Get Therapeutic Apheresis Service Request With Therapeutic Phlebotomy Orders.docx
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How to fill out the Therapeutic Apheresis Service Request With Therapeutic Phlebotomy Orders.docx online
Completing the Therapeutic Apheresis Service Request With Therapeutic Phlebotomy Orders form online is a straightforward process that ensures essential medical information is accurately conveyed. This guide will walk you through each section of the form, helping you to fill it out efficiently and correctly.
Follow the steps to complete the form effectively.
- Click the ‘Get Form’ button to access the document and open it in the online editor.
- In the Referring Site Information section, fill in the requesting location, the ordering physician's printed name, and the contact person's details along with their telephone number.
- Provide the Patient Information by entering the patient's full name, date of birth, Geisinger MRN if known, phone number, and address.
- For the Procedure Order, check the box next to the specific treatment being requested, such as Therapeutic Plasmapheresis or Plateletapheresis.
- In the Therapeutic Phlebotomy Order section, specify the hemoglobin or hematocrit level threshold, the volume to remove, and whether IV Normal Saline replacement is necessary.
- State the treatment diagnosis, including the primary treatment diagnosis and its corresponding ICD 10 code.
- Outline the treatment plan by checking the frequency of treatments and specifying the duration.
- For replacement fluid (if applicable), indicate the type of fluid to be used, along with any specific instructions.
- If necessary, provide details on special lab requests, including their frequency and any specific tests required.
- Complete the physician's information, including their name, phone number, signature, and date.
- Finally, fill in the Patient Insurance Information, including the primary and secondary insurance carrier and ID numbers.
- Once all sections are completed, you can save your changes, download the document, print it, or share it as needed.
Start filling out your forms online today to ensure a smooth and efficient process.
Apheresis is an invasive procedure. It has significant physiologic consequences, so the care of these patients requires continuous supervision. Phlebotomy is performed as an intervention for some disease management.
Fill Therapeutic Apheresis Service Request With Therapeutic Phlebotomy Orders.docx
This form is used to document a physician's request for a therapeutic collection. Therapeutic phlebotomy is performed in a medically supervised environment. Download forms to request specialty blood products and services from Carter BloodCare. Therapeutic Apheresis. ☑ If adverse reaction, then discontinue phlebotomy treatment and notify MRP; document amount of blood removed prior to discontinuation.
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