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BIOCHEMISTRY LAB FEEDBACK (WITHIN 24 HOURS)
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* Indicates required question
Patient name
*
Your answer
Hospital ID
*
Your answer
Date and time of requisition of sample
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Type - IPD or OPD
*
IPD
OPD
Other
Required
If IPD, mention who has despatched the sample and time of despatch
*
Your answer
Department/ Ward Number
*
Your answer
Investigation requested by
*
Intern
Junior Resident
Senior Resident
Consultant
Research purpose
Other:
Required
Category of investigation
*
For qualitative urine analysis, mention in "other"
Routine parameters
Special parameters
Quantitative urine analysis
Electrophoresis/ stone analysis
Required
Nature of query
*
For missing values, feedback should be provided on the same date of sample receipt. Kindly repeat test if missing values are identified at a later time.
Report not received
Erroneous values in report
Missing parameters in report
Other:
Required
Any other comments or requests
*
Please provide feedback/ requests regarding any new investigations to be started or how lab services can be improved
Your answer
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