The version of Shared Health's Biochemistry/Hematology requisition for clinics and community settings outside Winnipeg and Brandon. Alongside the core chemistry, hematology and drug-level tests, it adds tests common at rural sites: dipstick urinalysis, urine pregnancy, Group A strep antigen and qualitative HCG. Version V04, implemented provincially on March 20, 2024, is current; Winnipeg and Brandon clinics use R250-10-94 instead.
The ordering provider completes the asterisked provider and patient fields, copy-to recipients, fasting instructions, tests and any dose or travel details. The collector records the diamond-marked collection fields and, at a referring lab, the number of serum and plasma tubes sent.
Download the current version from the source each time; forms change without notice.
Biochemistry / Hematology Requisition - Clinics & Community, Outside Winnipeg and Brandon
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Both are Shared Health Biochemistry/Hematology requisitions for clinic and community patients. R250-10-92 is for sites outside Winnipeg and Brandon and adds dipstick urinalysis, urine pregnancy, Group A strep antigen and qualitative HCG, with dual test codes. R250-10-94 is for Winnipeg and Brandon clinics, and hospital patients use R250-10-91 or R250-10-93.
Effective March 20, 2024, version V04 updated some biochemistry test codes, added a section for the physician's fasting instructions, and removed oral glucose tolerance and glucose challenge tests, which moved to the General Endocrinology requisition. Hematology sections did not change, and less common tests that were dropped can still be written under Additional Tests.
Shared Health's FAQ states the ordering practitioner of record is legally responsible for critical results. R250-10-92 therefore makes the critical results phone number mandatory; for outpatients, an after-hours contact must be on the requisition or in the laboratory information system, or the specimen may be rejected.