Sample Referral Log template
A log in the Referral Laboratories and Consultants procedure (PR04), mapped to ISO 15189:2022 clauses 6.8, 7.2. Fill it in monthly. Used by the quality-management team.
LogISO 15189 · 6.8, 7.2Monthly
Calculated automaticallyRed = outside limits
Your LaboratorySample Referral Log | YL-QM-LOG-04-F05 v1.0
Record: Sample Referral Log — October 2026
| No. | Date | Sample ID / Accession No. | Patient Name / ID | Test(s) Requested | Referral Lab / Consultant | Reason for Referral | Date Sent | Date Result Received | Result Summary / Outcome | Result Filed? (Y/N) | Sent by (Initials) |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2026-10-01 | S26-1041 | S. Dlamini | Glucose | REF-26-001 | REF-26-001 | 2026-10-01 | 2026-10-01 | 5.08 | 5.05 | TM |
| 2 | 2026-10-08 | S26-1048 | A. Mensah | Creatinine | REF-26-002 | REF-26-002 | 2026-10-08 | 2026-10-08 | 4.99 | 4.97 | RN |
| 3 | 2026-10-15 | S26-1055 | L. Banda | ALT | REF-26-003 | REF-26-003 | 2026-10-15 | 2026-10-15 | 5.02 | 5.10 | SD |
| 4 | 2026-10-22 | S26-1062 | K. Otieno | Haemoglobin | REF-26-004 | REF-26-004 | 2026-10-22 | 2026-10-22 | 5 | 5.03 | AM |
| 5 | 2026-10-29 | S26-1069 | T. Moyo | Potassium | REF-26-005 | REF-26-005 | 2026-10-29 | 2026-10-29 | 4.98 | 4.93 | LB |
| 6 | 2026-11-05 | S26-1076 | R. Naidoo | Glucose | REF-26-006 | REF-26-006 | 2026-11-05 | 2026-11-05 | 4.93 | 5.08 | KO |
| 7 | 2026-11-12 | S26-1083 | S. Dlamini | Creatinine | REF-26-007 | REF-26-007 | 2026-11-12 | 2026-11-12 | 4.92 | 5.01 | TM |
| 8 | 2026-11-19 | S26-1090 | A. Mensah | ALT | REF-26-008 | REF-26-008 | 2026-11-19 | 2026-11-19 | 5.02 | 5.11 | RN |
Sign-off
| Role | Name | Signature | Date |
|---|---|---|---|
| Completed by | |||
| Reviewed by |
Shaded cells are calculated automatically. Values in red are outside their limits. † marks a corrected value (see Corrections).
Controlled document. Printed copies are uncontrolled unless stamped.Page 1
A4 landscape · first page · showing 8 of 8 rowsExactly as LabToolkit Pro prints it — with your logo and colours
What it records
- Date
- Sample ID / Accession No.
- Patient Name / ID
- Test(s) Requested
- Referral Lab / Consultant
- Reason for Referral
- Date Sent
- Date Result Received
- Result Summary / Outcome
- Result Filed? (Y/N)
- Sent by (Initials)
Sign-off
- Completed by
- Reviewed by
Related templates
- Referral Laboratory Evaluation Checklist (PR04-F01)
- Consultant Evaluation Checklist (PR04-F02)
- List of Approved Referral Laboratories and Consultants (PR04-F04)
- Guide: ISO 15189 documentation checklist
Clause references are to ISO 15189:2022; check them against your licensed copy of the standard.