• Tests shall ONLY be requested by registered Specialists/Medical Officers/ House Officers and dental practitioner involved in patient management

• Personnel authorised to request for drug of abuse (DOA) analysis are :

(a) Registered Medical Officer.

(b) Police Officer not below the rank of Sergeant.

(c) Agency Officer from the Agensi AntiDadah Kebangsaan (AADK).

(d) Customs Officer

(e) Others (as specified by the requesting agency)

     Reference:  Garispanduan  KKM Bagi Ujian Pengesanan Penyalahgunaan Dadah Dalam Air Kencing  Versi 2.0 Tahun 2021

• Certain test request shall require prior appointment / scheduling. Provision shall be made available for acceptance of appointment. Any cancellation or rescheduling of test must be immediately informed to the laboratory personnel.

• All requests shall be ordered using PER-PAT 301 form unless otherwise stated (refer to respective unit lists of tests).  All request forms must be legibly written or labelled with a patient information printed sticker. 

• The completed forms shall be signed and stamped by a doctor and accompanied by a properly collected specimen . 

• All the necessary information listed below MUST be filled in completely: 

(a) Patient’s name (full name in capital letters are highly recommended)

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 RAMONA BT RAHMAN (1ST TWIN)     

(b)  Identity Card 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 "space" , the letter E, slash sign (/)                            and child birth sequence

•  (e.g., 730422055116 E/4)

iii.   Twin patients should state E/1 (1st twin) and E/2 (2nd twin) at the end of guardian’s IC Number if the twins are firstborn

• • • • • • • (e.g., 730422055116 E/1 and 730422055116 E/2)

              iv.    For twin patients who are not firstborn, to write 12 digits followed by "space" , the letter E, slash sign (/) and child birth                                 sequence 

•  (e.g., 730422055116 E/4 for twin 1 and 730422055116 E/5 for twin 2 )

v.    Passport number should be used for non-Malaysian patient

               vi.    Police / army IC number can be used when necessary

               vii.   Refugees should be used UNHCR following series number.

              viii.   For patient's admitted without identity card during emergency disaster, to use hospital R/N number, slash and year of                                  admission. Requestor is to inform the lab once identity card number is known

(c)   Age /date of birth (compulsory in newborn /children who use mother's IC number for age adjusted reference range)

(d)  Gender (compulsory for gender adjusted reference range)

(e)  Ward/clinic and hospital’s official rubber stamp.

(f)   Relevant clinical summary and medication given.

(g)  Type of specimen and anatomic site of origin, where appropriate.

(h)  Provisional diagnosis. Use only commonly known abbreviations (please refer to Senarai Abbreviation di fasiliti KKM    

          2024)

(i)   Test requested. The test required must be clearly written.

(j)   Requesting Doctor’s name (clearly written), signature and official stamp.

(k)  Date and time specimen collected (an improperly timed specimen can give misleading results). 

(l)   Name of person collecting the sample/ Phlebotomist’s detail (if different person involved) clearly written. Signature with official      

              stamp

(m) Date specimen sent.

(n) Relevant routine laboratory results if relevant. 

Notes:

• Failure to filled the request form completely will subject the lab tests request to be rejected and might influence the outcome of testing results (especially tests which involves gender, age, specimen collection timing, relevant clinical history and drugs given for correct reference range and report interpretation by pathologist). Use only commonly known abbreviations (please refer to Senarai Abbreviation in Fasiliti KKM 2024).

• Use different request forms for requesting tests from different laboratories within Pathology Department. Do not mix form.

• Blood taking and labelling a patient's blood specimen shall be carried out by one person at the patient’s bedside. Please refer to Blood Collection Procedure educational series video for guide.

• All information is compulsory to fill. 

Urgent request shall be clearly indicated on request forms. 

•  Request form must be stamped URGENT.

•  Samples must be sent immediately to the laboratory.

Critical results will be communicated to the requesting ward or medical officer via phone call. Please refer to the respective unit for the comprehensive list of critical results and values. 

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

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

• Specimen container must be placed in an appropriate packaging. 

To ensure safe, accurate, and clinically appropriate specimen collection, please follow the instructions below when collecting and submitting specimens to the laboratory. 

1. Follow the approved collection procedure

Perform blood taking and specimen collection according to your local guidelines or standard operating procedure. Please refer to the Customer Educational Series, Quick Guide : Phlebotomy Best Practice, and Quick Guide: Order of Draw, where applicable.

2. Confirm the patient identity and requested tests

Identify the patient and verify the laboratory tests requested before collecting any specimen.

3. Verify patient identity using at least two identifiers

Before collecting any specimen, verify the patient’s identity by asking the patient to state at least two identifiers, for example full name and identification number, and check these against the patient identification wristband, case notes, and request form, where applicable.

For an unconscious patient, paediatric patient, or emergency situation, ask the relative or caregiver to state the patient’s full name and identification number, and verify these details against the patient identification wristband or case notes.

4. Confirm pre-examination requirements

Verify that the patient meets any relevant pre-examination requirements before specimen collection. These may include fasting status, medication status, time of last dose, cessation of medication, or collection at a predetermined time or time interval. Record this information where relevant. Obtain patient consent where indicated.

5. Use the correct container, volume, and mixing procedure 

Use the correct specimen container or tube for the requested test and ensure any required additive or preservative is used. Proper procedure, adequate specimen volume, and correct mixing are essential to maintain specimen quality and ensure accurate laboratory test results. Follow the recommended Quick Guide: Order of Draw to avoid contamination between tubes.

6. Transfer and handle the specimen correctly

Transfer the specimen immediately into the appropriate container as required by the procedure. Ensure the specimen is filled to the required volume and mixed properly where indicated to maintain specimen quality and support accurate test results.

7. Label the specimen immediately at the point of collection 

Label each specimen immediately at the bedside or point of collection, in the presence of the patient, to avoid mislabelling. Specimen containers shall be labelled with the patient’s name, IC number, and test requested, where necessary. Each specimen must be labelled with at least two patient identifiers, for example patient’s name, full IC number, RN, or barcode for Phlebotomy Unit. 

Include the test requested when necessary.

For Histopathology, Cytology, and specific Biochemistry tests where timing is critical, state the test name and the date and time of collection on the specimen container or as required by the laboratory (e.g. pre/post/ 1h/ 2hr, 0 minutes etc). Improperly timed specimens may give misleading results.

For tissue, culture, or body fluid specimens other than blood, state the specimen source either on the specimen label or on the request form.

Ensure that the label does not cover the whole tube. Leave sufficient space to allow the specimen level to be seen. 

8. Record collection details

Record the identity of the person collecting the specimen and the collection date. Record the exact collection time whenever this is relevant to specimen integrity or interpretation of results.

9. Separate or divide specimens only when required

Where specimen separation, centrifugation, aliquoting, or division is required, follow the laboratory’s instructions carefully. Ensure that all separated or aliquoted specimens remain correctly labelled and traceable to the original patient and request.

10. Stabilize and store specimens correctly before delivery

If the specimen is not delivered immediately to the laboratory, store and stabilize it according to the test-specific requirements. Maintain the required storage temperature and any other special conditions, such as protection from light or timely separation, to preserve specimen integrity before transport.

11. Ensure the specimen label matches the request form

Ensure that the patient name, identification number, registration number, barcode, and other relevant identifiers on the specimen label match the laboratory request form or electronic order. The request form must be complete and include all information required by the laboratory.

12. Package specimens correctly for submission

Each completed laboratory request form must be accompanied by the appropriately packaged specimen submitted for testing. Each package must contain specimens belonging to one patient only.

13. Dispose of collection materials safely

Dispose of needles, syringes, sharps, swabs, and other materials used during specimen collection safely and immediately into the appropriate designated containers in accordance with local safety and infection control requirements.

An improperly collected or contaminated specimen can give incorrect results. 

Venous blood is preferred.

• To ensure consistent and accurate result, follow strictly the volume of blood required for the type of test specified or fill blood till the mark on the label 

• To prevent haemolysis:

1.   Avoid collecting blood from an area of haematoma.

2.   The site of collection should be allowed to air dry after cleansing with 70% isoprophyl or ethyl alcohol.

3.   Ensure smooth venipuncture and steady flow of blood into the syringe.

4.   Do not force blood through needle while transferring blood into collection tube.

•   Strict aseptic technique should be practiced when performing blood collection for culture and sensitivity.

•   Draw of blood should be in a correct order beginning with blood culture followed by other routine blood collection tubes. 

•   Immediately and gently mix blood collection tube by inverting several times. Do not mix vigorously.

•   All clinical waste should be disposed according to standard for clinical waste management.

Specimen Transport:

To preserve specimen integrity and ensure timely testing, please follow the instructions below when sending specimens to the laboratory. 

1. Send specimens promptly

• Send specimens to the laboratory immediately after collection or within the transport time and stability limits stated in the Pathology Department list of test. 

2. Use the correct container and label each specimen properly

• Collect each specimen in the correct container or tube and close it securely. Label each specimen with at least two patient identifiers. Where relevant, include the specimen type or site and the date and time of collection.

3. Package specimens safely

• Place each specimen in a biohazard transport bag and package it appropriately to prevent leakage, contamination, or damage during transport. Keep the request form outside the specimen compartment, such as in the document pocket or attached externally, so that it remains clean and dry.

4. Maintain the required transport conditions

• Maintain the required transport temperature or cold chain for specimens that need controlled conditions. Follow any test-specific handling requirements stated in the Pathology Department test list or collection instructions, including the use of designated preservatives where applicable.

5. Follow the correct instructions if transport is delayed

• If transport to the laboratory is unavoidably delayed, store and stabilize the specimen according to the test-specific requirements provided by the laboratory. Where specifically instructed, specimens may need to be centrifuged, aliquoted, or stored at the appropriate temperature before transport. 

6. Use only the approved transport method

• Use only the appropriate and approved transport method for the specimen type, such as hand delivery, porter, courier service, or pneumatic tube, in accordance with laboratory requirements.

7. For courier transport, monitor temperature

• For transport by courier service, ensure that the required temperature is maintained and monitored throughout transport to preserve specimen integrity. Document temperature monitoring where required.

8. Separate specimens correctly

• Place multiple specimens in the same transport bag only when they are from the same patient and for the same laboratory unit. Ensure that each specimen is individually labelled and clearly matched to the request form. Do not place specimens from different patients or different laboratory units in the same transport bag.

9. Send specimens to the correct laboratory unit

• Ensure that all specimens are delivered safely to the correct laboratory unit performing the requested test and within the allowable transport time.

10. Report any transport problem immediately

• If a specimen is broken, leaking, damaged, or otherwise compromised during transport, inform the laboratory immediately. 

11. Meet specimen acceptance requirements

• Ensure that each specimen meets the laboratory’s acceptance requirements, including correct identification, suitable container, complete request form, acceptable transport condition, and compliance with required transport time and temperature. Specimens that do not meet these requirements may be rejected or may require further assessment by the laboratory.

• Only blood samples (with request form) should be sent using a pneumatic tube. 

• Please ensure that those blood specimen tubes are capped tightly before being delivered to any laboratory unit. 

• Sending samples such as body fluid, CSF, and urine samples using a pneumatic tube is strictly PROHIBITED. This is to avoid spillage of sample and hence the rejection of sample. These samples also should be separated based on the laboratory and sent directly (by hand) to the designated laboratory. 

• Please refer to Pneumatic tube guideline

List of general rejection criteria:

   ●  Incomplete request form 

   ●  Incomplete / Wrong patient identification (e.g. wrong patient's name, wrong I/C number)

   ●  Test request is not stated 

   ●  Sample tube or container is broken

   ●  Leaking specimen

   ●  Wrong container or blood tubes

   ●  Unlabelled specimen

   ●  Discrepancy between the patient’s particulars on the request form and that on the blood tube/container

   ●  No patient’s name on the slide (e.g., pap smear glass slide) 

   ●  No specimen/ form received for the test requested 

List of specific rejection criteria:

   ●  Specimen site not stated (e.g., histology specimen)

   ●  Aged sample that may yield invalid result (e.g., urine sent to the lab after more than 4 hours) 

   ●  Inappropriate specimen volume (either inadequate or overfilled)

   ●  Specimen is unsuitable for analysis (e.g., haemolysed/ clotted/ lipemic/ icteric sample)

   ●  Specimen contaminated with foreign additive or other substances

   ●  Duplicate test order 

   ●  Test not offered or test request cancelled by the requesting team

   ●  Sample submitted before the recommended interval (e.g. HbA1c should not be tested less than 3 months apart) 

   ● Sample sent using expired collection tubes 

   ● Specimen not properly preserved (e.g., histology specimen without formalin)

   ● Relevant clinical history not provided for special tests and histopathology

Note: When rejections are made, the rejection details will be documented in the LIS, including the name of the clinical staff informed, the patient's location, and, the time and date of the rejection. 

• Our lab accepts verbal requests for additional tests by calling or informing the respective units by the requesting medical practitioner followed by request form within a given time. 

• Acceptance criteria for verbal requests are stated in the user manual for each unit. 

• Clotted sample

• Lysed sample

• Lipemic sample

• Paraproteinemia

• Aged sample

• Icteric sample 

• Contaminated sample

• Insufficient/overfilled sample (Overfilling the tube can dilute the preservatives/anticoagulant, which may affect the integrity of the sample and alter the test results) 

• Wrong specimen preservative

• Inappropriate sample transportation