Critical Lab Value Acknowledgement Form
Document the receipt, acknowledgment, and follow-up actions for a critical laboratory result.
Patient Initials
*
Medical Record Number (MRN)
*
Date and Time of Critical Result
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Lab Test Name
*
Critical Value
*
Person Notified
*
Please Select
Ordering Physician
Nurse
Resident
Physician Assistant
Other
Method of Notification
*
Phone Call
In Person
Secure Messaging
Other
Follow-Up Action Taken
*
Repeat Test Ordered
Treatment Initiated/Modified
Clinical Team Notified
Patient Notified
Other
Additional Comments
Submit Acknowledgement
Should be Empty: