Clinical laboratory Inventory Management part 1st for medical laboratory

this topic is for the medical laboratory

1. Unit 7: Clinical laboratory Inventory Management: 7.1 Clinical laboratory records 7.2 Requisition slips (Test request form/TRF) 7.3 Lab reports format of different section 7.4 Record keeping and its importance 7.5 Maintain stock inventory 7.6 Maintaining expiry charts 7.7 Important of instrument maintenance sheet (Refrigerator, Incubator) 7.8 Important of daily cleaning record sheet 7.9 Logistics management 7.10 Important of computer in lab 7.11 Local information system (LIS) in modern lab

2. Clinical laboratory Inventory ( सूची ) Management Clinical laboratory inventory management is the process of controlling and tracking all supplies, reagents, and equipment used in a clinical laboratory.  It ensures that the right materials are available in the correct quantities when needed, minimizing waste and maximizing efficiency.  Effective inventory management is crucial for smooth laboratory operations, cost control, and maintaining quality patient care. 

3. 7.1 Clinical laboratory records Clinical laboratory records are the systematic documentation of all activities and findings within a clinical laboratory.  These records are essential for maintaining data integrity, supporting scientific conclusions, ensuring traceability of laboratory work, and facilitating effective management and quality control.  They encompass a wide range of information, from sample collection and processing to test results and quality control data. 

4. Clinical laboratory records encompass a wide range of documents and information related to patient testing and laboratory operations.  These records typically include patient identification, test orders, sample collection details, test procedures, quality control data, test results, and interpretive comments.  They also include personnel information, instrument calibration records, and documentation of any corrective actions taken. 

5. Patient-related information: Patient identification:  Name, date of birth, address, contact information, and unique patient identifiers.  Medical history:  Relevant past medical conditions, medications, allergies, and other pertinent ( प्रासंगिक ) clinical information.  Test requisitions and orders:  Documentation of tests requested by healthcare providers.  Specimen details:  Source and type of specimen collected. 

6. Laboratory procedures and results: Test procedures: Detailed descriptions of the methods used for each test, including any specific reagents, equipment, or media.  Quality control data: Records of daily instrument calibration and quality control checks to ensure accuracy and reliability.  Test results: Preliminary and final results, including any observations, interpretations, or calculations.  Analytic systems records: Records related to automated instruments used in testing, including printouts and quality control data. 

7. Proficiency testing records: Documentation of participation in external quality assurance programs and results.  Signatures of authorized personnel: Identification of individuals who performed the testing and/or verified the results.  Other important records: Inventory records:  Tracking of laboratory supplies, equipment, and reagents.  Instrument maintenance and calibration records:  Documentation of all maintenance and calibration procedures performed on laboratory equipment. 

8. Quality management records:   Records related to quality assurance activities, including audits, management reviews, and corrective actions.  Training records:  Documentation of personnel training and competency assessments ( योग्यता मूल्याङ्कन ).   Communication records:  Details of any verbal or telephone communications related to patient testing, including date, time, and personnel involved. 

9. Example Clinical Laboratory Sample Collection Record S.N. Date Patient Name Patient ID Age/Sex Test(s) Requested Sample Type Collected By 1 2025-07-24 Ram Shrestha P001 45/M CBC, ESR EDTA (Blood) Lab Tech A 2 2025-07-24 Sita Karki P002 32/F RBS, Lipid Profile Serum (Blood) Lab Tech B 3 2025-07-24 Bikash Thapa P003 27/M Urine R/M Urine (Midstream) Lab Tech A 4 2025-07-24 Anu Gurung P004 60/F LFT, Creatinine Serum (Blood) Lab Tech C

10. Requisition slips Test request form(TRF) A Test Request Form (TRF), or requisition slip, is a document used by healthcare professionals to request laboratory tests.  It essentially acts as a formal request for specific tests to be performed on a patient.  These forms are crucial for ensuring clear communication between the ordering physician and the laboratory performing the tests. 

11. Purpose: Requesting tests: TRFs are the primary method for requesting laboratory tests, including blood, urine, or tissue analysis.  Communication: They facilitate clear communication between the ordering physician and the laboratory regarding the tests needed and patient information.  Record keeping: TRFs serve as a record of the tests requested, aiding in tracking and reporting. 

12. Important Accuracy ( शुद्धता ) : Proper completion of the TRF ensures the correct tests are performed on the correct patient, minimizing errors. Efficiency ( दक्षता ) : Well-designed TRFs streamline the testing process, improving efficiency in the lab. Compliance ( अनुपालन ) : TRFs help ensure compliance with regulations and guidelines related to laboratory testing. 

13. Components of a Laboratory Requisition Form (LRF) 1. Patient Information Full Name Age / Date of Birth Sex Address Contact number Unique Hospital ID / OPD or IPD number

14. 2. Clinical Information Provisional diagnosis / Clinical history Relevant signs/symptoms Previous test results (if any) Pregnancy status (if applicable) 3. Test Requested Specific laboratory test(s) to be performed Test panel (e.g., CBC, LFT, RFT, etc.) Urgency: Routine / Urgent / STAT / Emergency Preferred reporting time (if needed)

15. 4. Specimen Information Type of specimen (e.g., blood, urine, sputum, CSF) Collection date & time Collected by (initials or name) Number of samples (tubes/containers) Special handling instructions (e.g., ice, protect from light) 5. Requesting Physician/Health Worker Details Name Department Signature Contact number Date & time of request

16. 6. Laboratory Use Section (for internal use only) Accession number / Lab number Date/time received Received by Condition of specimen (acceptable/not acceptable) Remarks Date/time reported Reported by / Verified by

17. 7. Additional Notes (Optional) Billing information Special requests Consent (e.g., for HIV testing) Barcode/QR code (if digital system used)

18. Lab reports format of different section A lab report is a formal document that describes the methods, results, and conclusions of a scientific experiment.  It's a way to communicate the findings of a practical investigation and demonstrate an understanding of the underlying scientific principles.  Essentially, a lab report explains what was done in an experiment, what was learned, and what the results mean.  Medical lab reports typically follow a structured format that includes patient information, test details, results, and reference ranges.  The report may also include abnormal result flagging, comments, and signatures of authorized personnel. 

19. 1. Patient Information: Patient's full name, Date of birth, Patient identification number or other unique identifier, and Other relevant demographic details (as needed).  2. Test Information: Date and time of sample collection, Date and time of analysis, Name of the test performed, and Specific test method or procedure (if applicable).  

20. 3. Test Results:  The numerical value of the result. Units of measurement for the result. Reference range (normal range) for the test. Indication of whether the result is within, above, or below the reference range. 4. Abnormal Results:  If a result falls outside the reference range, it is typically flagged as abnormal. The specific abnormality (e.g., "high," "low," ">") is often indicated. Abnormal results may be accompanied by a comment or note from the lab

21. 5. Comments and Recommendations:  Any relevant observations, notes, or comments from the lab or healthcare provider. Recommendations based on the results (if applicable). 6. Signatures:  Signature of the reporting pathologist (if applicable). Signature of the lab in-charge.

22. 7. Other Information:  TAT (Turn Around Time) information, if relevant. Registration number. Referring doctor's name and degree. Page number information. 8. Report Structure: The report may be divided into sections with clear headings, such as "Patient Information," "Test Results," "Reference Ranges," and "Comments".  The report should be clear, concise, and easy to understand.  It should adhere to specific guidelines regarding font size, spacing, and other formatting elements.  Some reports may include an abstract or summary of the test results.  Appendices may be included for detailed procedures or other supporting materials. 

23. 1. Lab reports format of hematology laboratory A typical hematology lab report includes sections for patient information, test details, results, interpretation, and potentially a discussion of the findings.  The specific format and content may vary slightly depending on the lab and the type of tests performed.  1. Header: Patient Information: Includes the patient's full name, date of birth, gender, patient ID, and potentially other identifiers like medical record number.

24. Doctor/Referral Information: Name and contact details of the referring physician or healthcare provider. Sample Information: Date and time of sample collection, date and time of report generation (TAT - Turnaround Time) and the type of sample (e.g., whole blood, bone marrow aspirate). Lab Information: Name and address of the laboratory, and potentially a unique report number. 

25. 2. Test Details: Test Name: Clear identification of the hematology tests performed (e.g., Complete Blood Count (CBC), Peripheral Blood Smear, Hemoglobin, etc.). Methodology: Briefly describes the method used for each test (e.g., automated cell counter, manual microscopy). Specimen Type: Specifies the type of sample used for the test (e.g., venous blood, bone marrow aspirate). 

26. 3. Results: Numerical Values: Presents the quantitative results of each test, often with reference ranges or normal values. Qualitative Findings: Describes any observed characteristics or abnormalities in the blood cells (e.g., cell morphology, presence of parasites). Units of Measurement: Specifies the units used for each result (e.g., g/ dL for hemoglobin, cells/µL for white blood cell count). 

27. 4. Interpretation: Analysis of Results:  A brief summary of the key findings, highlighting any significant deviations from normal ranges. Clinical Significance:  May include comments on the possible implications of the results for the patient's health. Recommendations:  May suggest further investigations or follow-up tests if necessary.  5. Discussion (Optional): Detailed Analysis:  A more in-depth discussion of the test results, potentially including a review of the patient's medical history and other relevant factors. Differential Diagnosis:  May suggest possible causes for the observed abnormalities. Recommendations:  More detailed recommendations for patient management and treatment. 

28. 2. Lab reports format of biochemistry laboratory Patient Information: Name: .................................................... Age/Sex: ...................... Patient ID: ...................... Date of Sample Collection: ............... Date of Report: ...................... Referred By: Dr. .............................. Specimen: Serum / Plasma / Whole Blood / Urine

29. Biochemistry Test Results S.N. Test Name Result Unit Biological Reference range 1 Blood Glucose (Fasting) 92 mg/ dL 70 – 110 2 Blood Glucose (Postprandial) 124 mg/ dL < 140 3 Urea 28 mg/ dL 15 – 40 4 Creatinine 1.1 mg/ dL 0.6 – 1.3 5 Uric Acid 5.8 mg/ dL 3.4 – 7.0 (M) / 2.4 – 6.0 (F) 6 Total Cholesterol 180 mg/ dL < 200 7 Triglycerides 150 mg/ dL < 150

30. Remarks: ................................................................ Laboratory Technician: (Signature & Name) Pathologist / Biochemist (Authorized Signatory): (Signature, Name, Reg. No.)

31. 3. Lab reports format of Microbiology laboratory Patient Details: Name: .................................................... Age/Sex: ...................... Patient ID: ...................... Date of Sample Collection: ............... Date of Report: ...................... Referred By: Dr. .............................. Specimen Type: Urine / Blood / Sputum / Stool / Swab / CSF / Others

32. Test Results S.N. Investigation Method Result / Findings Remarks 1 Gram Staining Microscopy Gram-positive cocci in clusters Suggestive of Staphylococcus 2 AFB Staining Ziehl-Neelsen No AFB seen 3 Culture & Sensitivity Aerobic Bacterial Culture Growth of E. coli See AST report below 4 Fungal Culture Sabouraud Dextrose Agar No fungal growth after 48 hrs 5 Widal Test Tube agglutination TO: 1:160, TH: 1:80 Positive 6 COVID-19 Antigen / RT-PCR Immunoassay / PCR Negative

33. Antibiotic Sensitivity Test (AST) (For E. coli isolate) Antibiotic Sensitivity Ampicillin Resistant Ciprofloxacin Sensitive Ceftriaxone Sensitive Nitrofurantoin Sensitive Gentamicin Resistant

34. Remarks: ................................................................................... Laboratory Technician: (Signature & Name) Microbiologist / Pathologist (Authorized Signatory): (Signature, Name, Reg. No.)

35. 4. Lab reports format of Immunology / Serology Patient Information: Name: ________________________ Age / Sex: ____________________ Patient ID / Lab No.: ___________ Date of Sample Collection: _______ Date of Report: ________________

36. Test Name: _______________________________ Parameter/Test Result Units Reference Range Interpretation / Comments Example: HIV Ab IgG / IgM Non-reactive / Reactive — Non-reactive Negative / Positive for HIV antibodies Example: Rheumatoid Factor (RF) 12 IU/ mL < 14 IU/ mL Within normal limits Example: ANA (Antinuclear Antibody) Positive / Negative — Negative Positive indicates possible autoimmune disease

37. Remarks: Laboratory Technician: ________________ Authorized Signatory: _________________

38. 5. Lab reports format of Blood Bank / Transfusion Medicine Patient Details: Name: ________________________ Age / Sex: ____________________ Patient ID / Hospital No.: _________ Ward / Bed No.: ________________ Date of Sample Collection: ________ Date of Report: _________________

39. 1. Blood Grouping and Rh Typing Test Result ABO Group A / B / AB / O Rh (D) Factor Positive / Negative Weak D (if applicable) Positive / Negative

40. 2. Antibody Screening (IAT / Indirect Coombs Test) Test Result Interpretation Antibody Screening Negative / Positive Presence/Absence of unexpected antibodies Auto Control Negative / Positive To detect autoantibodies

41. 3. Crossmatch Compatibility Donor Unit No. ABO/ Rh Group Crossmatch Result Compatible / Incompatible EX: 2025/0123 B Positive Compatible ✅

42. 4. Blood Component Issued Component Volume Date Issued Remarks Packed RBC (PRBC) 350 ml 25-07-2025 Transfused Platelets 50 ml 25-07-2025 To be transfused Remarks / Special Instructions: Tested By: _____________________ Verified / Authorized By: _________

43. 6. Lab reports format of Pathology laboratory Patient Details: Name: ___________________________ Age / Sex: ________________________ Patient ID / Lab No.: _______________ Specimen Collected From: __________ Date of Collection: ________________ Date of Report: ___________________ Referring Physician: _______________

44. Specimen Information Type of Specimen: (e.g., Breast tissue biopsy, Cervical smear) Clinical History / Provisional Diagnosis: Gross Examination Description of the specimen as seen with the naked eye: Microscopic Examination Description under microscope (tissue architecture, cell morphology, inflammation, malignancy, etc.):

45. Diagnosis / Impression Final diagnosis based on histopathological findings: Example: “Invasive Ductal Carcinoma - Grade II” Special Stains / Tests (if applicable): Test Performed Result Remarks PAS stain Positive For fungal elements Immunohistochemistry (IHC) ER: + ve , PR: - ve For breast carcinoma typing

46. Remarks / Recommendations: Reported By (Pathologist): ___________________ Signature & Stamp: __________________________