INTRODUCTION
1.0
GENERAL INTRODUCTION
Located at ground floor of main hospital block, Pathology Department of Hospital
Seberang Jaya started it service since 1995. This department is supported by
staffs from various levels of employment and covers five areas of diagnostic
pathology such as Haematology, Blood bank, Chemical Pathology,
Histopathology/Cytology and Microbiology
In addition to specialist clinics and wards at Hospital Seberang Jaya, the
department also offers services to other health institutions including Hospital
Bukit Mertajam, Hospital Kepala Batas, Hospital Sungai Bakap and other
SPT/SPU/SPS community clinic.
Other than diagnostic and consultation service, this department is also active in
providing training to various level and categories of laboratory personnel
including medical officer, scientific officers, medical laboratory technologist and
students from various local collage and universities.
The objective of this user manual is to provide useful information on the
laboratory services such as patient preparation, sample collection, results
interpretation and a list of the relevant telephone numbers.
2.0
VISION
The Department of Pathology is committed to be an excellent centre in providing
professional expertise in diagnostic services and will provide continuous training
in providing competent and knowledgeable personnel. This commitment will pave
the way for a community of Health Individuals as is the vision of ministry of
health.
3.0
MISSION
The Department of Pathology will be able to provide a team of professionally
dedicated personnel with a caring attitude and respect for human dignity.
4.0
OBJECTIVE
Pathology Department
1. To provide effective and efficient pathology service to help in patient care as
stated in STANDARD TAT.
Introduction
1
2. To provide laboratory tests and consultation to help in patients care and
management..
3. To improve quality of the service by upgrading test method and continual
education of personnel.
b. Blood bank
1. To provide safe and adequate blood and blood component for patient
management.
2. To educate the correct way of using blood and blood component.
3. To provide immediate and efficient services for Haemophilic patients
5.0
QUALITY POLICY
The Pathology services share the objectives of the Seberang Jaya Hospital and
contributes to their fulfilment by providing a consultative and analytical services
which meets the standards laid down by professional and other appropriate
bodies, in particular those promulgated by MSQH Accreditation system.
It is recognized that such standards can only be achieved and maintained by
adopting an innovative attitude. Our staff is our most important resource and
personnel development through education and training is encouraged.
Our Q strategies are:
1. Proper sample collection, transport, sample preparation and identification
2. Reliable analytical work so that systemic and random errors do not exceed
specified limits
3. Turnaround time within specified limits as stated in our Clients’ Charter
4. Data reported clearly and supplement with reference intervals (for
biochemical report)
5. Appropriate communication with the Clinicians so that they become aware
of the unexpected problems and errors
6. On- going training to new and existing laboratory staff
6.0
SERVICE HOUR
Haematology, Blood bank, Chemical Pathology,Microbiology
Monday to Friday
8.00am -5.00pm
24 hours service for certain tests in biochemistry; haematology, blood
bank and Microbiology (please refer to 10.0 for list of test).
Introduction
2
Histopathology & Cytology
Monday to Thursday
8.00 am – 1.00 pm
2.00 pm-5.00 pm
Friday
8.00 am-12.15 pm
2.45 pm-5.00 pm
Sunday, Saturday and public holidays: No service provided
Main Counter
Monday to Thursday
7.00 am – 5.00 pm
Friday
7.00 am-12.45 pm
2.45 pm-5.00 pm
After office hours:
5.00 pm – 9.00 pm: specimen will be received at respective unit
9.00 pm – 7.00 am: specimen will be received at Haematology Lab
counter
Saturday , Sunday , Public Holiday
9.00 pm – 8.00 am: specimen will be received at Haematology Lab
counter
We operate 24 hours a day with a full staff strength from Monday to Friday, 8.00
am to 5.00 pm and a reduced staffs after office hour and on weekend/public
holidays.
Non routine requests will not be performed after office hour
7.0
GENERAL RULES
1. Laboratory Requisitions
Introduction
3
All specimens must be accompanied by PER-PAT 301 request form (except
for special requirement stated in each section)
i.
ii.
iii.
iv.
v.
vi.
Clearly state patient’s detail such as NAME, IC NUMBER, RN, age,
ward/clinic
Specify the test required.
Sampling instruction (e.g. fasting, pre or post medication)
Relevant clinical details including provisional diagnostic and treatment.
Do not use abbreviations.
State date and time of the specimen collection
Medical Officer in charge must sign all forms. (In addition, certain
special test request must be countersigned by the specialist)
Urgent request must be justified by clinical summary, diagnosis and reason
for urgency. The word URGENT or STAT must be written or stamped clearly
in red on the form.
2. Specimen Collection
i.
ii.
iii.
iv.
v.
Clearly label all containers or slides with patient’s name, R/N or I/C and
date of the test requested.
Refer each section for special procedure if required.
Use the correct container provided by the lab.
Collect specific volume according to specified procedures.
If patient has to collect specimen himself, instruct clearly in simple
words that the patient understand.
3. Transport of Specimens
i.
ii.
iii.
All specimens must be treated as hazardous. It should be placed in
biohazard plastic container accompanied with a completely filled
laboratory request form
Despatch the specimen to the lab within appropriate time frame and
according to transport requirement of the tests
URGENT samples must be send to the lab immediately and notify
laboratory personnel.
4. Medico legal specimen
Must follow specific requirement needed
Introduction
4
i.
Sample collection of the requested tests must follow guidelines as
normal specimen
Specimen should be sealed and send directly to laboratory
Specimen should be sent to laboratory by designated personnel
Chain of custody must be maintain all the time and the sample should
be accompanied with a record book
ii.
iii.
iv.
8.0
GENERAL REJECTION CRITERIA
1. First level rejection
a)
b)
c)
d)
e)
f)
No Patient’s name
No I/C Number or RN(Registration Number)
No Location : Hosp/Unit/Ward/Clinic
No requesting doctor's name/rubber stamp/Off. IC
Broken / leaking container,
Sample taken/labelled by is not written
2. Second level rejection
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
9.0
Blood is haemolysed
Blood is clotted
Specimen insufficient
Specimen is collected in wrong container.
Mislabelling of specimen / form.
Test not indicated
No date/ time of specimen collection
No/ Insufficient clinical summary.
Test(s) is not available
Specimen is unsuitable for analysis
No Specialist signature
Others
RESULT/REPORT
Introduction
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1. Routine test results will be placed in the designated pigeon hole. Ward
personnel must ensure the pigeon hole is locked all the time
2. Urgent result will be collected by the awaiting ward/clinic staff.
3. Critical result will be notified to the requester immediately.
*Please refer to manual of each unit for critical result or panic value
10.0
LIST OF TEST AFTER OFFICE HOURS/URGENT BASIS
(List for normal routine please refer to each unit)
1. Blood bank
i.
ii.
iii.
iv.
Cross matching (GXM, GSH)
ABO Group and Rhesus
Coomb’s Test
Antibody Identification
2. Haematology
i.
ii.
iii.
iv.
v.
vi.
vii.
Full blood count
G6PD Test
PT/APTT
D-Dimer / Fibrinogen / FDP
Urine FEME (until 12.00 midnight)
Urine reducing sugar
Urgent Full Blood Picture
3. Chemical Pathology
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
Introduction
Amylase/Diastase
Blood Gases
Bilirubin total and direct
Calcium
Inorganic Phosphate
Magnesium
Glucose
Cardiac enzymes (AST, CK, LDH)
Renal Profile (Urea, Creatinine, Sodium, Potassium, Chloride)
Paraquat - Qualitative test on urine/gastric aspirate
C-Reactive Protein
6
xii.
xiii.
CSF for Biochemistry (Protein, Glucose, Chloride, Globulin)
TSH & FT4 (Congenital hypothyroidism Screening)
4. Microbiology
11.0
OUTSOURCING OF TEST
1. Certain tests which are not offered by this laboratory will be outsourced to
referral laboratory
2. Transportation of the specimen to referral laboratory will be managed by
the department except for some tests with special requirement
3. Outsource schedule:
i. HPP: sample will be sent daily before 9.00 am
ii. Others: sample must reach laboratory on Tuesday before 9.00 am
for pre analytical processing and packaging.
Introduction
7
12.0
TELEPHONE DIRECTORY
Contact number for Department Of Pathology, Hospital Seberang Jaya
Ext.
Pejabat Am
Head of Department
Dr. Hakimah Mahsin
Pakar Perunding Patologi Kanan (Jusa C)
160
Senior MLT (Pejabat am)
Pn. Hasnah Ahmad (JTMP U36)
Cik Vianita (JTMP U36)
159
Specimen receiving counter
170
Chemical Pathology
Blood bank
Head of Unit
Dr Tuan Hulwani Tuan Mohamad
Pakar Patologi (Hematology) UD54
Pegawai Perubatan
Dr. Shamsinar Ahmad (MO UD54)
Dr. Dr. Nurull Eddayu (MO UD44)
Senior MLT
En. Ramli Razak (JTMP U32) /En.
Charles (JTMP U32)
161
161
163
Asst. Information Officer
En. Raja Kamarrudin
163
Main Laboratory
164
Haematology
Head of Unit
Dr Tuan Hulwani Tuan Mohamad
Pakar Patologi (Hematology) UD54
161
Pegawai Perubatan
Dr. Dr Shamsuria Abdullah(MO UD44)
161
Senior MLT
Pn. Siti Salmiah (JTMP U32)
162
Main Laboratory
162
Head of Unit
Pn. . Hairani Othman
(Pegawai Sains Kimia Hayat C48)
156
Scientific Officer
Pn. . Nurazila Bt Azmi
(Pegawai Sains Kimia Hayat C44)
Pn. Tan Chai Seah
(Pegawai Sains Kimia Hayat C41)
165
Senior MLT
Pn. Maimunah bt Abdul Rahman
(JTMP U32)
Main Laboratory
Microbiology
Head of Unit
Pn. Kamala Devi
(Pegawai Sains Mikrobiologi
Perubatan C48)
Scientific Officer
Pn Norizal Mohd Zain
(Pegawai Sains Mikrobiologi
Perubatan C44)
Pn. Norhidayah Azmi
Pn Tan Chwee Ming
(Pegawai Sains Mikrobiologi
Perubatan C41)
158
158
157
157
Histopathology
Head of Unit
Dr. Faridah Bt Mohd Taib
Pakar Patologi (Histopathology) UD54
Introduction
160
Senior MLT
En. Othman Hashim (JTMP U32)
166
8
Pegawai Perubatan UD44
Dr. Nurul Huda Abdul Kadir
Senior MLT
Pn. Hasnah Ahmad (JTMP U36)
Main Laboratory
Introduction
161
Main Laboratory – Bacteriology
166
159
Laboratory – Serology
245
155
9
13.0 LABORATORY WORK FLOW
Receive request
at the main counter
Determine
urgency
Refer to
rejection
criteria
Request not
acceptable
Fill up rejection
form
CORE PROCESS FOR
PATHOLOGY SERVICES
Urgent request
Check
(1st stage)
Send direct
to unit
Sort specimen
Send specimens
to respective unit
Record in file and
photocopy
rejection form
Not
suitable
Check
(2nd stage)
Register requests
Inform ward if
necessary and
record details
Analyze/
Process
Despatch to
the pigeonhole
Repeat
analysis/ process
Validate /
Report
Results not
acceptable
Inform results/
Despatch to
pigeonhole
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