How to Write a Medical Microbiology Lab Report

A medical microbiology lab performs testing on human samples collected from different body sites. The tests are used to detect and identify any microorganisms capable of causing disease. The results of those tests are reported to the health care provider to aid in the treatment of the patient. According to the Clinical Laboratory Improvement Amendments (CLIA), a set of regulations from the federal government, laboratory reports from accredited laboratories in the United States must contain a set of standard elements.

Things You'll Need

  • Notes on the results of the testing
  • Information on the source of the sample
  • Information on the type of sample
  • Information on the requesting physician
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Instructions

  1. Specimen Information

    • 1

      Write the patient demographic information in the laboratory report. Per CLIA regulations, a minimum number of information elements must be included, such as the patient's name, date of birth, account number, or room number in the hospital. This helps match the report with the patient, assuring that the proper treatment will be given to the right person.

    • 2

      Write in the report the source of the specimen and the type of specimen it is. This will help the health care provider understand the results, especially if specimens were collected from the patient at the same time from different sources.

    • 3

      Write the time and date of the specimen's collection. This is important when multiple specimens are collected on the same patient at different times or dates.

    Specimen Results

    • 4

      Write any and all results of the microbiology testing, like Gram stain results, initial culture and isolation results, and any microbiology susceptibility results.

    • 5

      Write a final identification of any organisms isolated from the sample. Include all organisms, even if they are usually normal flora or contaminants.

    • 6

      Write the laboratory's information on the report, including who performed the testing or issued the final result. This is helpful to trace back any issues with the sample or its testing.

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