Emergency Point-of-Care Testing Patient ID Form

Use 999999999 for account number

Fax number 210-_____________ Att: POC
Instructions: This form should be used when Point-of-Care testing is performed and resulted
before a patient has been registered and has a medical record number. All required
information must be filled in. Please complete as much additional information as
possible so that matching of patients result(s) and patient identity can be accurately charted.
Any issues with patient ID will become the responsibility of the operator performing the POC
test.

Take completed form to lab:

Attention: Point of Care.
(Copy will be placed on patients chart.)
Emergent Patient ID: ________________
(number entered into analyzer)
**must be a unique number**

True Patient Information:

(affix patient admission label here)

Location of Patient:_________________________
Sex: (circle one)

Male

Female

(REQUIRED INFORMATION)

CRITICAL VALUE NOTIFICATION

Date of Test (required):_________________________

Whole blood glucose results

Time of test performance (required):_______________

given to/read back by:

Operator/Tech ID (required):_____________________

__________________________________
(Physician name/caregiver name and title)

Result of POC Test (required):___________________

At: ________(Time) on __________(Date)

(Circle test type) Glucose Strip test

By: _______________________________
(Name and title of RN/tech).

PATIENT INFORMATION VERIFIED BY (required; must be legible):____________________

TODAYS
DATE:______________________COMMENTS:______________________________________