Procedure Room Clinical Workflow

To ensure safe and efficient management of all clinical procedures conducted in Procedure Room 8, including routine, pre-planned, and emergency procedures. This SOP outlines patient flow, staff responsibilities, documentation standards, and infection control practices in alignment with ISO 9001 and MOH guidelines.

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Source of Patient Referrals to Procedure Room

Patients arrive at the Procedure Room from:

• Outpatient Department (OPD)
• Fever Clinic
• Maternal & Child Health (MCH) Unit
• TB Clinic
• NCD Unit

Referral types:

• Pre-planned — repeat blood taking, suture-to-open (STO), scheduled wound dressing
• Walk-in or urgent — acute hydration, emergency dressing, injection needs, unscheduled blood tests

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Pre-Procedure Safety Checklist

Before commencing any procedure, staff must verify the following:

1

Identity

Verify patient identity per clinic-wide Patient Identification & Safety protocol.

2

Allergies

Confirm allergies to latex, antiseptics, or medications before starting.

3

Anticoagulants

Ask about warfarin, aspirin, or DOACs before blood taking or STO.

4

Pregnancy Status

Confirm LMP for women of childbearing age before radiology referral or procedure.

5

Fasting

Verify fasting status when required for the requested blood test.

6

Consent

Confirm appropriate consent is obtained and documented.

Stop and Clarify

If any checkpoint cannot be verified, pause the procedure and consult the referring doctor before proceeding.

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Patient Flow Summary

Blood Taking

1

Triage A screening

• Identify patients coming for blood sampling only.
• Ask for the TCA card and completed blood form.
• For patients with fever or infectious symptoms, redirect to Fever Clinic↴ per triage protocol.

2

Provide registration queue number

Assign a queue number for eligible patients and direct them to the registration counter 12-15 waiting area.

3

Registration counter 12-15

Booked

Register patient details, process payment if required, and provide the patient with a QMS number.

4

Auto-allocate patient to respective unit

Arrived

Guide the patient to the waiting area at Room 17.

5

Call patient for procedure via QMS number

In Progress

• Verify patient identity by matching QMS number, name, and SystmOne record.
• Confirm the required blood test.
• Create the order in SystmOne.
• Print the thermal sticker label for the blood bottle.
• Provide the hazard plastic bag, labelled blood bottle, and blood form.
• Direct the patient to the blood-taking area in Room 8.

6

Blood taking procedure commenced

• Reconfirm patient identity and blood form.
• Match the bottle and name.
• Apply Infection Control Protocol.
• Perform blood sampling.
• Place filled bottle and form into the designated hazard plastic basket.
• Mark SAMPLE TAKEN in the Order Request Page.

7

Ensure patient is stable

Assess the patient post-procedure and ensure there are no acute symptoms or complaints.

8

Discharge home

Finished

Discharge if stable and remind the patient of the TCA date for blood review.

Sharps and Surface Safety

All sharps must be disposed of according to MOH sharps disposal protocols. Wipe down the blood-taking area between patients.

Referred Procedure

1

Consultation and assessment completed

In Progress

Doctor considers the patient for blood taking or procedure and auto-allocates the patient to Room 8 according to the required pathway.

2

Choose the correct Room 8 pathway

A

Blood test required

Diagnostic

• Examples: FBC, ESR.
• Auto-allocate to Room 8 and state the indication for allocation.
• Use CREATE ORDER in SystmOne and select the appropriate test.
• Update checklist and direct patient to the Room 8 waiting area.

B

Procedure required

In Progress

• Examples: injection, acute medication, hydration, ear irrigation, T&S procedure.
• Auto-allocate to Room 8 and state the indication of allocation.
• Update checklist and direct patient to the Room 8 waiting area.

3

Call patient for procedure via QMS number

Call the patient's QMS number, confirm arrival and request, begin the 2-Identifier check, and review the doctor's instruction.

4

Blood-taking pathway

Return Diagnostic

• Print thermal label sticker for the blood tube.
• Direct patient to the designated blood-taking zone.
• Apply Infection Control Protocol.
• Commence blood sampling.
• Mark SAMPLE TAKEN in the Order Request Page.
• Ask patient to bring the sample and lab form to Lab Counter 19.

5

Procedure pathway

Finished

• Perform the requested procedure.
• Use the OPD Procedure or Emergency Template in SystmOne for documentation.
• Update test or procedure outcome/result in SystmOne.
• Update checklist.

6

Return to referring doctor's room

Return the patient to the doctor's room once lab results are available or after the procedure is completed.

ED Referral

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Info: Role of MA & Nurse Incharge of Referral

• When a patient in Room 8 is assessed as requiring emergency department transfer, the MA's role is to stabilize, prepare, and escort while the referring doctor manages the clinical decision and referral letter.

1

Receive referral instruction

• Confirm the ED referral decision with the referring doctor.
• Review the printed referral letter and clinical notes in SystmOne.

2

Prepare patient

• Insert IV line if applicable.
• Administer stat medication when ordered.
• Prepare wheelchair or stretcher based on patient condition.

3

Coordinate transport

• If ambulance is available: staff escorts patient to ED.
• If ambulance is unavailable: MA calls 999 and commences the appropriate protocol.
• MA calls ED HPSF Muar to request ambulance dispatch.

4

Escort & handover

• OPD and Fever Clinic cases are escorted by MAs.
• MCH cases are escorted by PHN or nurses.
• Submit the referral letter to the ED team and complete verbal handover.

For the full ED referral protocol — including high-risk coordination (PSY, O&G, OSCC, infectious disease), referral letter requirements, and escort rules by unit — see OPD Referral & Escalation↴.

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Specimen Handling & Point-of-Care Testing

Blood Specimens

1. Label blood bottles at the bedside using the thermal printer after patient identity is confirmed. 2 Place filled bottles and completed forms into the designated hazard plastic basket.
2. Transport specimens to Lab Counter 19 within the timeframe specified by the test type.

Rapid Diagnostic Tests

1. Record the test type, batch number (when applicable), and result in SystmOne.
2. Positive results for notifiable conditions (e.g., HIV, Hepatitis B, Syphilis) must be escalated to the attending MO immediately.
3. Dispose of used rapid test kits in the biohazard bin.

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Escalation Protocol

• If a patient deteriorates during the procedure, the Medical Assistant must immediately inform the attending doctor for reassessment.
• Unstable or unmanageable cases are to be referred directly to the Emergency Department (HPSF Muar) following clinic referral protocols.
• All escalation must be documented clearly in SystmOne.

Escort rules by unit, MCH ED/Labor Room routing, and conditional pathways are detailed in OPD Referral & Escalation↴.

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Equipment, Consumables & Service Capacity

Equipment & Consumables Tracking

• All consumables and procedure-related materials are tracked using a logbook stored in the Procedure Store Room. Inventory is monitored and restocked weekly in coordination with the clinic supply officer.
• Larger medical assets and fixed equipment (e.g., procedure beds, suction units, diagnostic tools) are documented and monitored under the clinic's centralized Asset Management System (Maharani Asset Manager App).

Service Capacity

• The Procedure Room accommodates up to 110-130 blood-taking slots and approximately 15–20 wound dressing slots per day.
• Pre-planned procedures are handled on a demand basis without strict daily limits. However, if the number of procedures is excessive for a single day, the TCA appointment date may be rescheduled to another day (provided patient is stable, no urgent care needed) to ensure manageable workflow and patient safety.
• These capacity limits are enforced to prevent overcrowding, ensure efficient patient flow, and minimize risk of clinical errors.

For general appointment scheduling rules, TCA intervals, and slot limits across all units, see OPD Appointment & TCA Management↴.