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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:

Specimen collected in appropriate tube
Specimen adequately labeled
Specimen volume sufficient
No hemolysis, lipemia, or icterus
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]