Pre-Analytical Requirements

• 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:

  1. 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: 

1. Use different request forms for requesting tests from different laboratories. 

2. Blood taking and labelling a patient's blood specimen shall be carried out by one person at the patient’s bedside. 

3. All information is compulsory to fill. 

1. Ensure the specimen container used is suitable and not expired. 

2. The specimens should be collected, properly labelled and despatched according to the transport requirement for the tests requested.  

3. Specimen container must be placed in an appropriate packaging. 

1. 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.

2. 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. 

1. Incomplete request form

2. Wrong patient identification

3. Information on request form and specimen do not tally

4. Specimen/ form and container not suitable

5. Expired container

6. Test not offered 

7. No specimen/ form received

• Specific rejection criteria (Vetted in specific laboratories).

1. Haemolysed 

2. Clotted

3. Inappropriate specimen volume (inadequate or overfill)

4. Leaking

5. Unsuitable/unsatisfactory specimen (lipemic, icteric, diluted) 

6. Specimen contaminated with foreign additive or other specimen

7. Repeating test within inappropriate time

8. Sharing form/specimen

9. ABG specimen with needle or uncapped

Note:

1. 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. 

2. Unit with a LIS system will register the request in the system and produce a rejection report.

3. Laboratory staff will inform the rejection to the ward/ clinic/ health clinics and district hospital depend on unit procedure.

4. 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 :-

1. CD4/ CD8 count.

2. HIV

3. HIV Viral load

4. Drug Abuse

5. Referral test (except Chemical Pathology)

6. 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: -

1. 1. Bone Marrow and all referral hematology reports.

   2.  CD4/CD8 – in envelope.

   3.  Histopathology.

   4. Cytology. 

   5. HIV (Positive cases) & HIV Viral Load – in a sealed envelope. 

   6. Medico-legal – in a sealed envelope. 

   7. Urine For Abused Drugs – in a sealed envelope.

   8. Therapeutic Drug Monitoring (TDM) – Pharmacists will collect results at the Chemical Pathology Unit.

   9. Cord Blood TSH -  PPK Pediatric will collect result at Chemical Pathology Unit.

1. Tests which are not provided in Hospital Melaka will be referred or outsourced to other laboratories for analysis.

2. The specimens from Hospital Melaka are sent to the referred laboratory twice a week (Tuesday and Thursday). 

3. All requests for referred tests must be accompanied with relevant form. Call the respective laboratory for further clarification.

4. Results from the referral laboratory will be email to the respective requesting laboratory or collected by Hospital Melaka porter.  

5. 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.