CLINICAL LAB SCIENEC

CHAPTER 12: PROCEDURES FOR URINALYSIS AND BODY FLUIDS 297
Procedure Report Form: Urinalysis Report Form
Patient Name: _____________________ Pt. ID _______________ Date: _____________
Age: _______ Gender (Circle One) M F Physician: ____________________________
Time Requested: ___________ Time Performed: ___________ Time Reported: __________
Examination Requested: UA with Microscopic Dipstick UA Only
Culture and Sensitivity Other
Physical Examination
Color: Colorless Straw Yellow Amber Red Brown
Blue Green
Character (appearance): Clear Hazy Cloudy Turbid
Chemical Examination by Manual Dipstick [Multistix 10 SG (Bayer)]
(Circle the appropriate responses)
Glucose Negative 100 250 500 1000 >2000 mg/dL
Bilirubin Negative + (Small) ++ (Moderate) +++ (Large)
Ketones Negative Trace Small Moderate Large
Specifi c gravity 1.000 1.005 1.010 1.015 1.020 1.025 1.030
Blood (hemolyzed) Negative Trace Small Moderate Large
Blood (intact/non-hemolyzed) Negative Trace Moderate
pH 5.0 6.0 6.5 7.0 7.5 8.0 8.5
Protein Negative Trace +/30 (1+) ++/100 (2+) +++/500 (3+) >2000 (4+)
Urobilinogen Normal 2 4 6
Nitrites Negative Positive
Leukocytes Negative Trace Small Moderate Large
Confirmatory Test Results (Circle the appropriate responses)
Specifi c Gravity
(Urinometer/
TS Meter) 1.000 1.005 1.010 1.015 1.020 1.025 1.030
Acetone Negative, 1+ (small), 2+ (moderate), or 3+ (large)
Protein Trace 1+ 2+ 3+ 4+
Bilirubin Weak positive Strong positive
Clinitest 0 Trace ½% 1% 2% 3% 5%
Microscopic Examination
Constituent Reported Values Reference Values
White blood cells _____________________ 0–4/high-power fi eld (HPF)*
Red blood cells _____________________ 0–4/high-power fi eld
Squamous epithelial _____________________ Occasional; higher in females
Renal/tubular epithelial _____________________ 0
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