Shared Health's standardized requisition for outpatient biochemistry, hematology and therapeutic drug monitoring ordered from clinics and community settings in Winnipeg and Brandon. It covers electrolytes, renal and liver tests, lipids, A1c, TSH reflex, iron studies, CBC, coagulation, malaria and drug levels. Version V02, implemented March 20, 2024, added a fasting-instruction section; clinics outside the two cities use R250-10-92.
The ordering provider completes the provider, copy-to, patient and fasting sections and ticks the tests, with mandatory fields marked by an asterisk. The person collecting the sample completes the collection fields marked with a diamond.
Download the current version from the source each time; forms change without notice.
Biochemistry / Hematology Requisition - Clinic & Community, Winnipeg and Brandon
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The form warns that if copy-to information is missing, the report may not be sent to that recipient. Give the full last and first name, phone, fax and facility name or address for each copy. Missing or illegible mandatory fields elsewhere on the form can result in specimen rejection.
The therapeutic drug monitoring section, covering drugs such as lithium, digoxin, vancomycin trough, tacrolimus and valproic acid, states that dose information must be completed: the last dose date and time and the next dose date and time. For PT/INR, the form also asks whether the patient is on an anticoagulant and which one.
No. Shared Health's 2021 practice change states the requisitions are owned and document-controlled by Shared Health Diagnostic Services and cannot be altered for site-specific use without its approval. EMR vendors and print shops receive the official versions, and prior versions should be deleted from the EMR when a new form replaces them.