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Patan Academy of Health Sciences: Pcrlab@pahs - Edu.np Ewarsedcd@gmail - Co Pcrlab@pahs - Edu.np

This document is a laboratory sample collection form for suspected COVID-19 cases that will undergo RT-PCR testing. It collects patient details like name, age, symptoms, travel history, and comorbidities. It also documents the type of sample collected, how it was transported maintaining cold chain and triple packaging, and notes the form must be filled out and sample received by the lab by 10am for reporting within 24 hours. Details are also required to be sent electronically to specific email addresses.

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Bhageshwar Chaudhary
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564 views2 pages

Patan Academy of Health Sciences: Pcrlab@pahs - Edu.np Ewarsedcd@gmail - Co Pcrlab@pahs - Edu.np

This document is a laboratory sample collection form for suspected COVID-19 cases that will undergo RT-PCR testing. It collects patient details like name, age, symptoms, travel history, and comorbidities. It also documents the type of sample collected, how it was transported maintaining cold chain and triple packaging, and notes the form must be filled out and sample received by the lab by 10am for reporting within 24 hours. Details are also required to be sent electronically to specific email addresses.

Uploaded by

Bhageshwar Chaudhary
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Patan Academy of Health Sciences

Patan Hospital, Lagankhel, Lalitpur, Nepal


Laboratory Sample Collection Form for Suspected COVID19 Case (RT-PCR)

Date:      Reference Number:     

Patient’s Detail
Patient’s Name:      
Patient’s Age:       Sex: Male
Patient’s Temporary Address Province:       District:      
Municipality:       Ward:      
Patient’s Permanent Address Province:       District:      
Municipality:       Ward:      
Patient’s contact detail Landline:       Mobile:       Email:      
Name of hospital where      
patient is admitted
Patient’s Hospital ID      

Travel and Contact History


Details Yes
Travelled in last 28 days to the community which has detection of case Yes
Anyone from the family or close contact travelled last 28 days to the community which has detection of case Yes
History of close contact with COVID19 positive patient Yes
Health care worker taking care of COVID19 positive patient Yes
Symptoms
Fever Myalgia Rhinorrhea Anosmia
Cough SOB Sore throat Diarrhea

Comorbid conditions
     

Clinical condition: Asymptomatic

Radiological/Test result
Chest X ray      CT Chest      RDT     

Type of sample collected for RT-PCR


Nasopharyngeal Oropharyngeal (Throat) Endotracheal Aspirate Bronchialveolar

Transportation
Sample in VTM Triple layer packaging done Cold chain maintained

Information
Sample must reach Patan Hospital, PCR lab by 10 am
Reports will be made available after 12-24 hours
This form needs to be filled mandatory by clinician to send sample for COVID19 test
Sample from the patient not meeting the criteria of suspect and not in isolation facility won’t be accepted for COVID19 testing
Sample should be collected and transported in VTM in triple layer packaging and maintaining cold chain
As all testing are reported to government authority, above mentioned details need to be verified by authorized person of hospital
Please send this form electronically to pcrlab@pahs.edu.np
EDCD patient detail form is also required to fill up and sent to ewarsedcd@gmail.co and pcrlab@pahs.edu.np

Focal person for COVID19 Attending Doctor


Name:       Name:      
Position:       Position:      
Signature:       Signature:      
Phone number:       Phone number:      
Email address:       Email address:      
Patan Academy of Health Sciences
Patan Hospital, Lagankhel, Lalitpur, Nepal
Laboratory Sample Collection Form for Suspected COVID19 Case (RT-PCR)

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