Province of Ilocos Sur

GABRIELA SILANG GENERAL HOSPITAL

Vigan City
Date: _______________
HEMATOLOGY

Name:
Ward: Age: Classification:

Hemoglobin: WBC:
Hematocrit:
DIFFERENTIAL COUNT
Segmenters: Juveniles:
Lymphocytes: Monocytes:
Eosinophiles: Basophiles:
Stabs: Blast Cells:
Platelet Count:
Reticulocytes Count:
Bleeding Time: Clotting Time:
ESR:
Blood Typing: Rh Typing:
Malarial Smear:
Peripheral Smear:


Medical Technologist-on-duty

MYRNA N. CARANTO, RMT
Department Head
BRENDA I. ROSUMAN, MD, FPSP
Pathologist


Province of Ilocos Sur
GABRIELA SILANG GENERAL HOSPITAL
Vigan City

DATE:

FECALYSIS

NAME:
WARD: AGE: CLASSIFICATION:


OCCULT BLOOD: ________________
COLOR: _______________CONSISTENCY: ______________

MICROSCOPIC FINDINGS:


















Medical Technologist-on-duty

MYRNA N. CARANTO, RMT
Department Head
BRENDA I. ROSUMAN, MD, FPSP
Pathologist

Province of Ilocos Sur
GABRIELA SILANG GENERAL HOSPITAL
Vigan City


BLOOD CHEMISTRY

DATE:

NAME: AGE: SEX:
WARD: CLASSIFICATION:

RESULT NORMAL VALUES
FBS
CHOLESTEROL
HDL
LDL
TRIGLYCERIDES
BUN
CREATININE
BUA
TOTAL BILIRUBIN
DIRECT BILIRUBIN
TOTAL PROTEIN
ALBUMIN
SGPT
SGOT
SERUM Na
+

K
+

Cl
-

OTHERS


Medical Technologist-on-duty

MYRNA N. CARANTO, RMT
Department Head
BRENDA I. ROSUMAN, MD, FPSP
Pathologist

Province of Ilocos Sur
GABRIELA SILANG GENERAL HOSPITAL
Vigan City

DATE:
MISCELLANEOUS

NAME:
WARD: AGE: CLASSIFICATION:


KIND OF EXAMINATION:
Specimen:


Findings:

















Medical technologist-on-duty


MYRNA N. CARANTO, RMT
Department Head
BRENDA I. ROSUMAN, MD, FPSP
Pathologist

Province of Ilocos Sur
GABRIELA SILANG GENERAL HOSPITAL
Vigan City
URINALYSIS
Date: ________________
Name: ________________________________________________________
Ward: _____________ Age: ______ Classification: ____________________

COLOR: ___________________ REACTION: ___________________
CHARACTER: ________________ SPECIFIC GRAVITY: _____________
ALBUMIN: ___________________ SUGAR: _____________________

MICROSCOPIC FINDINGS

Hyaline: ______________________ Amorphous Urates: _________________
Course Granular: _______________ Calcium Oxalates: __________________
Fine Granular: _________________ Uric Acid: _________________________
Pus Cast: _____________________ Triple Phosphate: ___________________
Waxy Cast: ___________________ Amorphous Phosphate: ______________
Cylindroids: _________________ Ammonium Biurates: ________________

CELLS

Pus Cells: _________________________ Squamos: _____________________
RBC: ___________________________ Bladder: _____________________
Leucocytes: _____________________ Renal: _______________________
Mucus Threads: _________________ Bacteria: _____________________
Yeast Cells: _____________________ Others: _______________________



Medical Technologist-on-duty

MYRNA N. CARANTO, RMT
Department Head
BRENDA I. ROSUMAN, MD, FPSP
Pathologist



Gabriela Silang General Hospital
Department of Laboratory
Vigan City


BLOOD CROSSMATCHING RESULT


Name of Recipient: _______________________________ Age: _________ Sex: _________
Lab. No. ________________ Blood Type ____________ RH _______ Ward _____________
Source of Blood ________________________ Blood Component _____________________
Serial Number _________________________ Collection Date ________________________
Unit Blood Type & RH Type _______________ Expiry Date ___________________________
Quantity ______________________________

CROSSMATCHING
Type of Crossmatching Requested ( ) Routine ( ) Stat
Result of Crossmatching ( ) Compatible ( ) Incompatible
( ) No Hemolysis ( ) Hemolyzed

Date Issued ________________________ Date Crossmatched _______________________
Time _____________ AM/PM Time _______________ AM/PM


____________________ __________________
Medical Technologist Pathologist


GABRIELA SILANG GENERAL HOSPITAL


ID: Mode: Time:
Name: Gender : Age:
Chart Dept.: Bed No.:

Parameter Result Ref. range
____________________________________________________________________________
WBC x 10^9/L
Lymph x 10^9/L
Mid# x 10^9/L
Gran# x 10^9/L
Lymph% %
Mid% %
Gran% %

HGB g/L

RBC %
HCT %
HCV fL
MCH pg
MCHC g/L
RDW CV %
RDW SD fL

PLT X 10^9/L
MPV fL
PDW
PCT %

Sender: Tester: Checker:

Province of Ilocos Sur
GABRIELA SILANG GENERAL HOSPITAL
Vigan City

HEMATOLOGY

Patient ID: Last Name: First Name: Gender:
Age: Birthday: Dept.: Bed No.:
Sample ID: Run Time: Mode:

Parameter Result Unit Ref. range
WBC x10^9/L 5.00 10.00
Neu% % 50.0 70.0
Lymph % 20.0 40.0
Mon% % 3.0 12.0
Eos% % 0.5 5.0
Bas% % 0.0 1.0

RBC x10^12/L 3.50-5.00
HGB g/L 110-150
HCT % 37.0 -47.0
MCV fL 80.0 100.0
MCH pg 27.0 34.0
MCHC g/L 320-360
RDW CV % 11.0 16.0
RDW SD fL 35.0 56.0

PLT x 10^9/L 150-400
MPV fL 6.5 12.0
PDW 9.0 17.0


________________________
Medical Technologist-on-duty



__________________ ____________________ ________________
Requesting Physician Department Head Pathologist

GABRIELA SILANG GENERAL HOSPITAL
Department of Laboratory Medicine
Vigan City, Ilocos Sur

BLOOD CHEMISTRY

SurName: Sex:
First Name: Birthdate:
Age: Admis. Date:
Physician: Ward:
Address: Patient ID:
Notes: Sample ID:

Run Date:

Test Name Result Unit Normal Range
______________________________________________________________

Glucose
Creatinine
Urea
Cholesterol
HDL
Triglyceride
LDL
GOT/AST
GPT/ALT
Uric Acid
Phosphorous
Total Protein
Albumin
Total Bilirubin
Direct Bilirubin
LDH
Alkaline Phosphatase
Amylase
Calcium