Get the free Kleihauer Request Form

Leader Request Form 457/KLE CASE # : All requests for this test must be Patient Label: Ordering Physician: accompanied by this form. Any delays in returning this form or any incomplete information

How to fill out kleihauer request form

How to Fill Out Kleihauer Request Form:

1. Obtain the Kleihauer request form: The form can be obtained from the laboratory or healthcare facility responsible for conducting the test. It may also be available for download on their website or provided by the healthcare provider.
2. Fill in patient information: Provide accurate and complete patient information, including the patient's name, date of birth, medical record number (if applicable), and contact information. This information is crucial to ensure the test results are attributed to the correct individual.
3. Indicate ordering physician: Include the name, contact information, and medical license number of the ordering physician responsible for requesting the Kleihauer test. This allows the laboratory to communicate the results to the relevant healthcare provider.
4. Specify relevant details: Provide relevant details about the patient's condition or circumstances that warrant the Kleihauer test. This may include information about recent trauma, suspected fetal-maternal bleeding, or known blood disorders that require monitoring or intervention.
5. Include relevant clinical history: Describe the clinical history and relevant medical information that could impact the interpretation of the test results. This may include details about previous pregnancies, blood transfusions, or any underlying medical conditions that could affect the presence or severity of fetal-maternal hemorrhage.
6. Document recent interventions: If the patient has received any recent interventions, such as anti-D immunoglobulin administration or other therapies that might interfere with the test results, it is important to indicate them on the form. This allows the laboratory to consider these factors during the analysis.
7. Provide specimen details: Specify the specimen type and collection method. The Kleihauer test typically requires a blood sample, so indicate whether it is a venous or arterial blood sample, and the volume required for the test.
8. Include any additional instructions: If there are any specific instructions or requests for the laboratory, such as urgent processing or special handling requirements, make sure to include them on the form. This ensures that the laboratory staff can adhere to the necessary procedures.

Who Needs Kleihauer Request Form:

1. Obstetricians and gynecologists: These healthcare professionals often utilize the Kleihauer test to evaluate fetal-maternal hemorrhage in pregnant individuals.
2. Healthcare providers managing trauma cases: The Kleihauer test can be essential in determining the extent of maternal-fetal hemorrhage following trauma, allowing appropriate interventions to be implemented.
3. Individuals with blood disorders or complications: Patients with blood disorders or those who have experienced complications during pregnancy may require regular Kleihauer testing to monitor fetal-maternal hemorrhage and guide medical management.

Overall, the Kleihauer request form should be completed accurately and comprehensively to ensure the laboratory can interpret the test results correctly and communicate them to the relevant healthcare providers.

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What is kleihauer request form?

The kleihauer request form is a medical test used to determine the fetal-maternal hemorrhage (FMH) in pregnant women.

Who is required to file kleihauer request form?

Pregnant women whose healthcare provider suspects FMH may be required to file the kleihauer request form.

How to fill out kleihauer request form?

The kleihauer request form can be filled out by healthcare providers who are trained to perform the test and interpret the results.

What is the purpose of kleihauer request form?

The purpose of the kleihauer request form is to quantify the volume of fetal blood that has entered the maternal bloodstream.

What information must be reported on kleihauer request form?

The kleihauer request form must include the patient's demographic information, medical history, test results, and interpretation of the findings.