Essentials of Medical lab Terminology

Department of Medical Laboratory Technology

DSEU Dwarka Campus
B.Sc.-MLT (Sem-1)
Topic – Documentations
 Why documentation ?
• Medical diagnosis laboratories play a crucial role in deciding
the course of treatment. Hundreds of laboratories test several
thousand samples of blood, urine and other body fluids each
day. A record of testing activities includes procedures
adopted, calibration records of instruments, reference
standards used, etc. The information will help you when you
are in any trouble.
 Definition and types of Documents

Documents provide written information about policies,

processes, and procedures.
Examples: Standard operating procedures (SOP)
Records are the collected information produced by the
laboratory in the process of performing and reporting a
laboratory test.
Examples: completed forms, charts, sample logs, patient
records, quality control information, and patient reports.
 Policy

Policy is “a documented statement of overall intentions and

direction defined by those in the organization and endorsed
by management
“what to do” in a broad and general way.
 Processes
Processes are the steps involved in carrying out quality
policies(ISO:15189:2012) defines a process as a “set of
interrelated or interacting activities that transform inputs into
outputs.”
(how it happens)
 Procedures
Procedures are the specific activities of a process
(ISO:15189:2012) . procedure is easily described as the
performance of a test
“how to do it” (SOP)
Why are documents important?
Documents are the communicators of the quality system. All
policies, processes, and procedures must be written, so that
everyone will know the proper procedures and can carry them
out. Verbal instructions alone may not be heard, may be
misunderstood, are quickly forgotten, and are difficult to
follow.
Examples : Quality Manual for ISO accreditation, Standard
Operating Procedures (SOP),etc.
 Inventory Management
Scientific method of finding out how much
stock should be maintained in order to meet
the production demands and be able to
provide right type of material at right time, in
right quantities and at competitive prices
 Inventory management techniques
1. Create a stock list
a-Identifying low-turnover stock
b-Demand forecasting 
c-Stock audit
2. Assign stock level
a-Minimum stock level
b-Maximum stock level
3-Organise your workspace
4- Create procedures for inventory management
5-Invest in lab inventory management software
Laboratory Information Management System

LIMS started as a system to keep a record of test

samples, their results and all other particulars of
donor and patients sample. It acts as an interface
between the lab faculties and the database where all
the information and essential details are stored.
 Importance of LIMS
• Fewer transcription errors & faster processing with
direct instrument uploads
• Real time control of data quality with built in QC
criteria
• Direct report generation meeting specific client
requirements
• Direct electronic reporting to clients or direct client
access to data