SOP Laboratory

STANDARD OPERATING 2F, Phase 2, Vista Mall Taguig, Camellia
PROCEDURE AND QUALITY Taguig Rd., Brgy. Tuktukan, Taguig City,

VITACARE MEDICAL 1630
MANAGEMENT
Effective Date: Date Revised: CLINIC TAGUIG INC. Document no.: Revise no:
May 30,2018 May 22, 2018 01 01
MANAGEMENT RESPONSIBILITY
1. MISSION VISION
MISSION
________________________________________is committed to provide
diagnostic services with efficient and effective rendering of various laboratory
procedures, maintaining a highly competent staff who will provide excellent
customer service winning their trust and loyalty in serving various clients, both in
the corporate and the walk-in customers.
VISION
To attain and maintain excellent services through high quality standards in the
diagnostic and laboratory industry in the pursuit for prestige and integrity
Prepared By : Reviewed by By: Approved By :
MARK VRYAN B. CYNTHIA MARIE S.

PUYAOAN,RMT OLGA MUNAR-BAUSA, MD DELFIN
Chief Medical Technologist Pathologist Owner
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DOCUMENTED POLICY/ PROGRAM

1. POLICY ON CONTINUING PROGRAM FOR STAFF DEVELOPMENT AND TRAINING
1.1 PROVISIONS ON CONTINUING PROGRAM FOR STAFF DEVELOPMENT AND
TRAINING
1.1.1 The company shall allow Pathologist, Medical Technologist and
Laboratory Technicians to participate in any Periodic orientation, Seminar
workshop, Trainings and symposia to upgrade the competencies of the
staff to assure quality, integrity and effectiveness in the conduct of
medical, clinical laboratory and drug testing.
1.1.2 A yearly development plan shall be prepared in consultation with the
laboratory staff at the beginning of each year.
1.1.3 Provisions on continuing program for staff development and training.
1.1.3.1 The Head of the Laboratory shall submit the list of tentative
annual scheduled seminars to be submitted to the
management.
1.1.3.2 The company shall pay for the expenses including seminar fees,
foods, transportation and accommodation of the participant.
1.1.3.3 The days covering the said seminar/trainings shall be considered
as working day for the participant and should be paid
accordingly.
1.1.3.4 The company or participant may seek or solicit financial
assistance from their partners such as the suppliers.
1.1.3.5 The participant shall make a report (post seminar report) about
the training or seminar and submit to the Head of the
Laboratory with copy furnished to the Admin office.
1.2 DOH AND WITH CORRESPONDING CPD UNITS

1.2.1 PCQACL –Philippine Council for Quality assurance on Clinical Lab
1.2.2 PAMET – Philippine Association of Medical Technologist
1.2.3 PBCC – Philippine Blood Coordinating Council
1.2.4 PSMID – Philippine Society of Microbiology and Infectious diseases
1.2.5 PSP – Philippine Society of Pathologist
1.2.6 PAMLS- Philippine Association of Medical Laboratory Scientist
1.2.7 PHISMETH- Philippine Association of Schools of Medical Technologist

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1.3 OTHER GOVERNMENT LEAD ANGENCIES MAY CONDUCT SEMINARS AND

TRAINING ON THE FOLLOWING:
1.3.1 DRUG TEST-
1.3.2 HIV PROFFICIENCY
1.3.3 BACTERIOLOGY
1.3.4 TB DOTS / TB HIV
1.3.5 WATER ANALYSIS
1.3.6 IMMUNOLOGY AND SEROLOGY
1.3.7 BIOSAFETY AND BIOSECURITY
1.3.8 WASTE DISPOSAL MANAGEMENT
2. POLICY FOR HIRING, ORIENTATION AND PROMOTION FOR ALL LEVELS OF

PERSONNEL
2.1 POLICY ON HIRING/RECRUITMENT

2.1.1 The Management and selection committee shall strictly
implement the criteria for evaluation on all laboratory
applicants.
2.1.2 PROCEDURE:
2.1.2.1 The applicant shall submit documents like Curriculum
Vitae, Scholastic records, Certificate of employment
from previous employer, Trainings and seminars.
2.1.2.2 The applicant shall submit himself for an interview to
be scheduled by the management.
2.1.2.3 A panel composed of the Pathologist, Chief Medical
Technologist and a representative from the
management shall conduct the interview and
deliberation for all applicants.
2.1.2.4 The potential applicant shall be informed through the
management and shall discuss salaries, employment
status, benefits and pre-employment status.
2.1.2.5 Applicant shall accomplish the personal data sheet
form with 2x2 picture and, submit clearances (NBI
and POLICE), Government documents like PRC ID,
Board Certificates, Diploma, SSS, TIN, PAGIBIG and
PHILHEALTH NUMBER.
2.1.2.6 Applicant shall undergo a medical and Laboratory
examination test on Drug Test, HIV and chest X-ray.

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2.2 TERMS AND CONDITIONS OF EMPLOYMENT

2.2.1 A three months probationary period shall be offered to the appointee for
evaluation of his performance. A recommendation from the Chief
Medical Technologist to be agreed by the committee if the appointee
shall be renewed of his contract extending for the next three months. But
needs improvement or not to be renewed.
2.2.2 A regular employee shall be granted after successfully complied with all
mandatory and company requirements and after satisfactory rating of
evaluation for six (6) months probationary period and is entitled to the
benefits and privileges provided by Law.
2.3 ORIENTATION
2.3.1 Upon approval and after deliberation of the employee the management
will schedule for the orientation of the employee, the orientation may
takes 2 days before the official start of employment.
2.3.2 The Company shall conduct an orientation on the new appointee with
regards to Companies Mission and Vision, Organizational History and
Background, Functional units of the organizational structure, Products
and Services, Administrative Policies, Christian culture and Core Values,
2.4 POLICY ON PROMOTION FOR ALL LEVELS OF PERSONNEL

2.4.1 The company through the selection committee shall develop a
program of personnel development and criteria for evaluation
of performance of all personnel and fields on their
performance records as tool for selection on candidates for
promotion.
2.4.2 CRITERIAS ARE THE FOLLOWING
2.4.2.1.1 Personal development
2.4.2.1.2 Office decorum
2.4.2.1.3 Work attitude
2.4.2.1.4 Inter personal relationship
2.4.2.1.5 Performance
2.4.2.1.6 Occupational history
2.4.2.1.7 Education qualification and training

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3. POLICY FOR DISCIPLINE, SUSPENSION, DEMOTION, AND TERMINATION OF PERSONNEL IN

ALL LEVELS
3.1 The management shall strictly enforce written code of professional conduct for
maintaining order and discipline for all laboratory personnel and known all
personnel.
3.2 It should be in mind that the primary purpose of these disciplinary actions is
corrective not punitive. The intention is to reform the offender and deter others
from committing the same.
3.3 GENERAL RULES AND REGULATIONS

3.3.1 The written code of professional conduct/ discipline for all laboratory
personnel shall be enforced and known all personnel.
3.3.2 Any violations of the code of professional conduct shall be grounds for
suspension/ termination of a laboratory personnel.
3.3.3 All violations, suspension and relevant actions shall be documented and
filed in the personnel’s personal records
3.3.4 All suspensions shall be without pay. Unless otherwise provided all
terminations of cause shall carry with it automatic forfeiture of all
separation benefits
3.4 OFFENSES AND DISCIPLINARY ACTIONS

3.4.1 Offenses on attendance and punctuality
3.4.1.1 Failure to notify the immediate superior or head of the human
resource department of absence at least 1 hour before
commencement of work hour.
3.4.1.2 Failure to file application for leave of absence and other
supporting documents prior to actual leave.
3.4.1.3 Abandonment or unjustifiable absence of at least ten
consecutive working days is subject for dismissal.
3.4.1.4 Habitual absences or absence for five days in one calendar
month even with notification with the immediate superior or
head of the HRD.
3.4.1.5 Accumulated tardiness in excess of four times 15 minutes as a
grace period in one calendar month.

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3.4.1.6 Unauthorized undertime or leaving the workplace before the

completion of work hours, without clearance from the
immediate superior.
3.4.2 Offenses on wearing uniform/ appearance grooming
3.4.2.1 Failure to use identification card/ wear complete uniform during
work hours or within the company premises or whenever
required
3.4.2.2 Failure to immediate report lost or misplaced ID to the head of
the HRD.
3.4.3 Offenses against persons.
3.4.3.1 Engaging in or inducing another employee to engage in physical
altercation while within the company premises or within the
other job site.
3.4.3.2 Simple discourtesy or use of disrespectful, abusive, indecent or
offensive language on fellow employee, client, superior, guest or
other person doing business with the company.
3.4.3.3 Uttering unnecessary/ inappropriate remarks.
3.4.3.4 Threatening, coercing or harassing officers or fellow employees.
3.4.3.5 Scuffing, catcalls, unnecessary shouting or throwing of things
while at work, unnecessary name-calling or joking which might
offend other employees.
3.4.3.6 Acts of sexual harassment is subject for 4th offense
3.4.4 Acts of dishonesty
3.4.4.1 Falsification, unauthorized alteration or destruction of company
documents or records.
3.4.4.2 Making false statement in any document officially submitted to
the company, including application for employment with the
company.
3.4.4.3 False claim for pecuniary benefits/ monetary gain is subject for
dismissal
3.4.4.4 Forging the signature of fellow employee or superior is subject
for dismissal
3.4.4.5 Attempted, frustrated or consummated misappropriation of
company funds or property is subject for dismissal

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3.4.4.6 Knowingly punching/ swiping of fellow employee’s proximity or

time card with the knowledge and consent of the latter. Both
employees will be subject to 2nd offense.
3.4.4.7 Over –declaring overtime rendered subject for dismissal
3.4.5 Offenses Against Company Interest

3.4.5.1 Unauthorized disclosure of any confidential information or trade
secrets acquired by an employee on account of his or her
position
3.4.5.2 Unauthorized copying of licensed software application and all
such acts that violate intellectual property rights
3.4.5.3 Engaging , participating, directly or indirectly, in any transaction,
undertaking or business enterprise which amounts to conflict of
interest with the company
3.4.5.4 Sabotaging or deliberately causing damage to company
property and products, in order to disrupt operations or cause
losses to the company.
3.4.6 Disciplinary Action
3.4.6.1 First Offense = written warning
3.4.6.2 Second offense = 1 day suspension
3.4.6.3 Third offense = 1 week suspension
3.4.6.4 Fourth offense = cause of dismissal
3.4.6.5 Offenses that are subject for dismissal will be implemented
immediately
3.5 TERMINATION OF EMPLOYMENT BY THE COMPANY FOR JUST CAUSE:

3.5.1 The following are just causes under Article 282 of the Labor Code:
3.5.2 Serious misconduct or willful disobedience by the employee of the lawful
orders of the company or its representative in connection with his work.
3.5.3 Gross and habitual neglect by the employee of his duties.
3.5.4 Fraud or willful breach by the employees if the trust reposed in him by
the company or it’s duly authorized representatives.
3.5.5 Commission of a crime or offense by the employee against the person of
his employer or any immediate member of his family or duly authorized
representative.

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3.5.6 Other analogous causes.

*Termination of employment under just cause forfeits encashment
of vacation leave (VL) credit and payment of incentives.
3.6 NOTICE OF DEMOTION OR TERMINATION.

3.6.1 Unless otherwise specified in a written contract or by law, may
be demoted or terminated without cause and without any
reason being given for such action.
3.6.2 Whenever the employees supervisor and medical director or
operations manager determine that an employee should be
demoted or terminated, the medical director or operations
manager will send a written notification to the employee that
such a recommendation will be made by the next regular
board meeting or a special board meeting.
3.6.3 If an employee is recommended for demotion or termination,
the notice will includes:
3.6.3.1 The date of determination
3.6.3.2 The nature of the determination and the effective
date
3.6.3.3 The reasons for determination
3.6.3.4 The rights of the employee to examine his/her
personnel file and examine all written evidence which
has a bearing on such determination.
3.6.3.5 The employees appeal rights.
4. POLICY ON MANAGEMENT REVIEW

4.1 Regular staff meeting will be conducted every month or as needed, in order to
assess and resolve different laboratory issues; create updates and improvements on
current policies and guidelines, and other related topics to ensure quality laboratory
services are given to patients. The meeting will be proceed by the head of the
laboratory which is the Pathologist.
4.2 Each meetings held, will be documented in the following manner:
4.2.1 Date and Time of Meeting

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4.2.2 Attendance and signature of participants

4.2.3 Agenda of the meeting
4.2.4 Actions taken, plans or resolutions
4.2.5 Signature of approval by the head of the laboratory or clinical
administrator.
5. PROCEDURE FOR HANDLING COMPLAINTS AND CLIENT FEEDBACK AND OTHER INCIDENTS
5.1 Complaints
5.1.1 In cases wherein complaints were encountered by the laboratory. Staffs
should follow the guidelines below:
5.1.1.1 Step 1. Assessment
5.1.1.1.1 The complaint must be first assessed in order to
identify the gravity of the complaint and to determine
who will deal with the complaint and who needs to be
notified.
5.1.1.2 Step 2. Information Gathering.
5.1.1.2.1 Once assessed. Complainants must be asked to fill out
the laboratory complaint form indicating the date,
time, person involved, and other important related
details. Likewise, written report and explanation must
be immediately secured by the staff involved in the
incident. The Chief Medical Technologist, Pathologist
and Clinical Administrator must be notified in cases
wherein the complaints are unresolved, involved
serious consequences, complex medical issues or a
number of different staff, needed action that is beyond
the responsibility of the staff at point of service or
needed to be dealt with by someone with more
authority.
5.1.1.3 Step 3. Resolution and Outcome.
5.1.1.3.1 Once appropriate and sufficient documented
information and data were obtained. Options for
resolutions must be discussed jointly with the patient.
Explanation must be given in a factual way that can be

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understood by the patient and apology must be always

given in a humble and sincere manner. Reviewing the
laboratory procedures and policies must also be taken
into consideration.
5.1.1.4 Step 4. Implementation.
5.1.1.4.1 Corrective and appropriate actions, sanctions and
measures in lined with the sections of the laboratory
management standards must be implemented upon
approval by the Chief Medical Technologist,
Pathologist and Clinical Administrator to prevent
further complaints and improve quality management
within the laboratory.
5.2 Feedback, Comments and Suggestions
5.2.1 Suggestion boxes with accompanying forms are placed inside the
extraction room of the laboratory. This is to ensure that patient
recommendations, suggestions and comments will be noticed. Boxes will
be opened every end of the month and will be assessed based on
importance and significance to the laboratory department. Substantial
feedbacks will then be recorded and will be discussed during meetings in
order to formulate appropriate responses, plans or solutions that can be
implemented upon approval by the Pathologist and Clinical
Administrator.
5.3 Incidents
5.3.1 Incidents within the concerns of the laboratory must be immediately
stated and accompanying incident report must be secured. Assessments,
person involved and action/s taken must also be recorded and filed
within the laboratory.

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MANPOWER
1. ORGANIZATIONAL STRUCTURE
OWNER
HEAD OF THE LABORATORY/PATHOLOGIST
MEDICAL TECHNOLOGIST MEDICAL TECHNOLOGIST
OWNER: CYNTHIA MARIE S. DELFIN

PATHOLOGIST: OLGA MUNAR-BAUSA

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SR. MEDICAL TECHNOLOGIST: MARK VRYAN PUYAOAN

JR. MEDICAL TECHNOLOGIST: MARY CLAIRE BAPTISTA
2. JOB DESCRIPTION AND FUNCTION

2.1 Each position should have a written job description which should contain the
following:
2.1.1 Duties
2.1.2 Functions and responsibilities
2.1.3 Measurable standards of performance of the tasks
2.1.4 Hours of work
2.1.5 Who to communicate with
2.2 Each staff shall be required to sign their job description form which should be filled
in their individual personnel record.
2.3 Each staff should be required to document the fact that they have read the
required manuals that apply to their tasks.
3. DUTIES AND RESPONSIBILITIES
3.1 PATHOLOGIST
3.1.1 General and over-all supervision of the laboratory and all
examinations performed under the laboratory.
3.1.2 General supervision of conduct of all laboratory personnel.
3.1.3 Evaluates and ensures the quality of supplies/reagents used in
the laboratory with the recommendation of the Chief Medical
Technologist.
3.1.4 Provides other administrative support services such as
communications, security and maintenance.
3.2 CHIEF MEDICAL TECHNOLOGIST


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3.2.1 Supervise all laboratory personnel and the laboratory.

3.2.2 Performs quality control to ensure proper functioning of
instruments, reagents and procedures.
3.2.3 Ensures quality assurance of laboratory procedures.
3.2.4 Establishes and implements procedures to evaluate laboratory
test
3.2.5 Researches and investigates problems with clinical laboratory
procedures and makes or recommends modifications and
corrections as appropriate.
3.2.6 Reviews and trouble shoots minor discrepancy in clinical and
laboratory results.
3.2.7 Validates, calculates and tabulates results of tests performed,
posts findings to log books and quality control records and
makes reports of observations.
3.2.8 Responsible for inventory and census of reagents used.
3.2.9 Relays problems to Pathologist for immediate action.
3.2.10 Supervises and performs all analytical procedures in the
laboratory
3.2.11 Train newly hired staff or volunteers performing related work
3.2.12 Monitors usage of laboratory supplies.
3.2.13 Responsible for requisition of laboratory supplies.
3.2.14 Performs miscellaneous job-related duties as may be assigned
by the Pathologist.
3.3 MEDICAL TECHNOLOGY STAFF
3.3.1 Receives, logs and charges laboratory requests.

3.3.2 Blood extraction of patient.
3.3.3 Gives related instructions and requirements to patients prior to
blood collection.
3.3.4 Performs all analytical procedures in the laboratory.
3.3.5 Performs tests in all sections of the
3.3.6 Operates complex apparatus, instruments and machines.
3.3.7 Use standards and controls to improve reliability of lab results.
3.3.8 Works under pressure with speed, accuracy and precision.

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3.3.9 Adheres to high ethical standards of performance.

3.3.10 Enters and prints laboratory results in the computer.
3.3.11 Issues and signs laboratory test results.
3.3.12 Maintains orderliness and cleanliness in the laboratory.
3.4 LABORATORY TECHNICIAN/ PHLEBOTOMIST
3.4.1 Collect/ extract blood samples to the patient with care.

3.4.2 Assist the medical technologist in the performance of
laboratory tests and procedures
3.4.3 Responsible for maintaining general cleanliness of work areas.
3.4.4 Prepare laboratory monthly reports
3.4.5 Type laboratory results
3.4.6 Log laboratory result
3.4.7 Performs other task that may be assigned as needed
4. EVALUATION OF STAFF COMPETENCY
4.1 The competency level of each staff should be continuously evaluated.

4.2 Validation can be done through external certification, formal.
4.3 Certification or periodic informal sessions at various levels.
5. WORK ASSIGNMENT AND SCHEDULES
5.1 To maximize laboratory operations, medical technologist are being rotated in

different sections on monthly basis base on the schedule prepared by the
assigned staff and duly approved by the medical technologist. There are 2
shifts of medical technologist: 9am-6 pm and 12mm- 9pm, the phlebotomist
will have a special schedule 6am – 3 pm, the schedule may change when one
of the staff is off. Schedules are assigned by the chief Medical Technologist
and approved by the head of the laboratory
5.2 Our clinic laboratories offer a wide-range of examinations/tests, some tests
are being referred to our partner laboratories
MON TUES WED THURS FRI SAT. SUN.

MEDTECH 1 OFF 1pm- 1pm- 9am- 9am- 9am- 9am-

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9pm 9pm 6pm 6pm 6pm 6pm

12nn- 6am- 1pm- 12nn- 12nn- 1pm-
MEDTECH 2 9pm OFF 3pm 9pm 9pm 8pm 9pm
PHLEBOTOMIS 6am- 6am- 6am- 7am- 7am- 7am-
T 3pm 3pm OFF 3pm 3pm 3pm 3pm
PHYSICAL PLANT AND FACILITIES/ WORK ENVIRONMENT
1. PROGRAM OF PROPER MAINTENANCE AND MONITORING LABORATORY SITES AND

FACILITIES
1.1 The laboratory shall have adequate facility to accommodate efficient operation of
tasks required. There must be a system to provide safety to personnel,
environment and security to testing procedures and records.
1.2 The laboratory site facility must conform to the legal and regulatory requirements
of a secondary clinical laboratory. Within premises are area for specimen
collection and a toilet to afford privacy for urine and sperm count collection.
1.3 The laboratory working area will be used for Chemistry, Hematology, Clinical
Microscopy and Drug testing.
1.4 The Specimen Collection area or the Extraction area is just outside the working
area.
1.5 The site facility shall consider the flow of samples and activities to reflect the
logical sequence of sample reception, test analysis, storage and disposal.
1.6 The work area shall be situated remote and inaccessible to patients and non-
laboratory personnel. Security precautions shall be in place to prevent ready
access to samples, logbooks, records and documents, and sensitive equipment and
supplies.
1.7 The laboratory shall have adequate electricity, water supply and air-conditioning
that shall be needed for provision of efficient and safe operations.

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1.8 The laboratory shall be maintained clean and orderly at all times. It is the
responsibility of the Medical technologist to ensure cleanliness of their work area.
Maintain the policy “Clean as you go “.
1.9 There shall be adequate lighting and ventilation in all work areas. The lighting and
ventilation requirements shall follow the prescribed building code and DOH
infrastructure agency.
1.10 An area shall be designated within the laboratory for personal requirements of
personnel.
1.11 No eating or drinking shall be allowed within the working area. Taking of
alcoholic beverage and prohibited drugs shall not be allowed.
2. PROGRAM FOR PREVENTIVE MAINTENACE OF THE FACILITY

2.1 The management is responsible for the scheduling the preventive maintenance of
the facility.
2.2 The management will have accessible contacts to the one responsible to perform
the a preventive maintenance of the facility
2.3 The one who performed the preventive maintenance will log all the thing that are
done and signed the preventive maintenance logbook.
2.4 The proposed schedule of performing the preventive maintenance for the facility
are follows:
2.4.1 Air conditioning and Exhaust: Quarterly
2.4.2 Water supply : Every 2 months
2.4.3 Lighting: Quarterly
2.4.4 Structure of the facility : Annually
3. GUIDELINES ON LABORATORY BIOSAFETY AND BIOSECURITY
3.1 Security and Safety in the Laboratory should be the responsibility of all personnel.
Procedures should be adopted to maintain the security and the integrity of the
biological samples, documents and other records and more importantly the safety
in the working environment of its employees.
3.2 The Laboratory manager shall be designated the safety and security officer of the
laboratory who shall oversee, implement and monitor all its general activities.

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3.3 LABORATORY SECURITY AND PRACTICE
3.3.1 A laboratory must control access of unauthorized individual and

ensure that no unauthorized individual can gain access directly to
specimens, aliquots and records.
3.3.2 The patient’s relative or companion shall be limited to the
extraction/reception area.
3.3.3 Only authorized visitors can enter the offices within the laboratory.
He/She however will not be allowed to interfere with analytical
procedures. Exceptions to these rulings are equipment engineers,
product specialists who maintain/repair equipment and conduct
product demonstrations.
3.3.4 Cleaners, Engineering and maintenance personnel may enter the
analytical work areas and pathology offices provided that specified
work has been requested and provision for escort been accorded.
3.3.5 All records, logbooks, documents, files shall not be taken out of the
laboratory premises without the approval of the Head of the
Laboratory. Copies of laboratory results/reports may be secured by
the patient’s authorized representative.
3.3.6 All equipment must be used only as the instruction dictate. Any
equipment with moving parts must be used with care.
3.3.7 Keep the facility clean and clutter free.
3.3.8 Observe “Universal Precautions” when collecting, processing, storing,
shipping or transporting human blood and body fluids.
3.3.9 Restrain long hair, avoid loose clothing or jewelry and open-toed
shoes.
3.3.10 Wash hands after handling infectious material (even when gloves have
been worn) and before leaving the laboratory.
3.3.11 Decontaminate all contaminated materials before disposal or reuse.
3.3.12 Decontaminate laboratory surfaces following any spill of bio-
hazardous materials and at the end of each working day.
3.3.13 Report all spills and accidents/incidents.
3.4 HOUSKEEPING PROTOCOALS:
3.4.1 Cleaning with facility approved disinfection and water.

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3.4.1.1 In the basin, prepare the correct dilution of the facility

approved disinfectant.
3.4.1.2 Using one clean rag, clean all the surfaces in the room pay
special attention to surface with come into contact with hands
(eg. Computer, call bell, telephone, etc.).
3.4.1.3 Next, to clean the bathroom, change gloves and clean the
bathroom in the usual manner, with special attention to
surface which come in contact to with hands.
3.4.1.4 After cleaning the toilet, discard the facility approved
disinfectant and water from the basin, into the toilet flush
3.4.1.5 Rinse the basin with hot water.
3.4.1.6 Change gloves again.
3.4.2 Wiping with facility approved disinfectant.
3.4.2.1 Start in the patients room, spray all the flat surfaces with
facility approved disinfectant and with another clean rag, wife
all the surfaces.
3.4.2.2 After wiping all the surfaces in the room, change gloves and re-
clean the bathroom using approved disinfectant.
3.4.2.3 Put on clean gloves
3.4.3 Washing the floor.
3.4.3.1 Dry mop the floor

3.4.3.2 Prepare a fresh solution on facility approved disinfectant and
water in bucket to clean the floor.
3.4.3.3 Wash the floor with the clean mop head as per routine.
3.4.3.4 After the floor is washed, pour the water into the toilet and
flush
3.4.3.5 Place the mop heads and rags into a clean plastic bag to be
returned in housekeeping, keep all other equipment in the
room.
3.4.3.6 Remove outer gloves, then gown and finally the last pair gloves
3.4.3.7 Washed hands for 30 seconds
3.4.3.8 Leave the room and when outside, rub alcohol based hand
rinse agent to hands.

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3.5 PEST AND VERMIN CONTROL PROTOCOAL
3.5.1 Facility manager

3.5.1.1 The facility should be informed of all pest activity sighted by
other occupant or pest control vendors. If the facility manager
believes the pest problem is not being resolved or wants
additional pest control service, request for assistance should be
made.
3.5.2 Best Management Practices for Pest Control

3.5.2.1 Pest monitor traps. All pest monitor traps must be labeled with
a date and placed in a location on record. The record can be
either a map or else documented on a service report form.
3.5.2.2 Service report form. These forms documented the report of a
pest problem, actions taken to correct the problem and
findings relevant to the source of the infestation
3.5.2.3 A pest control technician will fill out a service report form on
each visit to the facility all service report forms will be kept in a
logbook on location.
3.6 Pest Monitoring
3.6.1 Insects and rodent survey traps will be placed in potential pest hiding
locations and checked monthly for the presence of pests. The
presence of pests will be reported on the service report form. The
commercial pest control technician will documented all control actions
taken and findings on the same service report form. When traps are no
longer effective, they will be replaced as needed.
4. LABORATORY SAFETY AND PRECAUTION
4.1 CHEMICAL HAZARDS
4.1.1 Use with extreme caution reagents which are strong acids and strong
base. Avoid splashes, spills, and eye and skin contacts. Do not inhale
fumes.

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4.1.2 Any chemical which contact the skin and eyes should immediately be
washed with running water for approximately 5 minutes unless the
label says otherwise.
4.1.3 Read all labels for precautions on handling and emergency
management of potential hazards of reagents.
4.1.4 In case of emergency/accidents, refer the problem to the Pathologist
for proper handling and treatment.
4.1.5 Chemicals should be disposed properly in accordance with
manufacturer’s instructions. However, directions which are explicitly
provided in the label as to disposal should be followed.
4.1.6 Mouth pipetting should no longer be practiced to avoid aspirating up
through the mouth.
4.2 BIOLOGICAL HAZARDS
4.2.1 All specimens are potentially infectious and should be handled with
EXTREME CARE
4.2.2 Laboratory coat should be worn at ALL times to avoid contamination
4.2.3 The following specimens should be handled with extreme caution:
4.2.4 All specimens for bacteriologic and serological studies
4.2.5 Icteric blood.
4.2.6 If request states a history of possible: HIV-AIDS, Typhoid fever,
hepatitis, Syphilis, Meningococcemia, Encephalitis.
4.2.7 The specimens at letter C shall be labeled with “BIOLOGIC HAZARD”
4.2.8 All those requests with attached potentially highly infectious material
labeled with “BIOLOGICAL HAZARD-HANDLE WITH EXTREME CARE”.
4.2.9 Biological specimen and any contaminated articles like lancets,
needles, syringes and highly infected specimen vials should be
disposed of or placed in biohazard bags of containers, soaked in
decontaminating solution before disposal.
4.3 FIRE HAZARD

4.3.1 Local regulations on fire safety, including the storage of flammable
solvents and reactive chemicals, the provision of suitable fire-fighting
equipment, and designation of laboratory fire safety officers and
scheduled of fire drills must be given a due regard.

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4.3.2 A Fire extinguisher is logically located near the laboratory and more
around the facility.
5. WASTE MANAGEMENT PRACTICE
5.1 All Medical and Administrative personnel are imposed to practice proper waste
segregation and disposal of waste.
5.2 Persons involved;
5.2.1 Medical Technologist
5.2.2 Medical Laboratory personnel
5.2.3 Pollution control officer
5.3 DETAILS OF HAZARDOUS HEALTH CARE WASTE
5.3.1 INFECTIOUS /PATHOLOGICAL WASTE, INCLUDING SHARPS AND

NEEDLES
5.3.1.1 Infectious waste are solid and liquid wastes that may contain
pathogenic organisms that can be transmitted thru puncture,
abrasion, cut in the skin, mucous membrane, inhalation and
ingestion.
5.3.1.2 Sharps including syringes should all be collected and placed in a
puncture- proof container, fitted with cover. The sharps shall
be pre-treated with chemical disinfectants
5.3.1.3 The puncture –proof containers shall be segregated and placed
in a red color coded plastic garbage bag marked with
“CAUTION: BIOHAZARD WASTE “
5.3.1.4 All urine specimen and other residuals of general healthcare
waste for disposal shall join the stream of domestic refuse or
municipal solid waste
5.3.2 CHEMICAL WASTE INCLUDING WASTE WITH HIGH CONTENT OR

HEAVY METALS
5.3.2.1 These are discarded solid, liquid, gaseous chemical materials
and products that may cause intoxication, either by acute or
chronic exposure, injuries, including burns. Routine of entry

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may be absorption thru skin, mucous membranes, eyes, or

direct contact with their genotoxic, flammable, corrosive or
reactive properties.
5.3.2.2 All chemical waste shall be classified packed in chemical
resistant containers and sent to a specialized treatment facility
(if available). The identity of the chemicals shall be clearly
marked on the containers. Hazardous chemical waste of
different types should never be mixed.
5.3.2.3 Waste with high content of heavy metals should be collected
separately. These may be sent to treatment facilities.
5.3.2.4 All chemical waste shall be segregated and placed in a yellow
plastic garbage bag with black band and appropriate markings
5.3.3 PRESSURIZED CONTAINERS
5.3.3.1 Gas stored pressurized containers, aerosols, cylinders used in

analytical testing once empty may be reusable, but certain
types may be disposed of.
5.3.3.2 All pressurized containers may be collected with general health
care waste once they are completely empty
5.3.3.3 Aerosol containers shall not be burned or incinerated
5.3.4 NON-HAZARDOUS HEALTH CARE WASTE
5.3.4.1 GENERAL WASTE

5.3.4.1.1 These are waste comparable to domestic waste
that do not pose any harm or hazard to human
health or environment. They are derived mostly
from administrative and housekeeping
functions
5.3.4.1.2 the laboratory shall practice waste
minimization by applying various methods:
waste-reduction at source, re-use, recycle,
waste segregation, composting
5.3.4.2 BIODEGRADABLE WASTE
5.3.4.2.1 use of sanitary landfill

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5.3.4.2.2 composting
5.3.4.2.3 where a municipal of city collection system is
available
5.3.4.3 NON-BIODEGRADABLE WASTE
5.3.4.3.1 recycle, re-use of: glass, metals, plastics,
computer, cartridges and others
5.4 WASTE HANDLING, STORAGE AND TRANSPORT
5.4.1 SEGREGATION:
5.4.1.1 Segregation at the point of waste generation for classification

and bagging in appropriate waste disposal bags or containers
shall be done by the medical technologist or authorized
laboratory personnel.
5.4.1.2 Waste containers must be designed to maintain its integrity
throughout handling, storage, transportation and treatment.
5.4.1.3 Separation of hazardous waste by color- coding of disposal
bag/containers will prevent accidents or unnecessary exposure
to infectious waste and will facilitate waste disposal. As
prescribed by the DOH (Department of Health) Environmental
Health Service for Hospital/ Health Facility Waste
Management, the color- coding shall be as follows:
Color of container and Type of container Type of waste

markings
Yellow, marked “HIGHLY Strong, leak-proof plastic Highly infectious waste
INFECTIOUS” bag, or container capable of
being autoclaved
Yellow Leak-proof plastic bag or Other infectious waste,
container pathological and
anatomical waste
Yellow, marked “SHARPS” Puncture-proof container Sharps
Brown Plastic bag or container Chemical and
pharmaceutical waste
ANY COLOR Lead box, labeled with the Radioactive waste
radioactive symbol

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Black Plastic bag General health-care waste

Green Green Plastic bag, Biodegradable waste
5.4.1.4 General health care waste should join the stream of the
domestic refuse for disposal.
5.4.1.5 Sharps should be collected all together whether they are
contaminated or not in a puncture-proof container with
disinfectant.
5.4.1.6 Bags and containers for infectious waste should be marked
with the international infectious substance symbol.
5.4.1.7 Highly infectious waste should, whenever possible, be sterilized
immediately by autoclaving. It therefore needs to be packaged
in bags that are compatible with the proposed treatment
process: red bags, suitable for autoclaving, are recommended.
5.4.1.8 Staff should never attempt to correct errors of segregation by
removing items from a bag or container after disposal or by
placing a bag inside another bag of a different color.
5.5 ON SITE COLLECTION, TRANSPORT AND STORAGE
5.5.1 Clinical staff should ensure that waste bags are tightly closed when
they are about three quarters full.
5.5.2 Bags should not be closed by stapling.
5.5.3 Sharp containers should be placed in yellow labeled bags before
removing inside the laboratory.
5.5.4 Wastes should be collected daily and transported to the central
collecting site.
5.5.5 A supply of fresh bags should always be readily available at the site of
waste generation
5.6 STORAGE
5.6.1 A Storage area is designated inside the health care facility.
5.6.2 Criteria of storage area:
5.6.2.1 should have impermeable, hard standing floor
5.6.2.2 with water supply for easy cleaning
5.6.2.3 it should be possible to lock to avoid unauthorized access

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5.6.2.4 should not be located in the proximity of foods or drinks

5.6.2.5 should have good lighting and least passive ventilation
EQUIPMENT
1. LIST OF LABORATORY EQUIPMENT
1.1 CLINICAL CHEMISTRY ANALYZER (Sapphire chemistry Analyzer BK-200)

1.2 HEMATOLOGY ANAYLYZER ( Boule M-Series M32S BD)
1.3 Binocular Microscope (CX23LEDRFS1)
1.4 Clinical Centrifuge 8 placer (Digisystem)
1.5 Clinical Centrifuge 12 placer (Digisystem)
1.6 Hematocrit Centrifuge (Digisystem)
1.7 Micropipette

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2. PROGRAM FOR CALIBRATION, PREVENTIVE MAINTENACE AND REPAIR OF

EQUIPMENTS
2.1 The laboratory equipment’s should be calibrated at least once every six months.
2.2 The medical technologist shall make a request for calibration every six months
thru the lab manager.
2.3 The medical technologist on duty shall follow all written procedures so as to
prevent untimely breakdown of equipment’s.
2.4 If the machine /equipment breaks down, the medical technologist on duty shall
inform immediately the Administrator for immediate action.
2.5 The equipment, maintenance and repair record must documented that all
instruments are properly maintained, calibrated cleaned and monitored
including the corrective measures and recommendations done.
3. EQUIPMENT DESIGN
3.1 Use only properly designed equipment that is capable of fulfilling its function,
as detailed in the experimental protocol, including the equipment used for the
generation, measurement, or assessment of data, as well as that used to
regulate the environment of the testing facility. Keep equipment accessible and
suitably located for proper operation, inspection, cleaning and maintenance.
Identify all equipment with a unique number, such as an inventory number, for
correlation with the calibration, maintenance and repair records.
4. DOCUMENTATION
4.1 Maintain written records of all inspection, maintenance, testing, calibration,

and/ or standardizing operations in equipment logs. Maintain equipment logs
for all laboratory abs field equipment, including centrifuges, freezers,
microscope, autoclaves, generators, etc. Equipment used in laboratory. Clearly
identify the log by equipment name and dates covered. Include the following
information in the log:
4.1.1 Dates and equipment’s is in operation.
4.1.2 Dates and result of inspection.

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4.1.3 Maintenance, including cleaning procedures. Describe whether

maintenance was routine and followed written standard
operating procedures.
4.1.4 Testing, calibration, and/or standardization operations.
4.1.5 Service and repair events. Record the nature of failure or
malfunction, how and when it was discovered, and any remedial
action taken.
4.1.6 Changes in configuration and addition of options.
4.2 Store all written records or equipment logs in the archives when they are no
longer kept in the laboratory or field station each log should be adequately
identified as to the piece of equipment and dates covered by the log.
5. CONTIGENCY PLAN INCASE OF EQUIPMENT BREAKDOWN

5.1 Laboratory staff should be well aware of manual methods in case of equipment
breakdown.
5.2 If the machine breakdown happens, the medical technologist on duty will
contact the supplier to provide a backup machines.
5.3 If the supplier cannot provide an immediate back up machines, medical
technologist on duty will do the manual procedure for STAT Specimen.
5.4 After the STAT specimen done, the medical technologist on duty will do basic
troubleshooting, if still the machine is not good, the medical technologist will
contact the supplier and try trouble shooting through phone. If the problem
persists, the medical technologist on duty will do an incident report address to
the head of the laboratory, and the head of the laboratory will coordinate with
the operational manager to do an action.
5.5 All machines are provide with UPS. The UPS must be charge all the time for the
operation to be continue in case of power outage.
5.6 All specimen request for clinical chemistry examination will be send to an
affiliated/ accredited laboratory
5.7 A back-up microscope and centrifuge must be available in case of a breakdown.
Warranties of equipment, in cases as such are used which usually lasts for a
year.
5.8 Laboratory examinations which are beyond the capability of the laboratory are
sent out to an affiliated/accredited laboratory. Results should be followed-up
within the day by the medical technologist and Operations Manager/Clinic
Administrator.

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5.9 In cases where the Medical Technologist on duty is absent, adjustments on

schedule should be made with the permission of the Chief Medical Technologist
and the Operations Manager/Clinic Administrator.
5.10 Emergency services: Whom to Contact, the telephone numbers and
addresses of the following should be prominently displayed in the facility:
5.10.1 The institution or laboratory itself (the address and location may
not be known in detail by the caller on the services called)
5.10.2 Operations Manager/Clinic Administrator/Directors of Clinical
Laboratory
5.10.3 Head of the Laboratory
5.10.4 Bio-safety Officer
5.10.5 Fire Officers
5.11 To avoid events of equipment malfunction, laboratory staff shall strictly

follow the calibration and maintenance procedures, adequately inspect, clean
and maintain all equipment before each use.
REAGENT AND SUPPLIES

1. QUALITY OF RECORDS
1.1 The clinic shall have an adequate supply of properly stored and inventoried
supplies and reagents for the examinations provided.
1.2 Supplies, reagents and material with soonest expiration dates must be utilized
first. Expiration dates shall be strictly monitored to avoid materials, supplies and
reagents wastage/spoilage. The Medical Technologist assigned in a section is

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responsible for monitoring each supply in his/her section and shall report to chief
medical technologist in requesting supplies of directly log the needed supply to
the requisition form which is always available in assigned area.
2. QUALITY CONTROL OF REAGENTS
2.1 Labels and inserts shall be read and followed prior to the preparation of reagents.
2.2 When prepared in-house, the reagent’s label must contain the following
information:
2.2.1 Name of the solution
2.2.2 Date of preparation
2.2.3 Expiration date (if known)
2.2.4 Storage temperature
2.2.5 Initials of persons preparing the solution
2.3 Each run must include one full set of controls. Quality control specimens are run
twice a week prior to the run of the analytical procedure.
2.4 The controls for each test run must yield results within the limits of the
manufacturer’s criteria for acceptability and validity of the run.
2.5 New calibration curves are made when new sets of reagents are opened or as
needed.
2.6 Reagents, calibrators and controls are stored and handled according to the
directions specified by the manufacturer.
2.7 All test kits must be used before the expiration date to ensure valid results.
2.8 Physical parameters of the test such as incubation time and temperature must be
followed to ensure proper performance.
2.9 Proper pipetting procedures shall be strictly observed to avoid variation in the
volume of reagents or specimens during transferring
3. TEMPERATURE MONITORING
3.1 Refrigerator used for reagents storage in laboratory must be labeled with words
to effect of: NOTICE- REAGENT AND SPECIMENS MAY BE STORED IN THIS
REFRIGERATOR. DO NOT USE FOR FOOD STORAGE. Refrigerator in the staff
lounge is specially use for food not for any reagents and supply.

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3.2 Proper monitoring of the laboratory refrigerator must be log in a monitoring

sheet located in front of the refrigerator for proper documentation.
4. MATERIAL SAFETY DATA SHEET
4.1 The supplier will provide the Material Safety Data Sheet in all reagents used in
the laboratory.
4.2 The Chief Medical Technologist will make a compilation of all the Material Safety
Data Sheet, which is always available when needed.
POLICY ON SECURITY OF SUPPLIES, SPECIMENS AND CONFIDENTIALITY OF RECORDS
1. SECURITY OF SUPPLIES
2.1 The laboratory ensures that the procedures for the purchase, receipt and
storage of all reagents guarantee that the quality of testing is not compromised.
2.2 All new lots of reagents are crosschecked and documented with previous lots to
ensure reproducibility. Environmental condition for the storage of all reagents
and consumables are monitored and documented.
2.3 The laboratory maintains a record of all laboratory supplies, including reagents
and consumables, this information includes:
2.3.1 Identify of the reagent or consumables
2.3.2 Manufactures name.
2.3.3 Contact information for the supplier or the manufacturer;
2.3.4 Date of receiving and date of entering into service;
2.3.5 Condition when received (e.g. acceptable or damaged.)
2.3.6 Manufactures instructions;
2.3.7 Records that confirms the reagents or consumables initial
acceptance for used.
2.3.8 Performance records that confirm the reagents or consumables
ongoing acceptance for use.
2.4 Store all supplies, controls, and reagents according to manufacturer’s
recommendations.
2.5 Store supplies, controls and reagents in designated storage areas of the
laboratory (e.g. chemistry refrigerator, chemistry freezer) generally, items are
stored nearest to their point of usage.

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2.6 Always rotate stock by the putting the newest item (with the longest expiration
dates) in the back and the oldest items (with the shortest expiration dates) to
the front of the refrigerator or freezer.
2.7 Check the expiration dates on all items each time they are used to ensure their
stability according to prescribed specification, unless otherwise specified, do not
use supplies, controls, and reagents past the manufactures stated expiration
date.
2.8 Safely discard supplies, controls and reagents once they become outdated.
2. SECURITY OF SPECIMEN
2.1 Specimen Receiving and Recording
2.1.1 All specimen from out patients must be received in the receiving area of
the laboratory.
2.1.2 Laboratory hours for out-patients is from 8:00 am to 7:00 pm daily.
2.1.3 Laboratory requests forms should be completely filled-out specifying the
examination desired and the name of the requesting physician.
2.1.4 The patient’s data must be recorded in the Entry/Receiving Logbook and
Send-out log book for sent-out procedures.
2.2 Specimen Collection, Handling, Processing & Storage
2.2.1 Clinical Chemistry, Immunology & Serology
2.2.1.1 Specimen Collection
2.2.1.1.1 Collection of specimen involves its proper technique,
transport of the specimen to the laboratory and the
proper identification of specimen
2.2.1.1.2 All specimens submitted must be of sufficient quantity,
fresh and free from hemolysis (blood serum sample)
and should be accompanied by a completely filled-up
laboratory request. Specimens coming from outside
should be transported in ice.
2.2.1.2 Specimen Handling
2.2.1.2.1 The handling of specimens must be in compliance with
the regulations regarding laboratory safety of this
manual. This includes, but is not limited to, the use of
gloves, protective lab coats, protective pipetting
shields, protective eyewear, and face shields, as
appropriate for the task being performed.

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2.2.1.2.2 Handwritten label, or pre-printed labels are to be

affixed to sample tubes (vacutainers, capillary tubes or
syringes) immediately after the specimen has been
obtained.
2.2.1.2.3 Tubes should be handled gently and kept in a stable,
vertical position after collection to promote better clot
formation and to prevent hemolysis.
2.2.1.2.4 Red tops are allowed to clot for 30 minutes at room
temperature. Do not release the clot by rimming the
tube with a wooden applicator stick prior to
centrifugation.
2.2.1.2.5 Samples are to be centrifuged within 30 minutes of
receipt unless constituent stability is such that more
rapid processing is indicated. Serum maybe separated
from the cells by decantation or aspiration. If delays in
testing are anticipated, the sample should be
refrigerated or frozen, depending on constituent
stability.
2.2.1.2.6 Tubes should be placed into the centrifuge in a pattern
designed to balance the centrifuge head. The same
sized tubes should be placed exactly opposite each
other. If an odd number of specimens is to be
processed, tube filled with water should be used for
balance.
2.2.1.2.7 Tubes are centrifuged with stoppers in place or with an
adequate closure. Serum tubes are spun for 10
minutes and plasma tubes are spun for 15 minutes.
2.2.1.2.8 Remove serum or plasma with a plastic transfer pipette
within 2 hours of collection (except for Glucose, must
be removed immediately). Do not re-centrifuge
specimens except shortly after original spinning and
before any aliquot has been taken.
2.2.1.2.9 Aliquots and dilutions must be clearly-labelled with
marking pen.
2.2.1.3 Specimen Storage

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2.2.1.3.1 Tubes should remain stoppered when not in use. Tests

which cannot be run immediately are to be aliquoted
(if necessary) labelled, and stored at refrigerator or
freezer temperature according to the storage
directions located under specimen in each procedure.
2.2.1.3.2 If specimen is stored in frozen state (0 to - 20C for 7
days), it must be thoroughly thawed and re-
centrifuged before processing.
2.2.2 Hematology
2.2.2.1 Specimen Collection and Handling
2.2.2.1.1 Collection of specimen involves proper technique,
transport of the specimen to the laboratory and the
proper identification of specimen.
2.2.2.1.2 All specimens submitted must be of sufficient quantity
(proper blood:anticoagulant ratio), fresh and free from
hemolysis and should be accompanied by a completely
filled-up laboratory request. Specimens coming from
outside should be transported in ice.
2.2.2.2.1 (Hematology) Store EDTA tubes at 2-8 C for 7 days
2.2.2.2.2 (Coagulation) The allowable time interval between
obtaining the specimen and testing the sample
depends on the temperature maintained during
transport and storage of the sample: 22-24C = 2 hours;
2-4 C = 4 hours; and -20 C = 2 weeks
2.2.3 Clinical Microscopy
2.2.3.1 Specimen Collection and Handling
2.2.3.1.1 Specimen brought into the laboratory should be
accompanied by a laboratory request, which contains
the patient’s name, age, sex, room, date and time
collection, type of specimen, procedure to be done and
the name of the requesting physician.
2.2.3.1.2 Random and early morning urine specimen should be
freshly voided into a sterile container.
2.2.3.1.3 Early morning midstream urine is preferred and should
not be mixed with night urine.

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2.2.3.1.4 Urine specimen should not be less than 15 cc, except in

cases of oliguria when difficulty of voiding is to be
considered. In such a case, volume should be
reported.
2.2.3.1.5 Seminal fluid collection should follow a period of
sexual abstinence 2-5 days. Must be submitted before
liquefaction.
2.2.3.2.1 Tests which cannot be run immediately are to be
stored in 2-8 C for 2 hours.
2.3 Criteria for Adequacy or Inadequacy of Specimens
2.3.1 Urine
2.3.1.1 At least 3ml of sample.
2.3.1.2 Specimen Required: 15-20 cc of mid-stream urine, early
morning or random urine, freshly voided into sterilized
container. It should be submitted within 1 hour after collection
2.3.1.3 5-10cc of freshly voided urine for Pregnancy Test (HCG)
2.3.2 Stool
2.3.2.1 pea size specimen
2.3.2.2 Specimen Required: 2-3 grams of freshly-collected (thumb-size).
Watery stool specimen should be submitted within 30 minutes
after collection and formed stool within 1 hour
2.3.3 Blood
2.3.3.1 3 to 5ml for routine chemistry
2.3.3.2 5 to 10ml for routine chemistry + special chemistry
2.3.3.3 1 to 3ml for CBC
2.3.3.4 2 to 3 capillary tubes for CBC
2.3.3.5 2.5 to 5.0ml Citrated blood for Coagulation studies
2.3.3.6 3ml oxalated blood for ESR
2.4 Criteria for Specimen Rejection
2.4.1 Unacceptable specimens are reported immediately. To avoid rejected

specimens, please refer to the instruction for specific specimen
requirement, collection and handling.
2.4.2 Mislabeled Specimens


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2.4.2.1 The name and/or identifying number do not match on the

sample and requisition.
2.4.2.2 The name and/or identifying number are missing from the
sample requisition.
2.4.3 Unsuitable Specimens

2.4.3.1 Specimens received from unknown clinics or facilities are
rejected. Only legally-authorized physicians and facilities may
submit specimens for processing.
2.4.3.2 Specimens received in leaking or unsealed containers are not
acceptable.
2.4.3.3 Quantity Not Sufficient (QNS) specimen
2.4.3.4 Hemolyzed blood specimen
2.4.3.5 Improperly-collected specimen
2.4.3.6 Inappropriate type of specimen or preservative
2.4.3.7 Unacceptable time lapse since collection.
2.4.3.8 Visible signs of contamination
2.4.3.9 Specimens not collected in the proper container
2.4.3.10 Improperly handled or transported specimens
2.4.3.11 Broken slides will not be accepted
2.4.4 Blood
2.4.4.1 Hemolyzed serum

2.4.4.2 Insufficient amount of blood extracted.
2.4.4.3 Prolong standing of specimen especially for blood chemistry.
2.4.4.4 Improperly labeled specimen
2.4.4.5 Incomplete patient’s data and request.
2.4.5 Urine
2.4.5.1 Heavily turbid urine especially if it is a pregnancy test.

2.4.5.2 2 hours old urine specimen for pregnancy test and routine
urinalysis.
2.4.5.3 Quantity not sufficient
2.4.5.4 Improperly labeled specimen
2.4.5.5 Specimen from outside must be transported following proper
procedures (e.g. placed in ice, protected from light, etc.)
2.4.5.6 Incomplete patient’s data.

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2.4.6 Stool
2.4.6.1 Stool contaminated with urine or toilet water

2.4.6.2 More than 1 hour for amoeba and parasites
3. CONFIDENTIALITY OF RESULT
3.1 The laboratory staff is responsible for the maintenance and storage of its
records.
3.2 Records stored shall be filed, labeled and must be retain for period for at least 2
years in storage cabinet.
3.3 Records shall be placed in a folders or binders inside the designated storage
cabinet to protect them from.
3.4 The laboratory use an electronic storage system that shall store and archive all
records electronically. This method will provide accurate representation of the
original records.
3.5 The laboratory shall ensure the integrity of data electronically stored under its
Information Technology Facilities
3.6 The data stored electronically shall have a back-up copies for future
3.7 Vital and confidential test results will be released by the person responsible
(medical technologist)
3.8 All test result will be released to the client only or any authorized representative
with date, time and signature of the recipient.
3.9 All results whether received or released shall be signed by the person
responsible indicating the date and time.
3.10 This procedure is to ensure confidentiality of test results to protect
disclosure to the public that may adversely affect the interest of the client.
TECHNICAL POLICIES AND PROCEDURES OF DIFFERENT SERVICES


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1. LABORATORY TESTS AVAILABLE
1.1 CLINICAL MICROSCOPY

1.1.1 Routine Urinalysis
1.1.2 Routine Fecalysis
1.1.3 Semen Analysis
1.2 CLINICAL HEMATOLOGY
1.2.1 Complete Blood Count
1.2.2 Complete Blood Count with Platelet
1.2.3 Platelet Count
1.2.4 Erythrocyte Sedimentation rate
1.2.5 Reticulocyte count
1.2.6 Peripheral Blood smear
1.3 CLINICAL CHEMISTRY
1.3.1 Glucose
1.3.2 Uric Acid
1.3.3 Blood Urea Nitrogen(BUN)
1.3.4 Creatinine
1.3.5 Cholesterol
1.3.6 Triglyceride
1.3.7 HDL/LDL/VLDL
1.3.8 SGOT/AST
1.3.9 SGPT/ALT
1.3.10 OGCT (Oral Glucose Concentration Test)
1.3.11 OGTT (Oral Glucose Tolerance Test)
1.4 SEROLOGY
1.4.1 ABO and RH TYPING
1.4.2 VDRL
1.4.3 HbsAg Screening
1.4.4 Pregnancy Test
*In cases of unavailability of laboratory procedure, the specimen shall initially collected and
recorded in the laboratory. The laboratory shall have the partner and memorandum of
agreement with the referring laboratory for the send out of test/ examinations which are not
available in the laboratory.
2. GENERAL FLOW CHART


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3. GENERAL RULES AND REGULATION ON TECHNICAL PROCEDURES

3.1.1 REQUISITION
Proper procedure assures adequate identification of the patient and the
specimen and indicates the examination desired and facilitates reporting of
report.
3.1.1.1 Identification of the patient (name and number)
3.1.1.2 Age, Sex
3.1.1.3 Requesting Physician
3.1.1.4 Patient Diagnosis
3.1.1.5 In addition, the following information must be maintained by
the laboratory
3.1.1.5.1 Condition of any unsatisfactory specimen e.g.
QNS
3.1.1.5.2 Type of test/ procedure performed
3.1.1.5.3 Date and time requested and when specimen
collected
*The laboratory shall use its own official request form with all the required
data
3.1.2 PATIENTS AND SPECIMEN IDENTIFICATION
3.1.2.1 Laboratory personnel must take utmost care with respect to

the proper identification of patients and specimen.
3.1.2.2 The receiving personnel should ask the name of the patient
3.1.2.3 He shall positively identify the patient name and age and
check these against the data written in the requisition form
3.1.2.4 If the patient is incapable of stating his/her name, the lab
personnel must seek proper identification by the other
persons who know the patient such as relative or any
companion.
3.1.3 REPORTING
3.1.3.1 Written Reports

2.1.3.1.1 A duly signed written report by the medical
technologist and pathologist.
2.1.3.1.2 All written reports should bear the patient’s
identification and requesting physician. The day

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and time of collection, date and time report are

also included.
2.1.3.1.3 All written reports are recorded on laboratory
logbooks for record keeping and administrative
purposes.
3.1.3.2 Verbal Reports
3.1.3.2.1 This is a major potential source of errors and

may results in medical liability so this is
discouraged. However, in emergency cases,
verbal reports may be allowed provided the
report is released to the physician by the
pathologist.
3.1.3.3 Cumulative Reports
3.1.3.3.1 When several analyses are performed on

specimen for the same patient, the results are
presented as a table in single sheet for the
clinician to determine at a glance the patient’s
progress and allow the lab staff to make
validations.
3.1.3.3.2 Serial Hgt results are reported cumulatively, the
entire tests one for the day are reported the
next day on table form in single sheet.
3.1.3.3.3 The laboratory has to communicate abnormal
results (PANIC VALUES) to ensure prompt and
reliable reporting. Appropriate record keeping
and retrieval are also necessary.
*The laboratory has to communicate abnormal results (PANIC VALUES) to ensure
prompt and reliable reporting. Appropriate record keeping and retrieval are also necessary.
3.1.4 EVALUATION OF TEST RESULT
3.1.4.1 In addition to adhering to given procedure, the lab staff has
additional responsibility to:

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3.1.4.1.1 Evaluate test results with regards to their

clinical relevance.
3.1.4.1.2 Release the results as soon as possible.
3.1.4.1.3 Check the consistency of the results with
regards to patient’s conditions.
3.1.4.1.4 Screen critical values at the earliest opportunity
to indicate a potentially dangerous condition
requiring immediate action/attention such
critical values should be reported even if they
were not requested on priority basis.
3.1.5 PRE-ANALYTICAL VARIABLES
3.1.5.1 TEST UTILIZATION

3.1.5.1.1 The laboratory suggests and monitors the
appropriateness of test requests
3.1.5.1.2 It plays a role in identifying situation in which
test utilization may be improved
3.1.5.2 PATIENT IDENTIFICATION

3.1.5.2.1 Correct identification of patient and specimen
3.1.5.3 TURN AROUND TIME

3.1.5.3.1 Delayed and lost requisition requisitions;
specimen and reports can cause major
problems in diagnosis and treatment.
3.1.5.4 PATIENT PREPARATION

3.1.5.4.1 Lab test results are affected by many factors
such as recent intake of food, alcohol or drugs
as well as smoking, exercise, stress, sleep and
posture during specimen collection and other
variables.
3.1.5.4.2 Proper patient preparation is essential
3.1.5.4.3 This lab has defined instructions and
procedures for patient preparation both by oral
and written instructions

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3.1.5.5 SPECIMEN COLLECTION

3.1.5.5.1 All lab staff are trained properly to collect
specimen through venipuncture, finger-prick
and arterial procedures (with supervision of a
resident physician).
3.1.5.6 PERSONNEL
3.1.5.6.1 The competency of the people assigned
responsibilities defined in the QMS is
determined on the basis of documented criteria
in the applicable job description for appropriate
education, trainings, skills and experience for
each required competency or work assignment.
3.1.5.6.2 The personnel shall be evaluated on a yearly
basis.
3.1.5.6.3 And they shall be allowed to attend quality
management programs, seminars or other
seminars/trainings related to their job
description.
3.1.6 ANALYTICAL VARIABLES
3.1.6.1 INSTRUMENT BASED – these will affect many of the methods

in the laboratory quality, calibration and /or analytical
balances and volumetric glassware stability of electric power
and temperature of refrigerators, freezers and centrifuges.
3.1.6.2 Temperature records are kept and maintained.
3.1.6.3 INDIVIDUAL-BASED – this variable relates directly to
individual’s analytical methods such as pipetting and mixing
technique.
3.1.6.3.1 ELEMENTS:
3.1.6.3.1.1 Standard and Calibration
 Highest quality method or the
definitive methods are used to
validate reference methods.

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3.1.6.3.1.2 Control Materials

 Specimens or solutions analyzed
solely for quality control purposes
and not for calibration.
 Must be stable, available in aliquots
or vials, which can be analyzed
periodically over a long-time
period.
 These control materials are run
together with the unknown
specimen everyday and their values
are recorded for statistical and
standard quality calibration carve
purposes.
 Use of CONTROL CHARTS AND
STATISTIC
3.1.6.3.1.3 WORK ENVIRONMENT
 The Executive Director has overall
responsibility for identifying,
implementing and maintaining
effective employee benefits and
workforce involvement.
 He shall also be responsible that
the working environment is hazard-
free.
3.1.6.3.1.4 EQUIPMENT/ SUPPLIES/REAGENTS
 The Chief Medical Technologist
ensures the suitability and
availability of equipment’s and
supplies used for the performance
of the service offered.
 The Chief Medical Technologist
shall assess the accuracy and
precision of reagents by performing
quality control tests.
3.1.7 POST ANALYTICAL VARIABLES

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3.1.7.1 DOCUMENTATION AND RECORDING

3.1.7.1.1 All analytical procedures done shall be
documented and recorded in corresponding
logbooks for future reference.
3.1.7.1.2 A laboratory file hard copy is kept for a period
of two years.
3.1.7.2 RELEASING
3.1.7.2.1 All laboratory reports shall bear the name and
signature of the medical technologist who
performed the test and of the pathologist.
3.1.7.2.2 The receiving person / patient shall affix his/her
signature in the releasing logbook once the
result is released.
4. SPECIMEN COLLECTION AND PATIENT PREPARATION
4.1 GENERAL RULES ON SPECIMEN COLLECTION
4.1.1 Universal Precaution should be followed at all times. Blood and other
body fluids from all patients should be considered infective. To
supplement the universal blood and body fluid precautions.
4.1.2 All persons collecting and processing blood and body fluid specimens
should wear gloves. Mask, protective eyewear and laboratory
gowns/coats, gloves should be changed and hands washed after
completion of specimen processing.
4.1.3 All laboratory staff must take precautions to prevent injuries caused by
needles, scalpels and other sharp instruments.
4.1.4 Staff with exudative lesions or weeping dermatitis should refrain from
all direct patient care and from handling patient care equipment until
the condition resolves.
4.2 BLOOD SPECIMEN
4.2.1 VENIPUNCTURE
4.2.1.1 Greet the patient. Establish a good rapport with the patient
4.2.1.2 Upon receive the requisition form check the patient
information and verify the patient identification by asking

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their name, age, address or any other identification written in

the requisition form to be sure for the patient. If the patient
has no ID/ unable to speak verify the identity to a reliable
source.
4.2.1.3 If fasting or any patient preparation required to the test to
performed the following must be follow:
4.2.1.3.1 Exercise or muscular activity: either excessive
or no causes transient biochemical constituent
in the plasma.
4.2.1.3.2 The following requires a minimum of 8 hours
fasting:
4.2.1.3.2.1 FBS
4.2.1.3.2.2 BUN
4.2.1.3.2.3 BUA
4.2.1.3.2.4 TP A/G Ratio
4.2.1.3.2.5 Cholesterol
4.2.1.3.3 The following requires 10-12 hours fasting:
4.2.1.3.3.1 Triglycerides
4.2.1.3.3.2 HDL/LDL
4.2.1.4 Assemble the equipment and supplies needed in
venipuncture.
4.2.1.5 Position the patient properly for easy and comfortable access
to the antecubital fossa.
4.2.1.6 Apply tourniquet several inches above the puncture site.
Never leave the tourniquet in place longer than 1 minute.
4.2.1.7 Select the suitable vein for puncture. Veins for antecubital
fossa, in particular, the median cubital, and the cephalic
veins, are preferred.
4.2.1.8 In case of difficulty accessing a venous line, the phlebotomist
or the medical technology staff shall ask the assistance of a
chief medical technologist or doctors on duty for
venipuncture procedure.
4.2.1.9 Arterial Procedure only don by the MD’s
4.2.1.10 The medical technologist shall inform the patients
of the intended procedure.

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4.2.1.11 Anchor the vein firmly, both above and below the
puncture site.
4.2.1.12 Apply the proper aseptic technique using 70% isopropanol
solution. Allow the area to dry. Do not touch the swabbed
area with any unsterile object.
4.2.1.13 Perform the venipuncture: enter the skin with the
needle at approximately a 15-30 degrees angle to the arm,
with bevel up, when the back flow of blood seen pull the
plunger smoothly to about hemolysis of the blood and let the
barrel full for the exact amount of blood needed for the test.
4.2.1.14 If several test requested you can use the venipuncture
using vacutainer tube. Please follow the order of draw of
tube.
4.2.1.14.1.1 blood culture tube (YELLOW TOP
TUBE)
4.2.1.14.1.2 citrated tube (BLUE TOP TUBE)
4.2.1.14.1.3 Serum tube/plain tube (RED TOP
TUBE)
4.2.1.14.1.4 Heparinize tube (GREEN TOP TUBE)
4.2.1.14.1.5 EDTA Tube (VIOLET/PURPLE TUBE)
4.2.1.14.1.6 Fluoride tube (GRAY TOP TUBE)
4.2.1.15 Release the tourniquet when blood begins to flow, never
withdraw the needle without removing the tourniquet.
4.2.1.16 Place a clean sterile cotton ball or gauze lightly over the
site. Withdraw the needle, the apply pressure to the site.
4.2.1.17 Apply an adhesive bandage strip over the cotton ball or
gauze to adequately stop bleeding and avoid hematoma.
4.2.1.18 All specimen must be properly and legibly labeled;
labeling shall be performed immediately after venipuncture
4.2.1.19 Mix and inverts the tubes with anticoagulant; do not
shake the tubes.
4.2.1.20 Dispose of the contaminated materials such as needles,
syringes, and cotton in a designated container.
4.2.2 SKIN PUNCTURE

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4.2.2.1 Select an appropriate puncture site. For infants, this is most

usually the lateral or medial plantar heel surface, in older
infants, the palmar surface of the last digit of the second,
third, or fourth fingers may be used. Other sites for skin
puncture are the plantar surface of the big toe, the lateral
side of a finger adjacent to the nail, and the earlobe. The site
of puncture must not edematous or a previous puncture site.
4.2.2.2 Warm the puncture site with a warm, moist towel no hotter
than 42 oC; this increase the flow of blood.
4.2.2.3 Apply the proper aseptic technique using 70% isopropanol
solution. Allow the area to dry. Do not touch the swabbed
area with any unsterile object.
4.2.2.4 Make the puncture with sterile lancet. Use a lancet with a
blade no longer than 2.4 mm to avoid injury to the calcaneus
(heel bone)
4.2.2.5 Discard the first drop of blood by wiping it away with a sterile
pad. Regulate further blood flow by gentle thumb pressure.
Do not milk the site because this may hemolyze the specimen
and introduce excess tissue fluid.
4.2.2.6 Collect the specimen in a suitable container by capillary
action.
4.2.2.7 Seal the specimen container insert clay in to each end of the
capillary tubes
4.2.2.8 Label the specimen container or the log directly to record
logbooks the name and ID of patients sample as use in the
analyzer.
4.3 URINE SPECIMEN
4.3.1 Greet the patient. Receive the requisition form of urinalysis.

4.3.2 Check the Job order no/ Control number, name, age, and gender
written legibly.
4.3.3 Identify the patient properly by verifying his/her identity with an ID.
After proper patient identification, label the container properly with
patient’s last name, first name middle initial, age, gender, and include

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other necessary information such as LMP, STAT, with PT and with micral
test.
4.3.4 Instruct the patient to catch the clean midstream portion of the urine.
4.3.5 For female patient, urinalysis is ideally done 7 days after the last day of
her menstruation otherwise advised/ requested by her attending
physician.
4.3.6 A urine specimen must be submitted in laboratory in a tightly sealed
vessel, labeled properly.
4.3.7 Check the validity of the specimen by examining the physical
appearance and volume.
4.3.8 “QNS” and contaminated specimen must be rejected and instruct the
patient to repeat collection.
4.3.9 STAT urinalysis shall be given priority and result shall be release 1 to ½
hours after submission of specimen.
4.4 SAMPLE FOR CULTURE AND SENSITIVITY
4.4.1 Specimens for culture and sensitivity testing shall be collected in a

sterile container. Early morning specimen is recommended for sputum
and urine culture, or as directed by the clinician.

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5. STANDARD OPERATING PROCEDURE IN CLINICAL CHEMISTRY
5.1 CHEMISTRY PROCEDURE

5.1.1 Upon receipt of blood samples and requisitions form in the chemistry
section, the MT shall check the tube labels against the name in the
request.
5.1.2 Centrifuge the clotted blood sample (about 20 mins after collection in
room temperature if clot activator is not incorporated in collection
tubes) for 10 minutes at a relative RPM of 850 to 1000x gravity. After
centrifugation, check for any evidence of hemolysis, lipemia, icterous,
chyle.
5.1.3 Blood chemistry shall be processed using an automated analyzer,
BIOBASE SAPPHIRE BK2OO. Refer to user manuals for detailed technical
procedures of the analyzer.
5.1.4 the following are the principles used by each test
5.1.4.1 Glucose- oxidase method
5.1.4.2 Blood Urea Nitrogen- Urease Method
5.1.4.3 Creatinine- Picric method
5.1.4.4 Blood Uric Acid- TBHBA
5.1.4.5 Cholesterol- Oxidase
5.1.4.6 Triglyceride- Oxidase
5.1.4.7 AST/SGOT- IFCC
5.1.4.8 ALT/SGPT-IFCC
5.1.4.9 HDL Cholesterol- Direct Method
5.1.5 Check index for other details about the chemistry test.
5.2 CRITICAL VALUES FOR CLINICAL CHEMISTRY

5.2.1 ALT: >100mg/dL
5.2.2 AST: >100mg/dL
5.2.3 BUN: >40mg/dL (not dehydrated/ no history of renal disease)

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>100mg/dL (patient with history of renal disease)

>20mg/dL increase in 24hr. (indicates acute renal failure)
5.2.4 FBS: <50 or>400mg/dL
5.2.5 BUA: >12mg/dL
5.3 FLOWCHART IN CLINICAL CHEMISTRY

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6. STANDARD OPERATING PROCEDURE IN CLINICAL HEMATOLOGY
6.1 HEMATOLOGY PROCEDURE AUTOMATED

6.1.1 Upon receiving s request, the Med Tech. enters the name of the
patient, age, sex, status, company if the patient is a member and the
date of extraction in the main log sheet of the laboratory and verify in
laboratory information system
6.1.2 Collect the specimen by either venipuncture or finger/ skin puncture.
For venipuncture, use an EDTA tube to make a direct smear for
differential count. While for finger prick collection an anticoagulated
capillary tube is used preparing also a direct smear for differential
count.
6.1.3 Boule Hematology Analyzer Model M32S. See the operators manual for
detailed procedure.
6.1.3.1 bring out the hematology controls to room temperature
from the refrigerator
6.1.3.2 disinfect the hematology section including the analyzer and
working table
6.1.3.3 Clean the analyzers and mix the hematology controls in
specimen mixer 15 minutes after standing in room
temperature. Run 3 levels of control. All parameters must be
within acceptable ranges before running patients specimen.
6.1.3.4 Specimens received in hematology section shall be logged in
the hematology logbook in ascending order based on
laboratory number. Logging should start with lab. No., last
name, first name, middle initial, age and gender
6.1.3.5 Put the specimen in the mixer if available or mix them
manually by inverting 8 times in 20 seconds.

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6.1.3.6 Enter the specimen ID in the analyzer, verify the ID in the

specimen tube and logbook, then run the sample.
6.1.3.7 STAT hematology request shall be released 1 to 1 ½ hours
after specimen collection. Otherwise, shall be released the
next day between 8am-5pm.
6.2 MANUAL HEMATOLOGY PROCEDURE
6.2.1 Material:
6.2.1.1 Counting chanber and thoma pipettes.
6.2.1.2 Drabskin’s solution for hemoglobin using Sahli pippete, WBC
and RBC diluting fluid for white blood cell and red blood cell
count.
6.2.1.3 Hemafuge for hematocrit determination
6.2.1.4 Wright stain for differential
6.2.2 HEMATOCRIT DETERMINATION

PROCEDURE:
6.2.2.1 Fill at least two capillary tubes approximately 2/3 full. If using
tubes with a colored ring at one end, fill from opposite end.
6.2.2.2 Seal unfilled end with non-absorbent sealing material
6.2.2.3 Place capillary tubes in opposite slots of micro hematocrit
centrifuge with the clay-filled end against the gasket. Be sure
to note position number if spinning specimens for more than
one patient.
6.2.2.4 Place the head cover of centrifuge and spin for 5 minutes or
the minimum time determined for maximum call packing of
the centrifuge. Open the lid and remove the tubes one at a
time for reading.
6.2.2.5 Determine the hematocrit by using hematocrit reading
device.

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6.2.3 HEMOGLOBIN DETERMINATION

PROCEDURE
6.2.3.1 Suck blood up to 20 mark of Sahli pipette.
6.2.3.2 Draw blood to 5 ml of Drabkin’s solution and let stand for 10
minutes.
6.2.3.3 Use water blank
6.2.3.4 Read at 540 nm
6.2.4 WHITE BLOOD CELL COUNT

PROCEDURE
6.2.4.1 Draw blood up to 0.5 mark of the WBC pipette and the
diluting fluid up to mark 11. Wipe off the excess blood
outside the pipette before immersing it in the diluting fluid.
6.2.4.2 Shake using the mechanical pipette shaker
6.2.4.3 Discard the first four drops and immediately fill both sides of
the counting chamber making sure not to cover charge the
chamber.
6.2.4.4 Focus under low power filed. Adjust the light so that the
leukocytes appear slightly iridescent round bodies with
definite outline.
6.2.4.5 Count the cells in the four corners (WBC SQUARE) of the
counting chamber. Include in the count those cells that lay
half in and half out of the upper and left hand lines.
6.2.4.6 Count both sides of the counting chamber
6.2.4.7 Calculation: no. of cells counted x 50 = WBC count
6.2.5 PLATELET COUNT (REESE AND ECKER METHOD)

PROCEDURE
6.2.5.1 Draw blood up to 0.5 mark of the red cell pipette.
6.2.5.2 Draw platelet diluting fluid ( Reese & Ecker) up to mark 101
after wiping off excess blood outside the red cell pipette.
6.2.5.3 Shake the pipette using the pipette shaker machine.

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6.2.5.4 Discard the first four drops and immediately fill both sides of
the counting chamber making sure that the chamber is not
over charged.
6.2.5.5 Allow to stand for 15 minutes in a close petri dish kept moist
with wet filter paper.
6.2.5.6 Count the platelets in the finely rules area of the chamber
6.2.5.7 Note: platelets are bluish and must be distinguished from
debris. They are oval, round or comma shape and vary in size
from 1-5 micra.
6.2.5.8 Normal Value: 150,000- 450,000 /cu mm
6.2.6 DIFFERENTIAL COUNTING

6.2.6.1 BLOOD SMEAR PREPARATION
6.2.6.1.1 Place a drop of blood at 0.05 inch from the
edge of the slide.
6.2.6.1.2 With the help of a spreader slide, position the
spreader slide at 45 degree angle and spread
the blood making a thick and thin characteristic
of a blood smear.
6.2.6.1.3 Air dry
6.2.6.1.4 Label with patient’s name, patient’s laboratory
number and date.
6.2.6.2 STAINING (wright stain)
6.2.6.2.1 PRINCIPLE: The typical color of cell nuclei,
namely purple, is due to molecular action
between eosin Y and azure B-DNA complex.
Both dyes build up the complex later. The
intensity of the staining depends on the azure B
content and on the ratio azure B/eosin Y. the
staining result can be influenced by several
factors such as the pH of the solutions and
buffer solutions, buffer substances, fixation,
staining time.
6.2.6.2.2 PROCEDURE
6.2.6.2.2.1 Filter the stain daily. Make sure smears are
thoroughly dried before staining.

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6.2.6.2.2.2 Dip the slide in hemacolor solution 1, 5

times, 1 second per dip.
6.2.6.2.2.5 Air dry the slide, the slides are pinkish
violet
6.2.6.2.3 READING
6.2.6.2.3.1 Read 100 WBC cells in Oil Emersion
Objective start from the feathery edge of
the smear using the differential counter.
6.2.7 ERYTHROCYTE SEDIMENTATION RATE

6.2.7.1 PROCEDURE
6.2.7.1.1 Fill the wintrobe tube up to the zero line
6.2.7.1.2 Place the wintrobe tube in an exactly vertical
position at room temperature and observe the
point on the mm scale to which the corpuscles
fall at exactly 1 hour.
6.2.7.2 NORMAL VALUE
6.2.7.2.1 Male and Female: 0-20 mm/hr.

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6.3 FLOWCHART IN CLINICAL HEMATOLOGY

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7. STANDARD OPERATING PROCEDURE IN CLINICAL MICROSCOPY

7.1 Routine Urinalysis
7.1.1 Principle
7.1.1.1 The microscopic examination is a vital part of the routine
urinalysis. It is a valuable diagnostic tool for the detection and
evaluation of renal and urinary tract disorders as well as
other systematic disease. Urine microscopy will only be
performed per physicians/primary care –giver request for
clinical management or per study protocol requirements.
7.1.2 Materials required
7.1.2.1 conical centrifuge tube, 10ml-15ml
7.1.2.2 microscope slides
7.1.2.3 covers slip
7.1.2.4 urine reagent strip
7.1.3 Equipment required
7.1.3.1 Microscope
7.1.3.2 clinical centrifuge, 2000 RPM
7.1.4 Procedure
7.1.4.1 Note the color, clarity and volume of urine and record on
urinalysis worksheet.

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7.1.4.2 Using the urine dipstick, immerse in to the urine and

compare with the chart given by the manufacturer. Note the
reading and record on urinalysis worksheet.
7.1.4.3 The microscopic examination should be performed on a 10-
15 ml centrifuge sample
7.1.4.3.1 Mix the sample well and pour 10-15 mL into a
15 mL conical centrifuge tube.
7.1.4.3.2 Centrifuge at 2000 rpm for 5 minutes.
7.1.4.4 Decant, then place a drop of the sediment on a clean slide
and cover with cover slip.
7.1.4.5 Adjust microscope light source
7.1.4.6 Examine under low-power magnification to locate cast and
elements that are present in only a few field; casts usually
congregate near the edge of the cover slip
7.1.4.7 Note the presence and type of crystals( crystals need only be
reported as present unless they are very abundant
7.1.4.8 Note the type and the average number of cast seen per low
power field on the worksheet.
7.1.4.9 View the sediment in High Power Objective (40x)
7.1.4.9.1 Count the presence of WBC and RBC in 5-15
fields rate the number of RBC and WBC as per
field start from the lowest number counted
field to the highest number counted field. Note
and record in the worksheet.
7.1.4.9.2 Estimate the number of Epithelial cell, mucous
treads, bacteria,yeast (budding or hyphae) per
high power field in observing 10-15 fields.
7.1.4.9.2.1 Reporting of the cells estimated are as
follows:
7.1.4.9.2.1.1 RARE- approximately 0-10% of the field
7.1.4.9.2.1.2 OCCASIONAL- approximately 15-25% of the field
7.1.4.9.2.1.3 FEW- approximately 25-50% of the field
7.1.4.9.2.1.4 MODERATE- approximately 50-75% of the fieldMANY- full field.
7.1.4.9.3 Note any Trichomonas vaginalis seen and
estimate the number per field (0-1, 0-3 etc.)

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7.1.4.9.4 Note any other organisms or objects seen such

as glitter cells or clue cells.
7.1.4.9.5 Record the results obtained on the urinalysis
worksheet, microscopic section.
7.1.5 Expected Values
7.1.5.1 color: straw to dark yellow
7.1.5.2 Clarity: Clear to turbid
7.1.5.3 Cast: none seen
7.1.5.4 WBC’s: 0-3/hpf
7.1.5.5 RBC’c: 0-3/hpf
7.1.5.6 Epithelial cells: Rare to many/lpf
7.1.5.7 Crystals : none seen
7.1.5.8 Organism: (bacteria, yeast, trichomonas): none seen
7.2 ROUTINE FECALYSIS

7.2.1 COLLECTION AND HANDLING OF STOOL SPECIMENS:
7.2.1.1 Collect directly into a clean, dry container and bring entire
specimen to the laboratory
7.2.1.2 Patient should be well instructed on preserving the specimen
if the time interval between collection and laboratory
examination becomes critical.
7.2.1.3 If stool is to be processed within 1 hour, it may be held at
room temperature, beyond 1 hour stool must be
refrigerated, trophozoites from refrigerated specimens can
regain motility in warm saline or warm slide.
7.2.1.4 37o C incubation destroys amoebas
7.2.2 DIRECT EXAMINATION – SALINE PREPARATION
7.2.2.1 Using an applicator stick, get a pea size stool specimen, place
it on a clean slide, place a drop of NSS and mix well.
7.2.2.2 cover with cover slip
7.2.2.3 Scan area under cover slip systematically on low power.

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7.2.2.3.1 look for hyaline refractive bodies that be

protozoan cysts or trophozoites
7.2.2.3.2 check for motility of protozoan trophozoites
7.2.3 DIRECT EXAMINATION – IODINE-STAINED(Temporary) PREPARATION
7.2.3.1 Using an applicator stick, get a pea size stool specimen, place
it on a clean slide, place a drop of NSS and lugol’s iodine, mix
well
7.2.3.2 Trophozoites can no longer be seen since they are destroyed
by iodine
7.2.3.3 Cytoplasm of protozoan cysts stains yellow-brown
7.2.3.4 Nuclear chromatin can easily be seen and number of nuclei
counted
7.2.3.5 Chromatoid bodies do not stain
7.3 SEMEN ANALYSIS
7.3.1 Sample collection and delivery
7.3.1.1 The following instructions for sample collection and delivery
are based on WHO recommendation. The subject should be
provided with clearly written or oral instructions concerning
the collection and, if required, transport of the semen
sample.
7.3.1.2 The sample should be collected after a minimum of 48 hours
and no longer than 7 days of sexual abstinence. The name of
the man, period of abstinence, date and time of collection
should be recorded. The time interval between the last
ejaculation and sample collection should be well defined and
preferentially as constant as possible in order to allow a
reliable interpretation of the results of sperm concentration
and motility. When the duration of abstinence is more than 7
days, sperm motility, i.e. the proportion of spermatozoa with
rapid progressive motility, may decline. If the duration of
abstinence is <48h, sperm concentration may be reduced,
but motility will probably not be affected.
7.3.1.3 Two semen samples should be collected for initial evaluation.
The interval of time between the collections will depend on
local circumstances but should not be less than 7 days or
more than 3 months apart. If the results of these

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assessments are remarkably different, additional semen

samples should be tested because marked variations in
sperm output may occur within the same individual. Analysis
of multiple semen specimens provides a reliable screen in the
evaluation of male factor infertility. Information and support
are important since semen analysis cause a moderate
amount of stress.
7.3.1.4 Ideally the sample should be collected in the privacy of a
room near the laboratory. If not, it should be delivered to the
laboratory within 1h after collection.
7.3.1.5 The sample should be obtained by masturbation and
ejaculated into a clean, wide-mouthed glass or plastic
container. If plastic is used, it should be checked for lack of
toxic effects on spermatozoa. The container should be warm
to minimize the risk of cold shock.
7.3.1.6 Ordinary condoms must not be used for semen collection
because they may interfere with the viability of spermatozoa.
In cases in which masturbation is not possible or against an
individual’s values, the specimen can be collected in a non-
spermicidal condom following intercourse. It has been shown
that semen samples collected during intercourse using a
special plastic condom or an elastic collection device tend to
have better parameters. Other authors, referring to their
experience, hold the view that the quality of the specimen
when collected in this way is generally compromised. This
way of collection should be considered for a second sample if
the first one shows a relatively low volume. Coitus
interruptus is not acceptable as a means of collection
because it is possible that the first portion of the ejaculate,
which contains the highest concentration of spermatozoa,
will be lost. Moreover, there will be cellular and
bacteriological contamination of the sample and the acid pH
of the vaginal fluid will adversely affect sperm motility.
7.3.1.7 Incomplete samples should be not analyzed, particularly if
the first portion of the ejaculate is lost. The sample should be
protected from extremes of temperature (not less than 20°c

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and not more than 40°c) during transport to the laboratory.

The sample should be examined immediately after
liquefaction and certainly within 1h of ejaculation.
7.3.1.8 Laboratory technicians should be aware that semen samples
may contain harmful viruses (e.g., HIV and viruses causing
hepatitis and herpes) and should therefore be handled with
due care.
7.3.2 TEST PARAMETERS
7.3.2.1 Volume: 2ml or more
7.3.2.2 Ph: 7.2-8.0
7.3.2.3 Sperm concentration: 20x10 (6th) spermatozoa per ml or
more
7.3.2.4 Sperm count: 40 x 10(6th) spermatozoa per ejaculate or more
7.3.2.5 Motility: 50% with forward progression or rapid progression
within 1 hr.
7.3.2.6 Morphology: 30 % or more with normal forms
7.3.2.7 Vitality: 75% or more live
7.3.2.8 WBC: Fewer than 1 x 10(6th)/ml
7.3.3 Macroscopic examination
7.3.3.1 Appearance:
7.3.3.1.1 The semen sample is first evaluated by simple
inspection.
7.3.3.1.2 A normal sample has a grey-opalescent
appearance, is homogenous and liquefies
within 60min at room temperature under the
influence of enzymes of prostatic origin.
7.3.3.1.3 In some cases, liquefaction does not occur
within the normal time period and this fact
should be recorded, as it may suggest
functional disturbance of the prostate.
7.3.3.1.4 The sample may appear clear if the sperm
concentration is too low. It may also appear
brown when red blood cells are present in the
ejaculate (hematospermia).
7.3.3.1.5 The sample should be well mixed in the original
container. Incomplete mixing is probably a

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major contributor to errors in determining

sperm concentration.
7.3.3.2 Consistency /Viscosity:
7.3.3.2.1 The consistency, also called viscosity, of the
liquefied sample can be estimated by gentle
aspiration into a 5-ml pipette and then allowing
the semen to drop by gravity and observing the
length of the thread formed.
7.3.3.2.2 A normal sample leaves the needle as small
discrete drops, while in cases of abnormal
consistency the drop will form a thread of >2
cm.
7.3.3.3 Volume:
7.3.3.3.1 The major component of the ejaculate volume
is made up of secretions from the accessory
glands.
7.3.3.3.2 The volume of the ejaculate should be
measured either with a graduated cylinder or
by aspirating the whole sample into a wide-
mouthed pipette by means of a mechanical
devices.
7.3.3.4 pH:
7.3.3.4.1 The pH is determined by acidic secretions of
the prostate and alkaline secretions of the
seminal vesicles. It should normally be in the
range of 7.2-8.0
7.3.3.4.2 To test pH, pH paper range 6.1 to 10.0 is used.
7.3.3.4.3 Whatever type of pH paper is used for this
analysis, its accuracy should be checked against
known standards before the use in routine
semen analysis.
7.3.3.5 Motility:
7.3.3.5.1 A fixed volume of semen (not more than 10 m l)
is delivered onto a clean glass slide and covered
with a 22x22 mm cover slip.

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7.3.3.5.2 The microscopic field is scanned systematically

and the motility of each spermatozoon
encountered is graded a, b, c or d according to
whether it show:
7.3.3.5.2.1.1 Rapid progressive motility.
7.3.3.5.2.1.2 slow or sluggish progressive motility
7.3.3.5.2.1.3 non-progressive motility
7.3.3.5.2.1.4 Immobility.
7.3.3.6 Counting the spermatozoa
7.3.3.6.1 The concentration of spermatozoa should be

determined using the hemocytometer method.
7.3.3.6.2 Chilled distilled water is used as diluent.
7.3.3.6.3 Pipette liquefied semen (using wbc pipette) up
to 0.5 mark, then pipette the diluent up to 11
mark
7.3.3.6.4 Discard 2-3 drops, before dispensing in the
counting chamber
7.3.3.6.5 Count the sperm cells by counting the 4 Large
Corners
7.3.3.6.6 The total sperm cells counted, multiply by
1000000.
7.3.3.7 Morphology
7.3.3.7.1 Sperm cells represent a unique population in
which up to 50% of the cells can have
morphological defects in normal fertile
individuals.
7.3.3.7.2 The following categories of defects should be
scored.
7.3.3.7.3 Head shape/size defects, including large, small,
tapering, pyriform, amorphous, vacuolated
(>20% of the head area occupied by unstained
vacuolar areas), or double heads, or any
combination of these.

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7.3.3.7.4 Neck and mid-piece defects, including absent

tail, non-inserted or bent tail (the tail forms an
angle of about 90° to the long axis of the head),
distended/irregular/bent mid-piece,
abnormally thin mid-piece or any combination
of these.
7.3.3.7.5 Tail defects, including short, multiple, hairpin,
broken, irregular width, or coiled tails, tails with
terminal droplets, or any combination of these.
7.3.3.7.6 Cytoplasmic droplets greater than one-third of
the area of a normal sperm head.
7.4 FLOWCHART IN CLINICAL MICROSCOPY

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COMMUNICATION AND RECORDS
1. GENERAL RULES AND REGULATION

1.1 STAT and routine laboratory examinations

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1.2 The proper laboratory request form must be completely filled up with the
following information
1.2.1 Name of patient
1.2.2 Age
1.2.3 Sex
1.2.4 Date
1.2.5 Name of attending physician
1.2.6 Company/ job order number or O.R. number if manual receipt is
being issued.
1.2.7 Diagnosis of the patient
1.3 Laboratory number is the assigned to each patient for PPE and APE while Job
Order No. issued as Lab. No. in patients for consultation. Staff receiving the
request must indicate their name and time received at the upper right corner of
the request form.
1.4 A cut off time 2:00 am for fasting patients with blood chemistry procedures
1.5 Indicate at the upper portion of the request form if it is STAT, otherwise it will
be released the next day
1.6 Identify the desired examination and check if it is available in the laboratory
1.7 Whenever there is a change in the doctors request send immediately to the
laboratory a corrected request form or inform the laboratory of the said
changes followed by the corrected request form.
1.8 Once has been performed, there will be no more cancellation of the request.
1.9 All data in requisition forms/ JO forms/ Official Receipt shall be recorded
properly and completely in the laboratory main log sheet before sending to
different sections or before filing.
2. PROTOCOL ON ROUTINE AND STAT SPECIMENS

2.1 ROUTINE SPECIMENS
2.1.1 Receipt.
2.1.1.1 the staff should check for the completeness of patient’s
pertinent data’s such as:
2.1.1.1.1 full name (including middle name)
2.1.1.1.2 age/sex
2.1.1.1.3 birth date
2.1.1.1.4 test(s) requested
2.1.1.1.5 requesting physician

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2.1.1.1.6 address or contact number(optional)

2.1.1.1.7 Company/ job order number or O.R. number if
manual receipt is being issued.
2.1.2 check for acceptability of specimen, proper anticoagulant ratio, and
how long it has been standing unpreserved
2.1.3 for tests that needs fasting, the technologist should ask the patient if
she/he observed proper fasting
2.1.4 Performance
2.1.4.1 for blood chemistry with fasting, processing will start at 9 am
2.1.4.2 for other tests, it should be performed immediately
2.1.5 Reporting of Results
2.1.5.1 results/reports should be signed by the staff who performed
the test
2.1.5.2 For blood chemistry results are released at 12:00 mm, same
day except for some tests that has been sent out.
2.2 STAT REQUEST
2.2.1 once a stat request is received, the staff shall attend to it right away
2.2.2 the test should be performed within 30 minutes or as soon as possible
2.2.3 If the test can’t be done right away, the med tech shall inform the
attending physician on how long the test can be done.
2.2.4 The result can be relayed thru telephone portals but extreme care
should be taken as to avoid misleading results.
2.2.5 The Stat request has no additional charge, it shall be charge just like
routine tests
3 REPORTING OF RESULT
3.1 ROUTINE RESULT
3.1.1 The laboratory must report an accurate and precise result.
3.1.2 Blood chemistry results should be all released before 8pm of the same
day except for those blood procedures for send out, culture, and with
schedule running.
3.1.3 Routine hematology test results are released to the reception once the
result is signed by the medical technologist except for the procedures
for send out.

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3.1.4 Routine clinical microscopy examinations results are released to the

reception once the result is signed by the medical technologist except
for the procedures for send out.
3.1.5 All send out procedures will be released the following day after
collection except for batch running and culture and sensitivity which
are released once the result are available.
3.1.6 All laboratory results are computer printed, verified, reviewed and
passed the quality control prior to release. All result released must
acknowledge by signing the releasing log book.
3.1.7 The electronic result must be release to patient in a manner that
ensures confidentiality of information
3.1.8 Never relay or interpret result to the patients, patients relative and
other unauthorized persons. When a representative is sent to pick-up
the result, always ask for filled up authorization letter duly signed by
the patient, patient’s ID and representative ID. Let the representative
write his / her full name in releasing logbook and affix his/her signature.
3.1.9 Strictly no results can be relayed through telephone or text message.
3.2 STAT RESULT

3.2.1 “STAT” specimen must be released after an hour.
3.2.2 All STAT results must be released immediately to the reception.
Likewise the other result.
3.2.3 Unofficial results can be released, but the laboratory shall release
Official results afterwards.
3.2.4 Result shall be logged accordingly and a laboratory copy of the result
should be on file.

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PROCEDURE FOR REPORTING WORKLOAD, QUALITY CONTROL, and INVENTORY

CONTROL.
1. PROCEDURE FOR REPORTING OF WORKLOAD

1.1. Staff workloads in each laboratory section shall be recorded on a daily
basis. This can be measured with the following formula:
Number of Workload= Number of Actual test+ Number of test repeated + (number of

QC run x Number of Lab Test) + Number of QC repeat Test.
1.2. The running of QC materials, which comprise 2 levels for clinical chemistry
and 3 levels for hematology, shall be done and recorded daily and shall do
the levey-Jennings chart obtain on a monthly basis.
1.3. If the workload has exceeded the capacity of single medical technologist
on duty, she/he shall request for additional manpower.
1.4. The Head of the lab shall make recommendations to the director
1.5. Running of QC material for more than once for each level in hematology
should be counted in the control inventory, for proper monitoring of the
control inventory, thus aiding in timely procurement.
1.6. Stock card are available in each section. Consumption of control material
shall be strictly monitored by logging religiously in the stock card.
1.7. Laboratory work load for each section (Census) must be documented
monthly. This includes the test/s and number of requisition for each
laboratory procedure/s. Both soft and hard copies of the document must
be secured and reported to the laboratory head every meeting.
2. PROCEDURE FOR REPORTING OF INVENTORY CONTROL

2.1 Inventory is a detailed, itemized, especially a periodic survey of all reagents and
supplies stock
2.2 Inventory procedure
 Observe the physical inventory count.
 Cut off analysis for the requisition of supplies and reagents
 First in First out policy

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
Inventory allowances. There should be a buffer for every reagent and supplies
especially for fast moving.
 log/record in the inventory logbook every items received including the
following data: date delivered/ received, name of reagent/ supplies, quantity/
number of reagents, date opened, date consumed, date of expiry, suppliers
name/ contact number.
 Monitor and log every item used,
 Update the monthly inventory sheet and send to purchasing department.
2.3 It is the responsibility of the medical technologist who opened a new batch of
reagents/ kits to make the accurate documentation in the inventory stock, affix
his/ her signature.
2.4 To maintain an adequate supply of reagents, the chief medical technologist
shall determine the average monthly consumption of each and maintain an
inventory stocks for 3 months.
2.5 When the inventory nears the end of the 3 months’ supply, the medical
technologist shall inform the chief medical technologist for the new requisition
of the reagent and determines the necessity of the requisition. Expired reagents
shall be disposed of approximately and in a timely manner.
2.6 The chief Medical Technologist shall centralize and collate all documents
pertaining to stock inventory, purchase order and laboratory audits.
3 PROCEDURE FOR REPORTING OF QUALITY CONTROL
3.1 The medical technologist will log on the quality control logbook all the daily
result of the quality control sample.
3.2 The chief Med Tech will do the Levy- Jenning every end of the Month.
3.3 To assure the quality of the result the following are done on a regular basis.
3.3.1 Make sure that all instrument/ equipment are free of impurities and
contamination
3.3.2 Check the expiration dates of the reagents and test kits.
3.3.3 Run the standard and control on the machines
3.3.4 Make sure that pipettes are calibrated and free of broken tips and
clogs
3.3.5 Ensure that the buffer solution for staining is changed regularly
3.3.6 Check the speed of the centrifuge

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3.3.7 Sets the refrigerator temperature appropriate for the storage of

specimen.
PROCEDURES FOR REPORTING AND ANALYSIS OF INCIDENTS, ADVERSE EVENTS
 Adverse incidents shall be dealt with utmost care, logic and professionalism,
the persons involve shall submit an incident report to the Executive Director
thru the Administrator on the details of what happened.
 The administrator shall investigate and analyze the situation. Once the
investigation and analysis is done, the administrator shall make a
recommendation report
1. CORRECTIVE ACTION
1.1 Evidence of non-conforming service, customer dissatisfaction or in
ineffective processes drives the corrective action system to
address problems requiring immediate correction and possible
additional long term action aimed at eliminating or reducing the
likelihood of its recurrence.
1.2 A defined and documented solving problem leading to root cause
identification and elimination is applied for corrective action
investigations.
2. PREVENTIVE ACTION
2.1 data from corrective action investigations, customer feedbacks,
employee suggestions and other appropriate sources is use to
identify the actions needed to eliminate the causes of potential
problems leading to an occurrence.
2.2 Investigating and eliminating the root cause of potential failures is
a critical part of the continuing improvement process.
2.3 Results of preventive action analysis and related recommendations
are presented to the senior management.

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RETENTION OF RECORDS AND SPECIMEN
 Laboratory staff must follow the following retention period for records and specimen
1. Records
1.1 Laboratory records: all laboratory records may keep for 15 years
1.3 Laboratory Logbooks: dispose 2 years after the last entry provided no
item is subject of a medico-legal case
1.4 Results/ Reports of examination: 15 years attached to the patient
medical records
1.5 Laboratory Request: dispose 1 year from date/ release of official
report/result
2. Specimen
2.1 Blood Smears: 7 days
2.2 Blood Samples: 7 days following appropriate storage conditions
2.3 Urine: 24 hours
2.4 Other body fluids for Clinical Pathology: 48 hours.

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POLICIES ON QUALITY ASSURANCE

1. Internal Quality Control Program
1.1 General Rules and Regulation
1.1.1 Quality control programs are set to ensure that the results generated
and reported are accurate and precise.
1.1.2 All laboratory personnel shall have a continuous competency program
through their attendance in conventions by their respective societies
that will prove useful to the laboratory. The laboratory personnel shall
file the certificates of attendance in the laboratory.
1.1.3 The Laboratory shall have appropriate and standard laboratory
methods, reagents, supplies and equipment which will be maintained in
good working condition. All laboratory equipment shall be monitored
and maintained daily, and will be the responsibility of the medical
technologist on duty. The medical technologist who made the
monitoring shall countersign the logbook provided for.
1.1.4 Procedure manuals must be available at all times in the laboratory.
1.1.5 Equipment in the laboratory should meet the manufacturer’s
requirements and specification.
1.1.6 Preventive maintenance, calibration and monitoring procedures
performed by the staff will assure the constant accuracy and precision
necessary for quality laboratory performance.
1.2 Quality Control of Equipment and Assays

1.2.1 Quality control runs are done daily. Values shall be within the
prescribed range before a laboratory examination is done to ensure the
accuracy and precision of the results. Westgard rules and
determination of possible shifts and trends must be noted and
immediate action must be done in cases of their presence.
1.2.2 Westgard Control Rules
1.2.2.1 12S – Warning sign. One control value fall outside the 2SD
limits.
1.2.2.2 13S – One control result exceeds the 3SD limits.

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1.2.2.3 22S – Two control results exceed the 2SD limits.

1.2.2.4 41s – Four consecutive control results exceed the 1SD limits.
1.2.2.5 R4s – The difference between the highest and lowest control
results exceed 4 SDs.
1.2.2.6 10x – Ten consecutive control results are on one side of the
mean.
1.2.3 Levey-Jennings Charts must be stored and filed for documentation.
1.2.4 Quality control reference materials must be filed for easy reference.
1.3 Quality Control of Specimens

1.3.1 Inspection of all specimens upon receipt and before testing will ensure
that they are suitable for the requested examination.
1.3.2 Unacceptable specimen is not to be processed unless repeated
collection is done. If however such is to be processed, a remark or note
will be written on the report indicating that the specimen was accepted
and processed as per ordering physician’s request.
1.3.3 Patient information which includes the name, age, and date of
extraction shall be written on the tube and on the specimen container.
1.3.4 Laboratory staff should strictly follow the policies written regarding
specimen handling rejection and storage.
2. Participation in National External Quality Assurance Scheme by the Department of

Health
2.1 The chief medical technologist must ensure that the laboratory actively
participates in the EQAS program given by the National Reference Laboratories as
a strict requirement for the yearly renewal of laboratory license-to-operate.
2.2 Hematology
2.2.1 EQAS registration and payment must be submitted personally to
National Kidney and Transplant Institute.
2.2.2 Original receipt and copy of the registration must be submitted to the
accounting area of the clinic and photocopy must be filed within the
laboratory.
2.2.3 Upon receipt of EQAS specimen, it must be treated as a regular
specimen and no special precautions must be done and run together
with patient sample.
2.2.4 Like other specimen, EQAS sample must be logged in the laboratory
Entry/Receiving log book and results must be recorded in the
Hematology logbook.

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2.2.5 Laboratory staff on duty during the date of receipt must follow the
accompanying instructions given by the assigned NRL regarding the
submission and reporting of results.
2.3 Chemistry
2.3.1 Chemistry EQAS registration is done via online and payment can be
submitted personally or through bank deposit addressed to the Lung
Center of the Philippines. The NRL must be notified regarding the
payment for confirmation.
laboratory.
2.3.3 Upon receipt of monthly EQAS specimen, it must be treated as a
regular specimen and no special precautions must be done.
Entry/Receiving log book and results must be recorded in the Chemistry
logbook.
2.4 Parasitology
2.4.1 Parasitology EQAS registration form can be downloaded online and
payment can be submitted personally or through bank deposit
addressed to the Research Institute for Tropical Medicine. The NRL
must be notified regarding the payment for confirmation.
laboratory.
2.4.3 Upon receipt of EQAS specimen, it must be treated as a regular
specimen and no special precautions must be done.
Entry/Receiving log book and results must be recorded in the Clinical
Microscopy logbook.

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2.5 NEQAS sample must be performed within the laboratory and using registered
laboratory equipment.
2.6 Sending-out of NEQAS sample is strictly prohibited and appropriate sanctions may
be given by to the staff involved.
2.7 In cases of failed or unsatisfactory results, all laboratory staff together with the
head of the laboratory must assess and create necessary actions that must be
done (e.g. recalibration, maintenance, reviewing SOP, training of staff etc.) to
prevent further erroneous results and to enhance laboratory accuracy and
precision for the benefit of catered patients.
2.8 In cases of 2 or more consecutive failures in EQAP, the laboratory shall comply
with the guidelines set by respective NRLs.
2.9 Recent EQAP certificates must be posted within areas that are visible to patients
while previous EQAP certificates must be stored and filed.

77 | P a g e
MANAGEMENT
May 30,2018 May 22, 2018 01 01
STANDARD OPERATING PROCEDURE FOR SEND OUT
1. There may be some request that are not available on the laboratory as we are only
limited to secondary category thus our services are limited as well.
2. The Medical Technologist on duty shall follow these guidelines:
2.1 Routine tests will be sent out to Diagnostic Laboratory
2.2 The referral laboratory shall provide the request form, and the staff shall fill up
the pertinent data and they will have to send a messenger to pick up the
specimen and request and payment.
2.3 Before sending out the specimen, the staff shall make sure that the specimen is
right for the requested test.
2.4 Some doctors have specific request on where to send the test, we shall consider
the request. We will have someone to bring the specimen to the requested
laboratory.
2.5 The payment shall come from the Accounting Office, the medical technologist on
duty shall inform the accounting staff on how much the test cost.
2.6 Once official result(s) is/are delivered, we shall have it photocopied and one copy
should be on file, while the official result will be released to the client/patient.

78 | P a g e

SOP Laboratory

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STANDARD OPERATING 2F, Phase 2, Vista Mall Taguig, Camellia

PROCEDURE AND QUALITY Taguig Rd., Brgy. Tuktukan, Taguig City,

Prepared By : Reviewed by By: Approved By :

MARK VRYAN B. CYNTHIA MARIE S.

DOCUMENTED POLICY/ PROGRAM

1.2 DOH AND WITH CORRESPONDING CPD UNITS

Prepared By : Reviewed by By: Approved By :

MARK VRYAN B. CYNTHIA MARIE S.

1.3 OTHER GOVERNMENT LEAD ANGENCIES MAY CONDUCT SEMINARS AND

2. POLICY FOR HIRING, ORIENTATION AND PROMOTION FOR ALL LEVELS OF

2.1 POLICY ON HIRING/RECRUITMENT

Prepared By : Reviewed by By: Approved By :

MARK VRYAN B. CYNTHIA MARIE S.

2.2 TERMS AND CONDITIONS OF EMPLOYMENT

2.4 POLICY ON PROMOTION FOR ALL LEVELS OF PERSONNEL

Prepared By : Reviewed by By: Approved By :

MARK VRYAN B. CYNTHIA MARIE S.

3. POLICY FOR DISCIPLINE, SUSPENSION, DEMOTION, AND TERMINATION OF PERSONNEL IN

3.3 GENERAL RULES AND REGULATIONS

3.4 OFFENSES AND DISCIPLINARY ACTIONS

Prepared By : Reviewed by By: Approved By :

MARK VRYAN B. CYNTHIA MARIE S.

3.4.1.6 Unauthorized undertime or leaving the workplace before the

Prepared By : Reviewed by By: Approved By :

MARK VRYAN B. CYNTHIA MARIE S.

3.4.4.6 Knowingly punching/ swiping of fellow employee’s proximity or

3.4.5 Offenses Against Company Interest

3.5 TERMINATION OF EMPLOYMENT BY THE COMPANY FOR JUST CAUSE:

Prepared By : Reviewed by By: Approved By :

MARK VRYAN B. CYNTHIA MARIE S.

3.5.6 Other analogous causes.

3.6 NOTICE OF DEMOTION OR TERMINATION.

4. POLICY ON MANAGEMENT REVIEW

Prepared By : Reviewed by By: Approved By :

MARK VRYAN B. CYNTHIA MARIE S.

4.2.2 Attendance and signature of participants

MARK VRYAN B. CYNTHIA MARIE S.

understood by the patient and apology must be always

Prepared By : Reviewed by By: Approved By :

MARK VRYAN B. CYNTHIA MARIE S.

HEAD OF THE LABORATORY/PATHOLOGIST

MEDICAL TECHNOLOGIST MEDICAL TECHNOLOGIST

OWNER: CYNTHIA MARIE S. DELFIN

MARK VRYAN B. CYNTHIA MARIE S.

SR. MEDICAL TECHNOLOGIST: MARK VRYAN PUYAOAN

2. JOB DESCRIPTION AND FUNCTION

3. DUTIES AND RESPONSIBILITIES

3.2 CHIEF MEDICAL TECHNOLOGIST

MARK VRYAN B. CYNTHIA MARIE S.

3.2.1 Supervise all laboratory personnel and the laboratory.

3.3 MEDICAL TECHNOLOGY STAFF

3.3.1 Receives, logs and charges laboratory requests.

Prepared By : Reviewed by By: Approved By :

MARK VRYAN B. CYNTHIA MARIE S.

3.3.9 Adheres to high ethical standards of performance.

3.4 LABORATORY TECHNICIAN/ PHLEBOTOMIST

3.4.1 Collect/ extract blood samples to the patient with care.

4. EVALUATION OF STAFF COMPETENCY

4.1 The competency level of each staff should be continuously evaluated.

5. WORK ASSIGNMENT AND SCHEDULES

5.1 To maximize laboratory operations, medical technologist are being rotated in

MON TUES WED THURS FRI SAT. SUN.