• Only Specialists/Medical Officers/ House Officers are authorized to request for laboratory tests. 

• 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. 

• Perform blood taking according to local guidelines or standard operating procedure.  Please refer to Customer Educational Series.

• 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: Order of Draw.

• 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.

• Stated test name, date and time specimen taken on the specimen container for Histopathology, Cytology specimen, and certain Biochemistry testing (e.g. pre/post/ 1h/ 2hr, 0 minutes etc) whenever time is crucial for interpretation of results. An improperly timed specimen can give misleading results. 

• Specimen containers should be labelled with the patient's name, IC number and test requested (when necessary). Labelled with at least two identifiers (i.e. patient’s name / full IC number/ RN/ barcode for Makmal Klinik Pakar) .

• The source of the specimen must be noted either on the specimen label or the test requisition form when the specimen is tissue, a culture or a body fluid other than blood.

• Ensure the label does not cover the whole tube. Leave some space to view the level of blood in the tube. 

• Ensure the label name / IC number/ barcode (minimum 2 identification) tally 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. 

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.

• The samples should be transported to the laboratory in appropriate time frame. Refer to the list of test in pathology department. 

• Seal every specimen securely to avoid leakage.

• The containers should be placed in biohazard plastic bags with the respective request forms stapled outside the bag / in the pocket. 

• Multiple specimens from the same patient for the same laboratory unit can be placed in the same biohazard specimen transport bag. Do not place specimens from more than one patient or laboratory unit in the same specimen bag. 

• Senders are responsible for ensuring that specimens are securely and safely delivered to the correct lab unit conducting the test. 

• The time of samples received at the counter should be clocked in by the laboratory user and the samples will subsequently be attended by the laboratory staff for the URGENT tests to be carried out. 

• 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. 

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 ve

• Seal every specimen securely to avoid leakage.

• 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