BLOOD DRAW

Pre-Draw Checklist:

Patient Identification Confirmed: [checkbox name="variable_1" value="YES"]
Patient Informed Consent Obtained: [checkbox name="variable_2" value="YES"]
Relevant Patient History Noted: (e.g., allergies, previous complications, etc.) [checkbox name="variable_3" value="YES"]

Fasting Status:
[checkbox name="variable_4" value="Fasting|Non-fasting"]

Blood Draw Procedure:

Site of Draw: [text name="variable_5" default=""]
Tourniquet Applied:
[checkbox name="variable_6" value="YES|NO"]
Needle Gauge: [text name="variable_7" default=""]
Number of Attempts: [text name="variable_8" default=""]
Type of Collection Tubes Used:
[checklist name="variable_9" value="Red Top Tube|Gold Top Tube|Light Blue Top Tube|Green Top Tube|Lavender or Purple Top Tube|Gray Top|Light Yellow Top Tube|Dark Blue Top Tube|Pink Top Tube|Black Top Tube|Yellow Top Tube"]
Time of Blood Draw:[text name="variable_10" default=""]
Patient Response:

Patient's Condition During Draw:[text name="variable_11" default=""]
Any Complications Noted: [textarea name="variable_12" default=""]
Patient's Condition Post-Draw: [textarea name="variable_13" default=""]

Post-Draw Care: [textarea name="variable_14" default=""]

Site of Draw Managed:
Post-Draw Instructions Given to Patient: (e.g., keep bandage on for 30 minutes, avoid heavy lifting)

Specimen Handling:
Labeling of Tubes Confirmed: YES

Specimen Transport Method: Hand delivered to lab    staff with patient information and order slips.

Additional Notes: [textarea name="variable_15" default=""]

Pre-Draw Checklist:

Patient Identification Confirmed:
Patient Informed Consent Obtained:
Relevant Patient History Noted: (e.g., allergies, previous complications, etc.)

Fasting Status:


Blood Draw Procedure:

Site of Draw:
Tourniquet Applied:

Needle Gauge:
Number of Attempts:
Type of Collection Tubes Used:

Time of Blood Draw:
Patient Response:

Patient's Condition During Draw:
Any Complications Noted:

Patient's Condition Post-Draw:


Post-Draw Care:


Site of Draw Managed:
Post-Draw Instructions Given to Patient: (e.g., keep bandage on for 30 minutes, avoid heavy lifting)

Specimen Handling:
Labeling of Tubes Confirmed: YES

Specimen Transport Method: Hand delivered to lab staff with patient information and order slips.

Additional Notes:


Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.4, 15 form elements, 99 boilerplate words, 5 text boxes, 4 text areas, 5 checkboxes, 1 check lists, 27 total clicks
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