Critical Value Acknowledgement- Mako Medical

Critical Value Acknowledgement
Submitters Name:

First NameLast Name
Submitters Email:
example@example.com
Clinic/Facility Name:
Clinical Contact Information
Please note the appropriate persons to serve as a contact for laboratory staff to relay clinical information, including critical values.
How does this account want to receive their critical values?
Do you want a backup email?
Primary:

First NameLast Name
Primary Phone:
Format: (000) 000-0000.
Secondary:

First NameLast Name
Secondary Phone:
Format: (000) 000-0000.
Tertiary:

First NameLast Name
Tertiary Phone:
Format: (000) 000-0000.
Backup Emails: (Back up email will only be used if we cannot reach a live person after trying to reach the contacts listed above. One attempt will be made to reach each contact provided. A voicemail will be left if available)
Backup Email #1
Backup Email #2
Backup Email #3
Email #1
Email #2
Email #3
Add additional email addresses:

- 1. Analyte: Blood Cultures | CRITICAL Values: ANY POSITIVE
  
  2. Analyte: Acetaminophen | CRITICAL Values: >70 μg/mL
  
  3. Analyte: Alcohol | CRITICAL Values: >300 mg/dL
  
  4. Analyte: Calcium | CRITICAL Values: ( LOW <6.0 ) ( HIGH >12.5 ) mg/dL
  
  5. Analyte: Carbamazepine | CRITICAL Values: > 12 μg/mL
  
  6. Analyte: Digoxin | CRITICAL Values: > 2.5 ng/mL
  
  7. Analyte: Glucose | CRITICAL Values: ( LOW < 60 ) ( HIGH > 400 ) mg/dL
  
  8. Analyte: Hematocrit | CRITICAL Values: ( LOW < 20 ) ( HIGH > 60 ) %
  
  9. Analyte: Hemoglobin | CRITICAL Values: ( LOW < 7.0 ) ( HIGH Male > 18.5 ) ( HIGH Female > 16.5 ) g/dL
  
  10. Analyte: Magnesium | CRITICAL Values: ( LOW < 1.1 ) ( HIGH > 4.4 ) g/dL
  
  11. Analyte: Lithium | CRITICAL Values: > 1.5 mmol/L
  
  12. Analyte: Phenytoin | CRITICAL Values: > 40 μg/mL
  
  13. Analyte: Phenobarbital | CRITICAL Values: > 60 μg/mL
  
  14. Analyte: Platelet | CRITICAL Values: ( LOW < 50 ) ( HIGH > 750 ) K/μL
  
  15. Analyte: Potassium | CRITICAL Values: ( LOW < 2.8 ) ( HIGH > 6.0 ) mmol/L
  
  16. Analyte: PT-INR | CRITICAL Values: > 4.5 sec
  
  17. Analyte: APTT | CRITICAL Values: > 105.6 sec
  
  18. Analyte: Sodium | CRITICAL Values: ( LOW < 120 ) ( HIGH > 155 ) mmol/L
  
  19. Analyte: Theophylline | CRITICAL Values: > 20 μg/mL
  
  20. Analyte: Total Bilirubin | CRITICAL Values: > 11.9 mg/dL
  
  21. Analyte: Valproic Acid | CRITICAL Values: > 150 μg/mL
  
  22. Analyte: Vancomycin | CRITICAL Values: > 40 μg/mL
  
  23. Analyte: WBC | CRITICAL Values: ( LOW < 2.0 ) ( HIGH > 30.0 ) K/μL
- Critical Value Approval Section
- I have reviewed the above critical values and understand that Mako Medical will call any patient result which fits the above criteria.
  
  Furthermore, I understand these values are subject to change without notice.
- Name:
  
  First NameLast Name
- Title/Position:
- Signature
Should be Empty:

Critical Value Acknowledgement

Clinical Contact Information

Critical Value Approval Section