A standard laboratory request form PER-PAT 301 is used for all categories of tests except stated otherwise.
All urgent / STAT requests is mandatory to use pink colour PER-PAT 301 form whereas a yellow colour PER-PAT 301 form is used for Emergency Department.
All request forms must be filled legibly or labelled with a patient information printed sticker. The completed forms shall be stamped and signed by a doctor or authorized personnel and accompanied by the properly collected specimens.
The following information must be provided for every request in the request form:
Patient’s details:
a. Name (in capital letters), e.g., AHMAD B. ABU.
i. Newborn patient use B/O followed by mother's name
ii. Twin patients should state 1st twin or 2nd twin after the name, e.g., B/O MAIMUNAH BT HASAN-1ST TWIN
b. Identity card (IC) number: -
i. Use new IC number for Malaysian patients (12 digits)
ii. Children who are using mother's / guardian’s IC Number, to write 12 digits followed by the letter E
(e.g., 730422055116E)
iii. Twin patients should state E/1 (1st twin) and E/2 (2nd twin) at the end of guardian’s IC Number
(e.g., 730422055116E/1)
iv. Passport number should be used for non-Malaysian patient
v. Police / army IC number can be used when necessary
vi. Refugees should be used UNHCR following series number.
c. Sex
d. Age / Date of birth - compulsory in newborn /children who use mother's IC number (for age adjusted reference range)
2. Location: Ward, Clinic, Hospital, Health Clinic
Note: For in patients, use patient label printed stickers and paste on the request form. Ensure the patient's details and location are stated clearly and correctly.
3. Patient’s clinical summary
a. Relevant clinical summary
b. Relevant medications of patients
c. Diagnosis / Provisional Diagnosis (Abbreviations are discouraged)
4. Test details: Mark (√) at the appropriate box for the tests required. Tests which are not listed in box, should be stated under the OTHERS column. The test required must be clearly written (Abbreviations are discouraged).
5. Specimen:
a. Date and time of specimen collection
b. Type of specimen and anatomic site (if relevant)
6. Requester detail:
a. Name clearly written
b. Signature with official stamp
7. Phlebotomist’s detail (if different person involved)
a. Name clearly written
b. Signature with official stamp
Note:
Use different request forms for requesting tests from different laboratories.
Blood taking and labelling a patient's blood specimen shall be carried out by one person at the patient’s bedside.
All information is compulsory to fill.
Ensure the specimen container used is suitable and not expired.
The specimens should be collected, properly labelled and despatched according to the transport requirement for the tests requested.
Specimen container must be placed in an appropriate packaging.
Perform blood taking according to local guidelines or standard operating procedure.
Identify the patient and type of laboratory tests requested.
Before any specimen is collected, the patient identity must be verified by asking them 2 identifiers (e.g., full name and identification number) and checking the answer given against information stated on patient identification wristband or case note.
If a patient is unconscious, paediatric patient or in an emergency situation, ask the relative or care giver to give the full name and identification number of the patient and check the answer given against information stated in the patient identification wristband or case note.
Proper procedure, adequate volume and mixing with correct specimen containers are of paramount importance in ensuring the quality of specimen and accurate laboratory test results. Please refer to Quick Guide: Sequence of Blood Filling According to Collection Tubes for Adult and Paediatric Patients, 1/2018 Edition 1.
Transfer the blood immediately into the appropriate specimen container as per procedure.
Specimens must be labelled with patient's name and IC number immediately at bed site to avoid mislabelling. Ensure it's accurate and legible.
Stated date and time specimen taken on the specimen container for Histopathology, Cytology specimen, and certain Biochemistry testing whenever time is crucial for interpretation of results.
Ensure the barcode label does not cover the whole tube. Leave some space to view the level of blood in the tube.
Ensure the label consist of name , IC number and barcode matches with the request form.
Each completely filled laboratory request form must be accompanied with appropriate packaging specimen submitted for testing. Each packaging must contains specimens belong to one patient.
Documentation
All requests must be recorded in Borang Penghantaran Dan Penerimaan Spesimen Jabatan Patologi, Hospital Melaka or despatched record with adequate information in 2 copies.
Transportation of Specimen
The specimens should be transported to the laboratory as specified according to the type of test immediately or in appropriate time frame and according to transport requirements.
Specimen rejection rates are aimed to be <2.0% and specimen rejection rates for inpatients should be less than 1% (MSQH 6th Edition 2021).
General rejection criteria.
Incomplete request form
Wrong patient identification
Information on request form and specimen do not tally
Specimen/ form and container not suitable
Expired container
Test not offered
No specimen/ form received
Specific rejection criteria (Vetted in specific laboratories).
Haemolysed
Clotted
Inappropriate specimen volume (inadequate or overfill)
Leaking
Unsuitable/unsatisfactory specimen (lipemic, icteric, diluted)
Specimen contaminated with foreign additive or other specimen
Repeating test within inappropriate time
Sharing form/specimen
ABG specimen with needle or uncapped
Note:
The laboratory staff at the main counter will fill the rejection form and a copy will be dispatched to the requesting ward/ clinic / health clinics and district hospital through pigeon hole.
Unit with a LIS system will register the request in the system and produce a rejection report.
Laboratory staff will inform the rejection to the ward/ clinic/ health clinics and district hospital depend on unit procedure.
Precious specimens e.g., CSF, tissue, paediatric specimen or etc will be processed if possible. It will be indicated in the report about the quality of the primary specimen which was unsuitable for testing or could have compromised the results.
Critical Results Notification
Tests with the critical value/results will be notified to the requestor or authorized personnels from the wards within 30 minutes during result validation. However critical value/results from outpatient will be informed to authorized personnel within office hours or on next working day (if weekend or public holiday). Please refer to Critical Result Values by laboratory.
Note: Critical values/results are defined when the test results fall outside the low or high limits or the presence of any unexpected abnormal findings, cell or organism that may potentially cause life threatening and/or requires immediate medical attention. These values may be identified from the routine or urgent test request.
Result / Report Release
Results /reports in Hospital Melaka will be viewed from the wards /clinics except for health clinics and district hospitals. All specialized hematology tests, HIV Ag/Ab and Viral load, TDM, Cord TSH, Urine For Abused Drugs, Anatomy Pathology (Cytology & Histopathology), medicolegal cases and when applicable will be printed by laboratory.
Tracing Results / Reports
Results / reports can be traced through Hospital Melaka porter system or via telephone except :-
CD4/ CD8 count.
HIV
HIV Viral load
Drug Abuse
Referral test (except Chemical Pathology)
Histopathology/Cytology.
Results / reports can be traced in the laboratory by using “Borang Pengesanan Keputusan Ujian Makmal” (HM/JP/QP-001/4).
Printed reports or results will be placed in the pigeonhole of the respective wards, clinics and health clinics located at the reception counter in the department. The attendants / porter from the respective wards, clinics, health clinics and district hospitals are required to collect them as soon as possible.
The following reports are despatched by attendant using despatch book or other mode of delivery to respective wards/clinics: -
Bone Marrow and all referral hematology reports.
CD4/CD8 – in envelope.
Histopathology.
Cytology.
HIV (Positive cases) & HIV Viral Load – in a sealed envelope.
Medico-legal – in a sealed envelope.
Urine For Abused Drugs – in a sealed envelope.
Therapeutic Drug Monitoring (TDM) – Pharmacists will collect results at the Chemical Pathology Unit.
Cord Blood TSH - PPK Pediatric will collect result at Chemical Pathology Unit.
Call respective laboratory for additional test request.
An additional test can be carried out if the specimen is both available and in acceptable condition.
Submit a new request form to the laboratory within the specified time frame.
If the sample or specimen is unavailable or unsuitable, the requester will be notified to recollect a new sample.
Additional tests will only be performed if the original test request form is complete with the DATE and TIME information.
Ensure the additional test request form is filled out completely, e.g., clinical history for special tests.
Please refer to the detailed information below:
Tests which are not provided in Hospital Melaka will be referred or outsourced to other laboratories for analysis.
The specimens from Hospital Melaka are sent to the referred laboratory twice a week (Tuesday and Thursday).
All requests for referred tests must be accompanied with relevant form. Call the respective laboratory for further clarification.
Results from the referral laboratory will be email to the respective requesting laboratory or collected by Hospital Melaka porter.
Tests which are not provided in MOH, will be sent to the private /university laboratory. Before sending the sample the clinical staff have to ensure the payment is done according to the local guidelines or standard operating procedure.