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Pathology Service Handbook PATHOLOGY SERVICE HANDBOOK Second Edition DEPARTMENT OF PATHOLOGY HOSPITAL SERDANG 2020 FOREWORD 1. HOSPITAL DIRECTOR Serdang Hospital is a government hospital that operates with the concept of Total Hospital Information System (THIS). Apart from providing medical services and treatment according to current needs for internal and external patients, this hospital is also a referral hospital equipped with various state-of- the-art facilities in providing secondary and tertiary levels of care. Given the significant impact of laboratory testing in providing support to clinical diagnosis and management as well as research contribution, it is timely for Pathology Department in producing this second edition handbook as a guide for users to the various range of services provided let it be in-house or external laboratory testing. I hope this handbook will be well utilised by all and with it the quality of our medical services continues to improve in providing the best in patient care as well as contribute to resource optimisation. DR ROHANA BINTI JOHAN Director Hospital Serdang iii 2. HEAD OF PATHOLOGY DEPARTMENT First and foremost, I would like to express my gratitude and congratulate the whole working committee who has worked hard to successfully produce this handbook. Serdang Hospital Pathology Service Handbook has been compiled to help healthcare workers aware on the requirements for testing and thus making the appropriate choices. This contributes to optimal use of resources, efficiency and importantly, better patient care. In this second edition of Pathology Service Handbook, there is updated information in accordance to the current development in pathology service nationwide that is intended as a source of reference to clients. I am hoping with the availability of this book will allow better access to our clients and they’ll be able to make the best use of our laboratory service with the provided information. I am looking forward to continuing collaboration with our clinical counterparts in providing optimal patient care. Thank you. DR NOR YATIZAH BINTI MOHD YATIM Head of Pathology Department Hospital Serdang iv PATHOLOGY SERVICE HANDBOOK 2020 Second Edition COMMITTEE MEMBER Advisor: Dr Nor Yatizah Mohd Yatim Co-ordinator: Dr Noorjehan Omar Dr Siti Nur Azwa Md Shahid Pn Norafaedah Mohd Nor Unit Representatives / Committee Members: Chemical Pathology: Dr Siti Hajar Umar Pn Yusniza Mamat Microbiology: Dr Lailatul Akmar Mat Nor Pn Naematul Ain Ahmad Najimudin Haematology: Dr Norsafina Zainal Dr Siti Nur Azwa Md Shahid Pn Siti Shazwa Nur Rosnan Anatomic Pathology: Dr Elmina Mohamad Mokhtar Pn Mastura Abdul Aziz Pn Suriani Samsuddin Transfusion Medicine: Dr Intan lliana Iliassa Pn Norhana Yaacob Our appreciation also goes to all past and present personnel of Pathology Department who have involved directly or indirectly in the publication of this handbook. v vi PATHOLOGY SERVICE HANDBOOK 2020 COMMITTEE MEMBER From left (back row): Dr Siti Nur Azwa, Pn Naematul Ain, Pn Mastura, Dr Norsafina, Pn Siti Shazwa Nur, Pn Yusniza, Pn Norafaedah, Pn Norhana. From left (front row): Dr Lailatul Akmar, Dr Intan lliana, Dr Nor Yatizah, Dr Elmina, Dr Siti Hajar. CONTENTS PAGES 1. VISION & MISSION viii 2. QUALITY POLICY & CLIENT CHARTER ix 3. GENERAL OPERATING POLICIES 1 4. LIST OF TESTS 19 • Chemical Pathology 20 • Haematology 58 • Medical Microbiology 63 • Anatomic Pathology 90 • Transfusion Medicine 96 5. CHEMICAL PATHOLOGY UNIT 99 6. HAEMATOLOGY UNIT 113 7. MEDICAL MICROBIOLOGY UNIT 121 8. ANATOMIC PATHOLOGY UNIT 147 HISTOPATHOLOGY 151 CYTOLOGY 156 9. TRANSFUSION MEDICINE UNIT 161 10. APPENDIX I: 175 GUIDE TO HANDLING OF BLOOD SPECIMEN 11. APPENDIX 2: 176 LIST OF REJECTION CRITERIA DISCLAIMER: Information in this booklet is true as at the time of issuance. vii VISION Department of Pathology will provide diagnostic services in line with the expert services offered by Hospital Serdang MISSION • Focusing on quality improvement and productivity by implementing teamwork, caring and professionalism. • Ensure continuous learning and training for all personnel. • Utilising appropriate best available technology with good networking. viii DEPARTMENT OF PATHOLOGY HOSPITAL SERDANG QUALITY POLICY Department of Pathology is responsible in handling laboratory tests based on internationally established methods, in line with the Good Laboratory Practices and follows the standards set by MS ISO: 15189. It is our policy to provide accurate laboratory results in reasonable time as outlined in the Pathology Service Handbook. It is our promise to practice continuous quality management CLIENT CHARTER • Every client will be treated with care, professionalism and consideration. • All requests will be reported according to the Laboratory Turn Around Time (LTAT) provided test requirements are followed. • All client’s complaints will be attended immediately. Investigation and feed back will be conducted by Department within 14 days. DEPARTMENT OF PATHOLOGY HOSPITAL SERDANG ix PATHOLOGY SERVICE HANDBOOK 2020 GENERAL OPERATING POLICIES DEPARTMENT OF PATHOLOGY HOSPITAL SERDANG 1 PATHOLOGY SERVICE HANDBOOK 2020 A. GENERAL OPERATING POLICIES 1.0 INTRODUCTION Pathology Department is one of the Clinical Support Services in Hospital Serdang. It provides pathology services which support the specialty services in Hospital Serdang as a tertiary hospital. Integrated concept is practised in this department for all routine and urgent tests including Chemical Pathology, Haematology, Medical Microbiology, Anatomic Pathology and Transfusion Medicine. This department incorporates “Laboratory Information System (LIS)” which is one of the components in “Hospital Information System (HIS)” in Hospital Serdang. Pathology Department of Hospital Serdang provides screening, diagnostic and consultancy services in the disciplines of Pathology: - Anatomic Pathology - Chemical Pathology - Haematology - Medical Microbiology - Transfusion Medicine 2.0 LOCATION Pathology Department is located on the third floor at the west wing of the hospital building, opposite the Specialist Office. 3.0 FUNCTIONS 3.1 To provide diagnostic services in the field of Chemical Pathology, Cytology, Haematology, Histopathology, Medical Microbiology and Transfusion Medicine to Hospital Serdang and surrounding health facilities. 3.2 To provide training in technical and analytical skills for personnel, staff of other government institutions and students from higher learning institutes. 3.3 To provide advisory and consultancy services to customers in matters related to services provided. 3.4 To conduct and assist research and development in pathology and other relevant clinical fields. DEPARTMENT OF PATHOLOGY HOSPITAL SERDANG 3 PATHOLOGY SERVICE HANDBOOK 2020 4.0 SCOPE OF SERVICES 4.1 The department of pathology provides the following services: 1. Chemical Pathology 2. Cytology 3. Haematology 4. Histopathology 5. Medical Microbiology 6. Transfusion Medicine 5.0 SERVICE HOURS Chemical Pathology, Haematology, Medical Microbiology and Transfusion Medicine provide 24 hours services for routine testing. Haematology, Histopathology and Medical Microbiology also provide 24 hours coverage for certain specialised tests. Name of Functional Specimen Reception Service hour Unit Counter Chemical Pathology Specimen Reception 24 hours Counter Haematology Specimen Reception 24 hours Counter Medical Microbiology Specimen Reception 24 hours Counter Transfusion Medicine Specimen Reception 24 hours Counter Cytology Specimen Reception Monday to Thursday: Counter i) 08:00 - 13:00 hours ii)14:00 - 16:30 hours Histopathology Histopathology Laboratory Friday: i) 08:00 - 12:15 hours ii) 14:45 - 16:30 hours 4 DEPARTMENT OF PATHOLOGY HOSPITAL SERDANG PATHOLOGY SERVICE HANDBOOK 2020 6.0 COMMUNICATION Any queries or problems related to pathology services can be directed to the telephone extensions as stated below: LOCATION EXTENSION Head of Department 5298 Department’s Office 1709 SPECIMEN RECEPTION Specimen Reception Counter 1678 Histopathology laboratory 1750 CHEMICAL PATHOLOGY Head of Unit 1725 Senior Scientific Officer 1722/1718 Scientific Officer 1690/1691/1697 Senior Laboratory Technologist 2017 Laboratory 1679 Outsource Section 1720 HAEMATOLOGY Head of Unit/ Pathologist (Haematology) 1735 Scientific Officer 1741 Routine Haematology 1681 Special Haematology 1734 MEDICAL MICROBIOLOGY Head of Unit 1731 Pathologist (Medical Microbiology) 1707/1708 Scientific Officer 1696/1695 Senior Laboratory Technologist 1752 Laboratory (Bacteriology / Mycology / 1757/1755/1753 Parasitology) Laboratory (Virology / Serology) 1728/2016/1732 Laboratory (TB) 1727 DEPARTMENT OF PATHOLOGY HOSPITAL SERDANG 5 PATHOLOGY SERVICE HANDBOOK 2020 LOCATION EXTENSION ANATOMIC PATHOLOGY Cytology Head of Unit 5332 Pathologist 1711/1712/1713/1715/1744/1706 Medical Officer 1768/1689 Scientific Officer 1694 Senior Laboratory Technologist 1718 Cytology Screener 1718/1763 Laboratory 7046 Histopathology Head of Unit 1744 Pathologist 5332/1711/1712/1713/1715/1706 Medical Officer 1768/1689 Scientific Officer 2014 Senior Laboratory Technologist 2014 Laboratory 1750/1751 Laboratory (Grossing) 1746 TRANSFUSION MEDICINE Head of Unit 1742 Scientific Officer 1741 Laboratory 2018 6 DEPARTMENT OF PATHOLOGY HOSPITAL SERDANG PATHOLOGY SERVICE HANDBOOK 2020 7.0 GENERAL TEST REQUEST INSTRUCTION 7.1 Tests are requested via eHIS except: (i) When system is down. (ii) Emergency uncross matched blood request. (iii) Request from external agencies. 7.2 All tests for referral lab shall be accompanied by system
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