Q26 – 42: Hematologic Findings at Diagnosis of Infection

*Hematologic Findings
Report values within seven days (+ / -) of the infection diagnosis date. If the lab was assessed multiple times within seven days (+ / -) of the diagnosis date, report the closest value.

Question 26: Date of complete blood count

Report the date of the complete blood count (CBC) performed closest to the date of diagnosis of the fungal infection being reported on this form. The CBC must have been performed within seven days of the date of diagnosis. If a CBC was not performed within seven days (+ / -) of the infection diagnosis date, leave the data field blank and override the FormsNet3^SM error.

If the exact date is not known, refer to General Instructions, General Guidelines for Completing Forms, for information about reporting partial or unknown dates.

Questions 27 – 36: Complete blood count results

For each value below, indicate whether the value was Known on the date reported above. If Known, report the value and corresponding units, if applicable.

• WBC: The white blood cell count is a value that represents all of the white blood cells in the blood. If the count is too high or too low, the ability to fight infection may be impaired.
• Neutrophils: Neutrophils are a subtype of white blood cell that fights infection. The value on the laboratory report may be a percentage or an absolute value. If an absolute value is reported, divide it by the white blood cell count for a percentage. Neutrophils are also known as polymorphonuclear leukocytes (PMNs).
• Monocytes: Monocytes are a type of white blood cell and are part of the innate immune response. The value on the laboratory report may be a percentage or an absolute value. If an absolute value is reported, divide it by the white blood cell count for a percentage.
• Lymphocytes: Lymphocytes are another subtype of white blood cell that fights infection. The value on the laboratory report may be a percentage of an absolute value. If an absolute value is reported, divide it by the white blood cell count for a percentage.
• Platelets: Platelets are formed elements within the blood that help with coagulation. A low platelet count, called thrombocytopenia, may lead to easy bleeding or bruising. Thrombocytopenia may require platelet transfusions.
  

Questions 37 – 39: Serum creatinine

Specify if the serum creatinine was Known within seven days of the infection diagnosis date. If Known, report the value, units of measurement, and the upper limit of normal for the lab report. If the serum creatinine was assessed multiple times, report the value closest to the diagnosis date.

If a serum creatinine test was not performed within the indicated time window, or it is not known if a serum creatinine test was performed, report Unknown.

Questions 40 – 42: ALT (SGPT)

Specify if the ALT (SGPT) was Known within seven days of the infection diagnosis date. If Known, report the value, units pf measurement, and the upper limit of normal for the lab report.

If an ALT test was not performed within the indicated time window, or it is not known if a test was performed, report Unknown.

Section Updates:

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