How to Apply for Laboratory
testing Facility
Dr. Lilibeth A. Fermin, MD,CFP,MPH
Municipal Revenue Code
Resolution
MOA with Pathologist
MOA with Other Referral facility on Outsourced Services
Application for License to Operate a General Clinical Laboratory
QUALITY
MANUAL
OF
PROCEDURE
(2012)
BASISTA RHU LABORATORY
MAGSAYSAY AVENUE, POBLACION,
BASISTA, PANGASINAN
This manual was developed by Ms. Maria Solana C. Carasig, RMT, Medical
Technologist of the Municipal Health Office of Basista, Pangasinan, for the
Accreditation of the Laboratory facility in this Municipality. It was written
in consultation with Dr. Lilibeth A. Fermin,M.D.,MPH, CFP, Municipal
Health Officer of Basista Pangasinan and also an associate professor at
Virgen Milagrosa University Foundation.
Thorough researches were made to be incorporate in the development
of this manual. Different books on hematology and laboratory
procedures were used. Suggestions from other Medical Technologist
was sought and considered. Mr. Brian Domingo, RNHeals from the
Department of Health assisted in the encoding and printing of this
Quality Manual of Clinical Laboratory Procedures.
INTRODUCTION
Long before the application for accreditation of the Laboratory facility
in Basista, Pangasinan, the Municipal Health Office of Basista is already
performing some laboratory procedures like sputum examination and
routine on a daily basis. The Department of Health wrote a letter to the
different health officers advising them to apply for the accreditation of
their laboratory facilities. In line with the advise, Hon. Manolito S. de
Leon, Local Chief Executive of the Local Government unit of Basista
sought the help of 1 Ang Pamilya Party List Rep. Reena Concepcion Obillo
thru Rep. Leopoldo Bataoil, Congressman 2nd District of Pangasinan for
the construction of the modern laboratory facility in Basista.
A new laboratory building was constructed with adequate laboratory
Equipment and instruments.The Municipal Health Office has a Medical
Technologist and a Health Aide with plantilla positions. A resolution was
passed by the Sangguniang Bayan of Basista allowing Municipal Health f
facility to apply for accreditation of its laboratory and a corresponding
Honorarium for Pathologist was appropriated in the Municipal’s Annual
Budget for calendar year 2012.
The health office utilizes workplace organization and work
simplification procedures to make work faster, safer and more effective.
the Quality Standard of Procedures develop positive attitudes among
health workers and cultivates a culture of effeciency, effectiveness and
service improvement. It is also one of the basic tools for improving
productivity and quality.
TABLE OF CONTENTS
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INTRODUCTION
VISION/MISSION
GENERAL POLICIES, PURPOSE AND FUNCTIONS
LABORATORY QUALITY ASSURANCE MANAGEMENT
ORGANIZATION AND LABORATORY PERSONNEL
PERSONNEL POLICIES AND PROCEDURES
RECEIVING OF LABORATORY REQUEST AND RELEASING OF
RESULTS
GUIDELINES ON SEND-OUT SPECIMENS
PROCEDURE AND OUTSOURCING OF EXAMINATIONS …
GUIDELINES ON BLOOD EXTRACTION
STANDARD OPERATING PROCEDURES OF DIFFERENT
SECTIONS
CONTINGENCY PLAN
SOP ON REPORTING & ANALYSIS OF INCIDENTS, ADVERSE
EVENTS
LOCATION MAP OF LABORATORY
FLOOR PLAN
ORGANIZATIONAL CHART
LIST OF PERSONNEL
LABORATORY FLOWCHART
Continuation. . .
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LABORATORY PROCEDURES
A. CLINICAL MICROSCOPY
1. DIRECT SPUTUM SMEAR MICROSCOPY
2. URINALYSIS
3. FECALYSIS
4. PREGNANCY TEST
B. HEMATOLOGY
1. COMPLETE BLOOD COUNT
1.1 .WHITE BLOOD COUNT
1.2 .DIFFERENTIAL COUNT
1.3.HEMOGLOBIN DETERMINATION
1.4. HEMATOCRIT DETERMINATION
1.5.. RED BLOOD CELL COUNT
2. PLATELET COUNT
3. BLOOD TYPING
C. BLOOD CHEMISTRY
1.GLUCOSE DETERMINATION
2. CHOLESTEROL DETERMINATION
3. TRIGLYCERIDE DETERMINATION
4. URIC ACID DETERMINATION
5. BLOOD UREA NITROGEN DETERMINATION
6, HDL- CHOLESTEROL DETERMINATION
7. CREATININE DETERMINATION
LIST OF EQUIPMENT/ INSTRUMENT
REFERENCES
A. CLINICAL
MICROSCOPY
1.
DIRECT SPUTUM SMEAR MICROSCOPY
2.
URINALYSIS
3.
FECALYSIS
4.
PREGNANCY TEST
B. HEMATOLOGY
1. COMPLETE BLOOD COUNT
1.1 WHITE BLOOD CELL COUNT
1.2 DIFFERENTIAL COUNT
1.3 HEMOGLOBIN DETERMINATION
1.4 HEMATOCRIT DETERMINATION
1.5 RED BLOOD CELL COUNT
2. PLATELET COUNT
3. BLOOD TYPING
C. BLOOD CHEMISTRY
GLUCOSE DETERMINATION
2. CHOLESTEROL DETERMINATION
3. TRIGLYCERIDE DETERMINATION
4. URIC ACID DETERMINATION
5. BLOOD UREA NITROGEN DETERMINATION
6. HDL /LDL DETERMINATION
7. CREATININE DETERMINATION
1.
E. NEWBORN SCREENING
1.
BACKGROUND
2.
NBS PROCEDURE
3.
NBS LABORATORY
4.
DISORDERS
5.
RESULTS AND
CONFIRMATION
D. TUBERCULIN SKIN TEST
1.
PLAN FOR A SUCCESSFUL TST
2.
PERFORMING THE TST
3.
READING TST
CARE AND MAINTENANCE
EQUIPMENT/
INSTRUMENTS
 MICROSCOPE
 CLINICAL
CENTRIFUGE
 HEMATOCRIT CENTRIFUGE
 ACCUCHECK ACTIVE UNIT
 ACCUTREND GCT UNIT
 KERNEL MULTICHECK UNIT
 STAT FAX
 PIPETTING DEVICE
OF