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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             ╔══════════════════════════════════════════════════════════════════╗                                                                                                      ║  Your Hospital Name Here  Monthly Urinalysis Quality Control Log ║                                                                                                      ╚══════════════════════════════════════════════════════════════════╝                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Month:                          Year:                                                                                                                                                                                                                                                                                               ╔═══════════════╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╗                                                                                           ║    Date:      │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ╚═══════════════╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╝                                                                                           ╔═════════════════════════╤═══════════════════════════════════════════════════╗                                                                                           ║Normal Control Results:  │ Lot #                 Expiration Date:            ║                                                                                           ╠═══════════════╤═╤═╤═╤═╤═╪═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╣                                                                                           ║  Leukocytes   │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║  ─────────────┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─╢                                                                                           ║  pH           │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║  ─────────────┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─╢                                                                                           ║  Protein      │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║  ─────────────┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─╢                                                                                           ║  Glucose      │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║  ─────────────┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─╢                                                                                           ║  Ketones      │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║  ─────────────┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─╢                                                                                           ║  Urobilinogen │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║  ─────────────┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─╢                                                                                           ║  Bilirubin    │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║  ─────────────┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─╢                                                                                           ║  Blood        │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ╠═══════════════╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╣                                                                                           ║    Specific   │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║      Gravity  │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ╚═══════════════╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╝                                                                                                                                                                                                                                                                     ╔═════════════════════════╤═══════════════════════════════════════════════════╗                                                                                           ║Abnormal Control Results:│  Lot #                Expiration Date:            ║                                                                                           ╠═══════════════╤═╤═╤═╤═╤═╪═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╤═╣                                                                                           ║  Leukocytes   │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║  ─────────────┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─╢                                                                                           ║  pH           │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║  ─────────────┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─╢                                                                                           ║  Protein      │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║  ─────────────┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─╢                                                                                           ║  Glucose      │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║  ─────────────┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─╢                                                                                           ║  Ketones      │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║  ─────────────┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─╢                                                                                           ║  Urobilinogen │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║  ─────────────┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─╢                                                                                           ║  Bilirubin    │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║  ─────────────┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─┼─╢                                                                                           ║  Blood        │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ╠═══════════════╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╪═╣                                                                                           ║    Specific   │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ║      Gravity  │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ║                                                                                           ╚═══════════════╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╧═╝