client EHR system may be utilized Ex.( Electronic orders are another way of sending specimen information to the laboratory).
Only release tissue to a Hendrick contracted specimen courier. Please verify their employee badge.
The courier utilizes an appropriate insulated transport container for room temperature, refrigerated, and frozen specimens. These containers are validated periodically for temperature range viability. A copy of these validations is provided to Clinical Pathology Associates.