1. Patient identification records
A surveyor will pick a patient and ask you to show who they are, when they attended, and what was done. With paper registers this means finding the right register, then the right page, then reading a handwritten entry. In a system, it means searching a name or patient number.
- Unique patient number for every patient
- Complete demographic details recorded at registration
- Searchable history — not just the current visit
2. Sample identification and traceability
The critical question is whether a specimen can be linked back to the right patient with confidence. This is where handwritten tube labels fail and barcoded labels succeed.
- A unique sample identifier for each specimen
- Barcode or QR labelling rather than handwriting
- A record of collection date, time and collection point
- Traceability if the sample was referred from another centre
3. Test records and result entry
- The tests requested for each patient, on record
- Reference ranges used to interpret each result
- Which staff member entered each result
- A record of any correction, rather than an overwritten value
4. Verification and authorisation
A report should not reach a patient without a documented verification step. Inspections look for evidence that results are reviewed and authorised before release.
- Who verified the report, and when
- Confirmation that unverified results cannot be released
- Signatures (physical or digital) on issued reports
5. Report content and delivery records
- Patient details, test names, results, units and reference ranges on the report
- Laboratory identification on the report
- A record of when and how the report was delivered to the patient
Delivery records matter more than most labs expect, particularly when patients later claim they never received a result. WhatsApp dispatch and online portal access both create a timestamped record.
6. Equipment and quality records
- Calibration and maintenance logs for analysers and instruments
- Reagent and kit inventory records, with batch numbers where applicable
- Daily internal quality control records
7. Staff and access records
- A record of which staff member has access to which function
- Evidence that access is granted according to role, not shared between staff
How to make each record retrievable in seconds
The purpose of all of the above is not paperwork for its own sake — it is that an inspection can be answered without a search. In a paper lab, producing a two-year-old patient's complete trail can take hours. In PathCare it is a search: the registration, the sample barcode, the result entry, the verifying pathologist, the report and the delivery time are all in one record.
If you want to see what that looks like in practice, our PHC compliant lab software page walks through each requirement with a live demo option, and plans start from PKR 2,000 per month.
Arslan Javed
Founder of PathCare Solutions. Has spent over eight years implementing lab management software in pathology and diagnostic laboratories across Pakistan, including offline deployments and analyser integration.