ISHBT - CMC VELLORE EQAS– HEMOSTASIS MODULE

RESULT ENTRY FORM 2018

PIN NUMBERSURVEY #
  1. PROTHROMBIN TIME

RESULTS (Enter your results in the boxes below, by giving the mean values of duplicate tests)

Results /

Spec ID #

/ Spec ID #
Prothrombin Time (PT)
(secs)
MNPT*
Interpretation
(Section F)
INR
Interpretation
(Section F)

*: MNPT = Mean Normal Prothrombin Time

  1. ACTIVATED PARTIAL THROMBOPLASTIN TIME

RESULTS (Enter your results in the boxes below, by giving the mean values of duplicate tests)

Results

/

Spec ID #

/ Spec ID #
APTT
(secs)
Mid point of reference interval #
Interpretation
(Section F)

# Mid point of Reference Interval = Lower limit + Upper limit

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2

  1. THROMBIN TIME

RESULTS (Enter your results in the boxes below, by giving the mean values of duplicate tests)

Results

/

Spec ID #

/ Spec ID #
Thrombin Time(TT)
(secs)
Interpretation
(Section F )

PIN NUMBERSURVEY #

  1. FIBRINOGEN ASSAY

RESULTS (Enter your results in the boxes below, by giving the mean values of duplicate tests)

FIBRINOGEN ASSAY / Spec ID # / Spec ID #
RESULT (mg/dL)
INTERPRETATION
(Section F)
  1. FACTOR VIII: C ASSAY

RESULTS (Enter your results in the boxes below, by giving the mean values of duplicate tests)

Factor VIII / Spec ID # / Spec ID #
Result (U/dl)
Interpretation
(Section F)
  1. FACTOR IX: C ASSAY

RESULTS (Enter your results in the boxes below, by giving the mean values of duplicate tests)

Factor IX / Spec ID # / Spec ID #
Result (U/dl)
Interpretation
(Section F)

PIN NUMBERSURVEY #

  1. VON WILLEBRAND FACTOR (ANTIGEN) ASSAY

RESULTS (Enter your results in the boxes below, by giving the mean values of duplicate tests)

VON WILLEBRAND FACTOR ASSAY / Spec ID # / Spec ID #
RESULT
INTERPRETATION
(Section F)
  1. VON WILLEBRAND FACTOR RISTOCETIN COFACTOR ASSAY

RESULTS (Enter your results in the boxes below, by giving the mean values of duplicate tests)

VWF:RCo / Spec ID # / Spec ID #
RESULT
INTERPRETATION
(Section F)

SECTION F: INTERPRETATION CODE

Test / Interpretation code
Prothrombin time
Activated Partial Thromboplastin Time
Thrombin Time
Fibrinogen assay
Factor VIII assay
Factor IX assay
Von Willebrand Antigen Assay / Normal / 1
Borderline / 2
Abnormal / 3
INR / Above therapeutic interval / 4
Within therapeutic interval / 5
Below therapeutic interval / 6

PIN NUMBERSURVEY #

The following details are mandatory and will help in the organization of the program:

Date survey received: (dd/mm/yyyy)

Date survey returned: (dd/mm/yyyy)

Name: ______

Signature: ______

Use only the provided result entry forms/Xerox copies for result submission.

Effective: 17/04/2018 / Version 2.1 / Haemostasis Result Entry Form / 1/4