F-QM-PRE-002-A-V0 — Referral Laboratory Register, Annual Evaluation & Send-Out Log
Type: Form · Version: V0 · Status: DRAFT — UNAPPROVED · Served read-only from the bundled QMS copies. The Drive master is untouched.
Parent document: LAB-QM-PRE-002 — Referral Laboratory Policy (parent is encoded in the form number)
Rendered in-browser from the project's Word file F-QM-PRE-002-A-V0-referral-laboratory-evaluation-checklist.docx (policies-docx / forms-docx — the file Junry reviews). Formatting is faithful, not pixel-perfect; the DOCX is the official copy.
| Document # | F-QM-PRE-002-A-V0 | Parent Document | LAB-QM-PRE-002 — Referral Laboratory Policy |
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# SECTION A — REFERRAL LABORATORY REGISTER & ANNUAL EVALUATION
Part 1 — Referral Laboratory Information & Regulatory Standing
| Field | Details |
|---|---|
| Name of Referral Facility: | Samar Provincial Hospital (SPH) Clinical Laboratory (Primary Referral Partner) |
| Complete Address & Location: | Catbalogan City, Samar, Philippines |
| Contact Persons & Telephone: | |
| Official Email Address: | |
| DOH License to Operate (LTO) No.: | LTO-____________________ (Category: Level 2 / Tertiary Clinical Laboratory) |
| Validity Date of DOH LTO: | Valid Until: YYYY-MM-DD |
| MOA / Service Contract Status: | [ ] Active Notarized MOA on file [ ] In Renewal / Annual Review |
| Evaluation Scope & Type: | [ ] Initial Pre-Contract Qualification [ ] Annual Performance Review [ ] Ad Hoc Audit |
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Part 2 — Mandatory Quality and Technical Competency Checklist
| Evaluation Dimension | Standard Requirement | Rating (Satisfactory / Unsatisfactory / NA) | Verification Findings & Evidence |
|---|---|---|---|
| 1. Licensure & Legal Standing | Current DOH License to Operate covers all referred test menus. | Verified copy of current LTO on file in Quality Office. | |
| 2. Pathologist Oversight | Continuous clinical and technical supervision by licensed Pathologist. | Pathologist name verified on official reports. | |
| 3. Quality Assurance | Active IQC program and documented enrollment in certified EQAS / NEQAS. | EQAS certificates verified for chemistry, serology, hematology. | |
| 4. Specimen Directory & Stability | Clear instruction directory for specimen volume, anticoagulant, and stability. | Directory available at TCH receiving bench. | |
| 5. Packaging & Cold Chain | Validated transport container with cold gel packs for thermal protection. | Insulated cooler box with monitored ice packs inspected. | |
| 6. Turnaround Time (TAT) | Published turnaround times conform to clinical emergency and routine needs. | Routine TAT <= 24h; urgent stat tests communicated promptly. | |
| 7. Critical Value Escalation | Direct phone / SMS immediate notification protocol for life-threatening values. | Direct contact numbers verified and tested. | |
| 8. Official Report Integrity | Releases results on official referral laboratory stationery with complete signatures. | Original printed reports transmitted and filed into patient chart. |
Evaluation Recommendation: [ ] Approved for Continued Referral [ ] Conditionally Approved with CAPA [ ] Suspended / Disapproved Evaluator Sign-Off: CMT / LQM: ____________________________________ Date: ____________________ Pathologist Approval: Pathologist: _________________________________ Date: ____________________
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# SECTION B — CONTROLLED SEND-OUT & DISPATCH TRACKING LOG
Instructions: Log every specimen sent to a referral laboratory. Check returned results against this log daily. Chart results only on the referral laboratory's original report.
| Log # | Date & Time Sent | Patient Full Name | MRN / Hospital No. | Test(s) Referred | Specimen Type & Container | Referral Category (A: Gap / B: Downtime) | Courier / Carrier Name | Dispatched By (MT Initials) | Date & Time Result Rec'd | Result Flag (Normal / Abn / Crit) | Charted To Ward By |
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# SECTION C — MONTHLY RECONCILIATIONS & ROLES REVIEW
Part 1 — Medical Technologists
I confirm that all send-out specimens were checked against two patient identifiers, that packaging kept the cold chain intact, and that returned results were released only on official referral laboratory reports:
- Medical Technologist Signature: ________________________________________ Date: ____________________
Part 2 — Laboratory Aides
I confirm that specimens were packed securely, cooler box ice packs were ready, and I helped with courier handover:
- Laboratory Aide Signature: ________________________________________ Date: ____________________
Part 3 — Chief Medical Technologist / Laboratory Quality Manager Monthly Audit
All referred specimens were reconciled. Any TAT delays, specimen rejections, or critical notifications were reviewed and closed:
- Signature: ________________________________________ Date: ____________________