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HUSM/HEMA-UPT/QP-01

RECEIPT OF SAMPLE

HAEMATOLOGY AND TRANSFUSION MEDICINE LABORATORY HOSPITAL UNIVERSITI SAINS MALAYSIA

Prepared by:

Dr. Marini Ramli

15.08.2009

Checked by:

Dr. Suhair Abbas

01.10.2009

Approved by:

Assoc Prof Dr Rosline Hassan

01.11.2009

Effective date:

01.11.2009


HAEMATOLOGY AND TRANSFUSION MEDICINE LABORATORY, HUSM Page RECEIPT OF SAMPLE TITLE: TABLE OF CONTENT Version (HUSM/HEMA-UPT/QP-01) Amendment

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TABLE OF CONTENT

1

Title of Quality Procedure

2

Table of Content

3

Record of Amendment and Record of Review

4

Objective, Scope, Abbreviation, Definition and References

5

Procedure and Responsibility

6

Record

7

Flow chart Appendices

i. Appendix 1 : Criteria for sample rejection ii. Appendix 1 : List of routine and coagulation tests requested through LIS

Prepared by Checked by Approved by

Dr. Marini Ramli Dr. Suhair Abbas Assoc. Prof. Dr Rosline Hassan

Issued Date Effective Date

15.08.2009 01.11.2009


HAEMATOLOGY AND TRANSFUSION MEDICINE LABORATORY, HUSM Page RECEIPT OF SAMPLE TITLE: RECORD OF Version (HUSM/HEMA-UPT/QP-01) AMENDMENT AND RECORD Amendment OF REVIEW

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RECORD OF AMMENDMENT VERSION NO

DATE

DESCRIPTION OF AMMENDMENT

BY

RECORD OF REVIEW DATE OF REVIEW

Prepared by Checked by Approved by

NAME OF REVIEWER

Dr. Marini Ramli Dr. Suhair Abbas Assoc. Prof. Dr Rosline Hassan

SIGNATURE OF REVIEWER

Issued Date Effective Date

SIGNATURE OF APPROVAL

15.08.2009 01.11.2009

HAEMATOLOGY AND TRANSFUSION MEDICINE LABORATORY, HUSM


Page RECEIPT OF SAMPLE (HUSM/HEMA-UPT/QP-01)

TITLE: OBJECTIVE, SCOPE, ABBREVIATION, DEFINITION AND REFERENCES

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Version

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Amendment

1

1. OBJECTIVE Receive ONLY the correct sample and request form from clinics, wards and other hospitals for laboratory tests. 2. SCOPE This procedure is applicable to all types of sample such as blood, bone marrow, body fluids and tissues together with laboratory request form received at the Hematology/Transfusion Medicine Laboratory, HUSM. 3. ABBREVIATION MLT PAP PT AK STAT HL TML LIS

: : : : : : : :

Medical Laboratory Technologist Pembantu Am Pejabat Pembantu Tadbir Atendan Kesihatan Short Turn around Time Haematology Laboratory Transfusion Medicine Laboratory Laboratory Information System

Section

:

Various divisions within the HL/TML

Demography

:

A process of registering patients’ data (such as Name, registration number, sex, age etc) into LIS, Computer or registration book.

4. DEFINITION

Haematology and : Coagulation routine test

Series of tests that are done during office hours and do not require appointment.

5. REFERENCES 1) MHT/DD H11/T18 : www.medic.usm.my/haematology. Buku Panduan Perkhidmatan Makmal Hematologi & Perubatan Transfusi Jilid 6. Prepared by Checked by Approved by

Dr. Marini Ramli Dr. Suhair Abbas Assoc. Prof. Dr Rosline Hassan

Issued Date Effective Date

15.08.2009 01.11.2009

HAEMATOLOGY AND TRANSFUSION MEDICINE LABORATORY, HUSM Page

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RECEIPT OF SAMPLE (HUSM/HEMA-UPT/QP-01)

TITLE: PROCEDURE AND RESPONSIBILITY

Version Amendment

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6. PROCEDURE AND RESPONSIBILITY

NO 6.1

ACTIVITY a. Receive ALL samples at the HL/TML counter

RESPONSIBIL ITY MLT/‘PAP/PT/ AK’

REFERENCE

b. Stamp the sample dispatch book with receiver’s name, date and time of receipt c. Check and verify the sample and request form:

MLT/’PAP/PT/ AK’

i. Accept the sample that fulfills the criteria

Refer Appendix 1

ii. Sample and laboratory request form that do not fulfill the criteria should be rejected with explanation. d. Stamp the request form with date and time of receipt of sample i. For rejected sample, return the form to the ward/clinic or other hospital and keep the duplicate as record ii. For rejected form, request for a new complete form 6.2

a. Request of sample is confirmed through LIS for Haematology routine and Coagulation tests.

MLT/’PAP/PT/ AK’ Refer Appendix 2

b. For other tests, the requests are recorded in the computer or registration book at the respective section. 6.3

Distribute the sample to the respective section

Prepared by Checked by Approved by

Dr. Marini Ramli Dr. Suhair Abbas Assoc. Prof. Dr Rosline Hassan

MLT/’PAP/PT/ AK’

Issued Date Effective Date

15.08.2009 01.11.2009

HAEMATOLOGY AND TRANSFUSION MEDICINE LABORATORY, HUSM Page RECEIPT OF SAMPLE Version (HUSM/HEMA-UPT/QP-01) TITLE: RECORD Amendment

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7.

RECORD

NO

TYPE OF RECORD

7.1

Record of request form

7.2

Request form a. Routine tests b. Tests with interpretative report (FBP, G6PD)

7.3

Sample Rejection form/book

Prepared by Checked by Approved by

LOCATION LIS or computer Registration book at respective section

RETENTION PERIOD No limit 7 years

Store

3 years 7 years

Respective section

1 year

Dr. Marini Ramli Dr. Suhair Abbas Assoc. Prof. Dr Rosline Hassan

Issued Date Effective Date

15.08.2009 01.11.2009

HAEMATOLOGY AND TRANSFUSION MEDICINE LABORATORY, HUSM Page RECEIPT OF SAMPLE TITLE: FLOWCHART Version (HUSM/HEMA-UPT/QP-01) Amendment 8.

FLOW CHART

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Receive sample at counter

Check and Verify

No Request fulfill criteria

Yes Accept if fulfill the criteria in checklist Reject with explanation Record

Distribute to the section

Prepared by Checked by Approved by

Dr. Marini Ramli Dr. Suhair Abbas Assoc. Prof. Dr Rosline Hassan

Issued Date Effective Date

15.08.2009 01.11.2009 Appendix 1

CRITERIA FOR SAMPLE REJECTION 1. Clotted sample except when serum is required. 2. Duplicate request 3. Insufficient sample. Refer to www.medic.usm.my/haematology Buku Panduan Perkhidmatan Makmal Hematologi & Unit Perubatan Transfusi Jilid 6.


4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

-

Excess sample. Refer to www.medic.usm.my/haematology Buku Panduan Perkhidmatan Makmal Hematologi & Unit Perubatan Transfusi Jilid 6, bahagian panduan penolakan spesimen dan ujian. Lysed sample. No prior appointment for special tests No accompanying request form. No accompanying sample. Wrong container. Refer to www.medic.usm.my/haematology Buku Panduan Perkhidmatan Makmal Hematologi & Unit Perubatan Transfusi Jilid 6. Unlabeled container. Discrepancy of Name & RN between the request form and sample. More than 6 hours of sample collection (For Morphology Test) More than 2 hours of sample collection (For Coagulation Test) Sample is not transported in ice that is put in separate plastic (For Coagulation Test) Sample is embedded or placed directly in the ice (For Coagulation test) No stated time of the sample collection (for Coagulation test) Incomplete request form except Haematology tests: at least 2 identifiers are required. Carbon copy is not filled up. Sample which is not registered in the LIS system For patient requiring blood transfusion under emergency or critical condition, the request will be processed even if the following conditions are not conformed: Carbon copy request form is not filled up Volume of specimen less than required volume. Data regarding history of previous transfusion and patient’s blood group are not filled up in the request form. Blood request form slip is not accompanied when taking the blood however, need two patient’s identifications presented i.e name and RN Plain tube used or clotted patient’s sample The request of blood will be processed and released to the patient UPT Medical Officer will be informed immediately regarding process and release The request of blood will be processed and released to the patient.

Other sample rejection criteria refer STM for specific tests.

HUSM/HEMA-UPT/QP-01/A1 Appendix 2

LIST OF ROUTINE AND COAGULATION TESTS REQUESTED THROUGH LIS


1. Full Blood Count (FBC) 2. Full Blood Picture (FBP) 3. Reticulocyte Count (Retic) 4. Erythrocyte Sedimentation Rate (ESR) 5. Bleeding Time 6. Prothrombin Time (PT) 7. Activated Partial Thromboplastin Time (APTT) 8. D-Dimer 9. Fibrinogen Level 10. DIC Screening 11. Thrombin Time 12. Reptilase Time 13. Mixing Test 14. Thrombophilia Workup a. Protein C activity b. Protein S activity c. Free Protein S d. Anti thrombin e. APCR f. Lupus anticoagulant 15. Von Willebrand’s Workup a. Factor VIII b. Von Willebrand factor antigen c. Von Willebrang factor activity d. RiCof e. Collagen Binding Antigen (CBA)

HUSM/HEMA-UPT/QP-01/A2


QP01