Critical Value Acknowledgment

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Clinical Contact Information

Please note the appropriate persons to serve as a contact for laboratory staff to relay clinical information, including critical values.
How does this account want to receive their critical values? *
Do you want a backup with email? *

Phone must have an active voicemail to allow voicemails if we are unable to reach a live person: (must have atleast 1)

 * Primary
Name
Phone Number
 Tertiary
Name
Phone Number
 Secondary
Name
Phone Number

Backup Emails: (Back up email will only be used if we cannot reach a live person after trying to reach the contacts listed above. One attempt will be made to reach each contact provided. A voicemail will be left if available)

Critical Values List

1. Analyte: Blood Cultures | CRITICAL Values: ANY POSITIVE

2. Analyte: Acetaminophen | CRITICAL Values: >70 μg/mL

3. Analyte: Alcohol | CRITICAL Values: >300 mg/dL

4. Analyte: Calcium | CRITICAL Values: ( LOW <6.0 ) ( HIGH >12.5 ) mg/dL

5. Analyte: Carbamazepine | CRITICAL Values: > 12 μg/mL

6. Analyte: Digoxin | CRITICAL Values: > 2.5 ng/mL

7. Analyte: Glucose | CRITICAL Values: ( LOW < 60 ) ( HIGH > 400 ) mg/dL

8. Analyte: Hematocrit | CRITICAL Values: ( LOW < 20 ) ( HIGH > 60 ) %

9. Analyte: Hemoglobin | CRITICAL Values: ( LOW < 7.0 ) ( HIGH Male > 18.5 ) ( HIGH Female > 16.5 ) g/dL

10. Analyte: Magnesium | CRITICAL Values: ( LOW < 1.1 ) ( HIGH > 4.4 ) g/dL

11. Analyte: Lithium | CRITICAL Values: > 1.5 mmol/L

12. Analyte: Phenytoin | CRITICAL Values: > 40 μg/mL

13. Analyte: Phenobarbital | CRITICAL Values: > 60 μg/mL

14. Analyte: Platelet | CRITICAL Values: ( LOW < 50 ) ( HIGH > 750 ) K/μL

15. Analyte: Potassium | CRITICAL Values: ( LOW < 2.8 ) ( HIGH > 6.0 ) mmol/L

16. Analyte: PT-INR | CRITICAL Values: > 4.5 sec

17. Analyte: APTT | CRITICAL Values: > 105.6 sec

18. Analyte: Sodium | CRITICAL Values: ( LOW < 120 ) ( HIGH > 155 ) mmol/L

19. Analyte: Theophylline | CRITICAL Values: > 20 μg/mL

20. Analyte: Total Bilirubin | CRITICAL Values: > 11.9 mg/dL

21. Analyte: Valproic Acid | CRITICAL Values: > 150 μg/mL

22. Analyte: Vancomycin | CRITICAL Values: > 40 μg/mL

23. Analyte: WBC | CRITICAL Values: ( LOW < 2.0 ) ( HIGH > 30.0 ) K/μL

Critical Value Approval Section

I have reviewed the above critical values and understand that Mako Medical will call any patient result which fits the above criteria.
Furthermore, I understand these values are subject to change without notice.
Approving Authority Signature *
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