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skills/clinical-reports/assets/lab_report_template.md

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+# Laboratory Report Template
+
+## Patient Information
+
+**Patient Name:** [Last, First]  
+**Medical Record Number:** [MRN]  
+**Date of Birth:** [MM/DD/YYYY]  
+**Age/Sex:** [Age years, M/F]
+
+**Ordering Physician:** [Name]  
+**Location:** [Inpatient unit / Outpatient clinic]
+
+---
+
+## Specimen Information
+
+**Specimen Type:** [Blood / Serum / Plasma / Urine / CSF / Other]  
+**Collection Date/Time:** [MM/DD/YYYY at HH:MM]  
+**Received Date/Time:** [MM/DD/YYYY at HH:MM]  
+**Reported Date/Time:** [MM/DD/YYYY at HH:MM]
+
+**Accession Number:** [Lab accession number]  
+**Specimen Condition:** [Acceptable / See comments]  
+**Fasting Status:** [Fasting / Non-fasting / Unknown] (if relevant)
+
+---
+
+## Laboratory Results
+
+| Test Name | Result | Units | Reference Range | Flag |
+|-----------|--------|-------|----------------|------|
+| [Test] | [Value] | [Unit] | [Normal range] | [L/H/Critical] |
+
+### Example: Complete Blood Count (CBC)
+
+| Test | Result | Units | Reference Range | Flag |
+|------|--------|-------|----------------|------|
+| White Blood Cell Count | 12.5 | × 10³/μL | 4.5-11.0 | H |
+| Hemoglobin | 10.2 | g/dL | 12.0-16.0 (F), 14.0-18.0 (M) | L |
+| Hematocrit | 31.5 | % | 36.0-48.0 (F), 42.0-52.0 (M) | L |
+| Platelet Count | 245 | × 10³/μL | 150-400 | - |
+| MCV | 88.5 | fL | 80.0-100.0 | - |
+| MCH | 29.5 | pg | 27.0-33.0 | - |
+| MCHC | 33.2 | g/dL | 32.0-36.0 | - |
+| RDW | 14.5 | % | 11.5-14.5 | - |
+
+**Differential:**
+| Cell Type | Result | Units | Reference Range | Flag |
+|-----------|--------|-------|----------------|------|
+| Neutrophils | 75 | % | 40-70 | H |
+| Lymphocytes | 15 | % | 20-40 | L |
+| Monocytes | 7 | % | 2-10 | - |
+| Eosinophils | 2 | % | 1-4 | - |
+| Basophils | 1 | % | 0-2 | - |
+
+### Example: Basic Metabolic Panel (BMP)
+
+| Test | Result | Units | Reference Range | Flag |
+|------|--------|-------|----------------|------|
+| Sodium | 138 | mEq/L | 136-145 | - |
+| Potassium | 3.2 | mEq/L | 3.5-5.0 | L |
+| Chloride | 102 | mEq/L | 98-107 | - |
+| CO2 | 24 | mEq/L | 22-30 | - |
+| Blood Urea Nitrogen | 28 | mg/dL | 7-20 | H |
+| Creatinine | 1.8 | mg/dL | 0.6-1.2 (F), 0.7-1.3 (M) | H |
+| Glucose | 145 | mg/dL | 70-100 (fasting) | H |
+| eGFR | 42 | mL/min/1.73m² | >60 | L |
+
+---
+
+## Interpretation / Comments
+
+[Clinical interpretation when applicable]
+
+**Example for Anemia:**
+```
+Normocytic anemia with elevated WBC. Differential diagnosis includes anemia of chronic 
+disease, recent blood loss, or hemolysis. Consider reticulocyte count, iron studies, 
+and peripheral smear for further evaluation. Clinical correlation recommended.
+```
+
+**Example for Electrolyte Abnormality:**
+```
+Hypokalemia detected (K+ 3.2 mEq/L). Common causes include diuretic use, GI losses, or 
+inadequate intake. Recommend potassium repletion and follow-up testing. Moderate 
+azotemia present, consistent with acute kidney injury or chronic kidney disease. 
+Clinical correlation with patient history and prior results recommended.
+```
+
+---
+
+## Critical Values
+
+[If any results meet criteria for critical values]
+
+**Critical Result:** [Test name] = [Value] [Units]  
+**Reference Range:** [Normal range]  
+**Significance:** [Life-threatening, requires immediate action]
+
+**Notification:**
+- **Called to:** [Name and title of person notified]
+- **Date/Time:** [MM/DD/YYYY at HH:MM]
+- **Read-back verified:** [Yes]
+- **Notified by:** [Lab personnel name]
+
+**Example Critical Values:**
+- Glucose <40 mg/dL or >500 mg/dL
+- Potassium <2.5 mEq/L or >6.5 mEq/L
+- Sodium <120 mEq/L or >160 mEq/L
+- Hemoglobin <5.0 g/dL
+- Platelets <20 × 10³/μL
+- WBC <1.0 × 10³/μL or >50 × 10³/μL
+- INR >5.0 (on warfarin)
+- Positive blood culture
+- Positive CSF Gram stain
+
+---
+
+## Quality Control
+
+**Specimen Quality:** [Acceptable / See note]
+
+**QC Notes:**
+- [X] Specimen collected in appropriate tube
+- [X] Specimen adequately labeled
+- [X] Specimen volume sufficient
+- [X] No hemolysis, lipemia, or icterus
+- [X] Specimen processed within acceptable time
+
+**Issues (if any):**
+- [ ] Hemolyzed - may affect [specific tests]
+- [ ] Clotted - unable to perform coagulation studies
+- [ ] Insufficient volume - limited testing performed
+- [ ] Delayed processing - stability concerns for [specific analytes]
+
+---
+
+## Methodology
+
+**Test Method:** [Instrumentation and methodology]
+
+Examples:
+- **CBC:** Automated cell counter (Sysmex XN-1000)
+- **Chemistry:** Spectrophotometry (Beckman AU5800)
+- **Glucose:** Enzymatic assay, hexokinase method
+- **HbA1c:** HPLC (high-performance liquid chromatography)
+- **Troponin:** High-sensitivity immunoassay
+- **Drug levels:** Liquid chromatography-mass spectrometry (LC-MS/MS)
+
+---
+
+## Special Tests Examples
+
+### Hemoglobin A1c
+
+| Test | Result | Units | Interpretation |
+|------|--------|-------|----------------|
+| HbA1c | 8.5 | % | Consistent with poorly controlled diabetes |
+| HbA1c | 8.5 | % (69 mmol/mol) | Target <7% for most patients |
+
+**Reference Ranges:**
+- Non-diabetic: 4.0-5.6%
+- Prediabetes: 5.7-6.4%
+- Diabetes diagnosis: ≥6.5%
+- Treatment target: <7% (individualized)
+
+### Lipid Panel
+
+| Test | Result | Units | Reference Range | Desirable |
+|------|--------|-------|----------------|-----------|
+| Total Cholesterol | 245 | mg/dL | - | <200 |
+| LDL Cholesterol | 160 | mg/dL | - | <100 |
+| HDL Cholesterol | 38 | mg/dL | - | >40 (M), >50 (F) |
+| Triglycerides | 235 | mg/dL | - | <150 |
+| VLDL Cholesterol (calc) | 47 | mg/dL | - | <30 |
+
+### Coagulation Studies
+
+| Test | Result | Units | Reference Range | Flag |
+|------|--------|-------|----------------|------|
+| PT | 18.5 | seconds | 11.0-13.5 | H |
+| INR | 2.8 | ratio | 0.8-1.2 | H |
+| PTT | 42 | seconds | 25-35 | H |
+
+**Therapeutic Ranges (INR):**
+- Atrial fibrillation: 2.0-3.0
+- Mechanical heart valve: 2.5-3.5
+- DVT/PE treatment: 2.0-3.0
+
+### Thyroid Function Tests
+
+| Test | Result | Units | Reference Range | Flag |
+|------|--------|-------|----------------|------|
+| TSH | 8.5 | μIU/mL | 0.4-4.0 | H |
+| Free T4 | 0.7 | ng/dL | 0.8-1.8 | L |
+| Free T3 | 2.1 | pg/mL | 2.3-4.2 | L |
+
+**Interpretation:** Findings consistent with primary hypothyroidism
+
+### Urinalysis
+
+**Physical Examination:**
+- Color: [Yellow / Amber / Other]
+- Clarity: [Clear / Cloudy / Turbid]
+- Specific Gravity: [1.005-1.030]
+
+**Chemical Examination:**
+| Test | Result | Reference |
+|------|--------|-----------|
+| pH | 6.0 | 5.0-8.0 |
+| Protein | Trace | Negative |
+| Glucose | Negative | Negative |
+| Ketones | Negative | Negative |
+| Blood | 2+ | Negative |
+| Bilirubin | Negative | Negative |
+| Urobilinogen | Normal | Normal |
+| Nitrite | Negative | Negative |
+| Leukocyte Esterase | Positive | Negative |
+
+**Microscopic Examination (if indicated):**
+- WBCs: [number] /hpf (normal <5)
+- RBCs: [number] /hpf (normal <3)
+- Epithelial cells: [Few/Moderate/Many]
+- Bacteria: [None/Few/Moderate/Many]
+- Casts: [Type and number]
+- Crystals: [Type if present]
+
+---
+
+## Microbiology Report Format
+
+### Culture Results
+
+**Specimen Source:** [Blood / Urine / Sputum / Wound / Other]  
+**Collection:** [Date and time]
+
+**Gram Stain:**
+[Results of Gram stain if performed]
+Example: "Many Gram-positive cocci in clusters, many WBCs"
+
+**Culture Results:**
+
+**Organism:** [Identified organism]  
+**Quantity:** [Light / Moderate / Heavy growth] or [CFU count]
+
+**Antimicrobial Susceptibility Testing:**
+
+| Antibiotic | Result | MIC (μg/mL) |
+|------------|--------|-------------|
+| [Drug name] | S/I/R | [Value] |
+
+Example:
+| Antibiotic | Result | MIC |
+|------------|--------|-----|
+| Ampicillin | R | >16 |
+| Ceftriaxone | S | ≤1 |
+| Levofloxacin | S | 0.5 |
+| Vancomycin | S | 1 |
+
+**Interpretation:** S = Susceptible, I = Intermediate, R = Resistant
+
+---
+
+## Molecular/Genetic Testing
+
+**Test:** [Specific test name]  
+**Method:** [PCR / Sequencing / Array / Other]  
+**Result:** [Detected / Not detected / Variant identified]
+
+**Interpretation:**
+[Clinical significance of result]
+
+---
+
+## Reference Laboratory Results
+
+[For send-out tests]
+
+**Test:** [Name]  
+**Performed by:** [Reference lab name and location]  
+**Result:** [Value]  
+**Reference Range:** [Range]  
+**Method:** [Methodology]  
+**Reported:** [Date]
+
+---
+
+## Laboratory Director Signature
+
+**Medical Director:**  
+[Name, MD]  
+[Board Certifications]  
+[CLIA License Number]
+
+**Electronically signed:** [Date]
+
+---
+
+## LOINC Codes (for interoperability)
+
+[LOINC codes for each test when applicable for electronic reporting]
+
+Example:
+- Hemoglobin: 718-7
+- Glucose: 2345-7
+- Creatinine: 2160-0
+- TSH: 3016-3
+
+