To begin, it is essential to caution that Laboratory (lab) reports are not treated in isolation but alongside clinical findings and other relevant examinations. And because results may not correspond with one’s feeling, it’s advised that one does not take personal decisions based on his/her laboratory report unless a clinician gives the go ahead. This write-up is aimed at giving you an idea of a typical lab report, understanding it’s components and how they relate. This will help you to be at the same pace with your doctor/clinician and also help you relate well with your medical history. Hence it’s advised not to use this relevant health information to your disadvantage.
A typical lab report should have a letterhead/footer denoting the logo of the testing facility, partners, contacts, license and any other relevant information. The benefit of the header here is similar to that of any other business – establishing credibility, trustworthiness, contacts information and so on. The header may also have other information but are of much less important as far as this write-up is concerned.
Now let us move to the demographic section. This section contains vital information for patient identification and traceability. It should contain patient’s demographic details, referrer’s details (test requester/physician/specialist), date and time of sample collection, reception and reporting. This section is intended to provide all relevant information relating to the sample that was processed. At the patient demographic section, patient name must be correct and corresponding to a unique identity number and sometimes lab index or accession number. The section also must contain the patient date of birth (age), gender and a contact details. Most labs will strictly require these information as they determine other sections of the report as explained in subsequent sections. The dates help to know the turnaround time (time taken for report to be ready) of the test and how to prepare and book subsequent tests. The demographic section is one important section and hence accuracy and appropriateness of this section can be linked to how meticulous the lab is, its capacity, and their trustworthiness which go a long way to describe the accuracy of the other sections of the report.
The body and Results: This is where the actual lab report is recorded. This section does not have same structure for all tests but should contain similar content.
Also, most report are recorded under section headings such as the test name. The test name is the name of the test as recorded in the labs records. It may be a recognized abbreviation, such as LFT for Liver Function Test, or a full name of the test and sometimes with codes. It may be described with the method used in testing, as well as the sample type that was used. Eg, HIV1/2 p24, Serum, 4th Gen.
The results section of the lab report records the actual finding that the lab recorded. It may be divided into two sections; Normal and Abnormal, where result that are considered normal by the labs data are recorded under normal and otherwise as abnormal. Results are recorded either as figures, a word, phrase, a sentence or paragraph(s) description. For instance, a result for Creatinine in serum will be reported as 75.0 and results for Serum pregnancy test (qualitative) is reported as negative or positive. Results may also come with flags to categorise them: ‘H’ for High, ‘L’ for low. Sometimes, they may be expressed with the plus sign (+) and increase up to about 4+. Results may also be highlighted or boldened to indicate critical values. The results section of the report should be of much concern as this is the main reason the analysis was conducted.
The Unit Heading: Units of measurement are very important description in healthcare. The lab is one department that pays much attention to units. Inappropriate use of units can render tests invalid, ambiguous or total distrust for the lab as results may not be reproducible in other labs. Understanding the use and interpretation of the unit are mainly for professional use. It is however important to know the relevance of a unit utilized in a report before one hastens to discredit a particular lab report. Also note that some tests (qualitative test) do not have units.
Reference Range: Reference ranges may be recorded as biological reference, normal range or standard range. The ranges are established researched values for a test in presumably normal persons or under acceptable/stable physiological conditions. Reference ranges are lab dependent as they depend on instruments used, methods and research papers used but are usually in close range with different labs if same units or methods of measurements are used. Reference ranges for some tests depend on gender, age and physiological stage (pregnancy) hence the need to record them accurately. A reference range has lower limit and upper limit. It is good to note that a result out of the range may not necessarily be abnormal in your case. The more reason it’s recommended to have your own history to serve as reference for subsequent tests.
Lab reports are good description of the laboratories and their procedures. A disorganized lab test report with so much incomprehensibility, errors and typos, among others are not good indication of a meticulous lab procedure. Choosing a good and standardized lab is of much essence as well as sticking to one or two labs for reference sake.or visit MMALAB