Clinical Laboratory Policy and Procedure Manual
Clinical Laboratory Policy and Procedure Manual
About this Manual
Clinical Laboratory Policy and Procedure Manual is a manual containing many of our policy and procedure templates for the medical office, hospital, and other healthcare organizations. The policies cover: Joint Commission (JCAHO or TJC) • CMS • HIPAA • CDC • AAAHC and more.Want access to all our manuals? Click here
SECTION 01 - DOCUMENT AND PROCESS CONTROL
1001 - Clinical Laboratory Policy and Procedure Manual1002 - Preanalytic Systems1003 - Analytic Systems Assessment1004 - Control Procedures1005 - Test Systems, Reagents, Supplies1006 - Postanalytic Systems Assessment1007 - Daily Review of Patient Results1008 - Problem Log Policy1009 - Errors in Patient Test Orders or Results - Problem Log Form1010 - Identification of Patients1011 - Patient Identification for Clinical Care and Treatment1012 - Labeling of Specimens1013 - Transport of Specimens to the Clinical Laboratory1014 - Skin Puncture Blood Collection1015 - Venous Blood Collection1016 - Blood Smears1017 - Multiple Specimen Collections1018 - Test Orders1019 - Ordering STAT Laboratory Tests1020 - Verbal and Written Orders - General1021 - Electronic Health Record Test Requests and Reporting1022 - Laboratory Reports (Results)1023 - Reporting of Critical Results of Tests and Diagnostic Procedures1024 - Reference Values1025 - Insert Facility Reference Ranges1026 - Panic Values1027 - Insert Facility Panic Values1028 - Manual Requisitions1029 - Chemistry I, Chemistry II - Manual Requisition Form (Sample)1030 - Maternal Serum Marker Prenatal Screening1031 - Specimen Identification1032 - Flow Cytometry - Lymphocyte Subset and CD34+ Hematopoietic Stem Cell Enumeration1033 - Flow Cytometry Analysis of Neoplastic Hematolymphoid Cells1034 - Identification of Staff Performing Tests and Reporting Results1035 - Retention of Laboratory Records1036 - "Hand-Off" Communication
SECTION 02 - EMERGENCY MANAGEMENT
SECTION 03 - ENVIRONMENT OF CARE
3001 - Laboratory Safety Program3002 - Clinical Laboratory Safety3003 - Security - Clinical Laboratory3004 - Manufacturer Recalls and Hazardous Device Notices3005 - Medical Device Recall Notification3006 - Notice of Recall/Warning Form3007 - Recall/Warning Status Report Form3008 - Disposing of Recalls3009 - Hazardous Materials and Waste Management Plan3010 - Hazardous Chemical Communication Program3011 - Hazardous Materials Identification and Labeling3012 - How to Read Safety Data Sheets (SDS)3013 - Hazardous Materials and Waste - Spills3014 - Formaldehyde Precautions3015 - Formaldehyde Spill - Emergency Action Plan3016 - Formaldehyde Monitoring Record Form3017 - Formaldehyde Test Kit3018 - Reagents3019 - Hazardous Materials and Waste - Training3020 - Chemical Training Record Form3021 - Incompatible Chemicals - In Storage and Reactions3022 - Hazard Surveillance Detection Survey - Clinical Laboratory3023 - Fire Safety - Clinical Laboratory3024 - Types of Fire Extinguishers3025 - Electrical Safety3026 - Equipment Condition and Safety3027 - Laboratory Equipment - Inspection, Testing and Maintenance3028 - Instrument Maintenance3029 - Instrument Problem Log Form3030 - Calibration and Calibration Verification3031 - Flow Cytometry Instrument3032 - Proper Usage of Centrifuge3033 - Sinks3034 - Eyewash Stations (Plumbed)3035 - Staff Latex Sensitivity
SECTION 04 - HUMAN RESOURCES
4001 - New Employee Orientation4002 - Inservice Education and Continuing Education4003 - Inservice Training Form - Clinical Laboratory4004 - Competency Assessment4005 - Competency Record - Coagulation4006 - Competency Record - Hematology4007 - Hematology Competency Test4008 - Blood Bank/Serology Competency Test4009 - Hazardous Chemicals and Safety Competency Test4010 - Position Description/Performance Evaluation - Clinical Laboratory Director4011 - Performance Evaluation - Population-Specific/Age-Related Competency - Clinical Laboratory Director4012 - Annual Competency Clinical Skills Assessment - Clinical Laboratory Director4013 - Position Description/Performance Evaluation - Chief Medical Technologist4014 - Performance Evaluation - Population-Specific/Age-Related Competency - Chief Medical Technologist4015 - Annual Competency Clinical Skills Assessment - Chief Medical Technologist4016 - Position Description/Performance Evaluation - Medical Technologist Supervisor4017 - Performance Evaluation - Population-Specific/Age-Related Competency - Medical Technologist Supervisor4018 - Annual Competency Clinical Skills Assessment - Medical Technologist Supervisor4019 - Position Description/Performance Evaluation - Medical Technologist - Blood Bank4020 - Performance Evaluation - Population-Specific/Age-Related Competency - Medical Technologist - Blood Bank4021 - Annual Competency Clinical Skills Assessment - Medical Technologist - Blood Bank4022 - Position Description/Performance Evaluation - Medical Technologist - Chemistry4023 - Performance Evaluation - Population-Specific/Age-Related Competency - Medical Technologist - Chemistry4024 - Annual Competency Clinical Skills Assessment - Medical Technologist - Chemistry4025 - Position Description/Performance Evaluation - Medical Technologist - Hematology4026 - Performance Evaluation - Population-Specific/Age-Related Competency - Medical Technologist - Hematology4027 - Annual Competency Clinical Skills Assessment - Medical Technologist - Hematology4028 - Position Description/Performance Evaluation - Medical Technologist - Microbiology4029 - Performance Evaluation - Population-Specific/Age-Related Competency - Medical Technologist - Microbiology4030 - Annual Competency Clinical Skills Assessment - Medical Technologist - Microbiology4031 - Position Description/Performance Evaluation - Medical Technologist - Serology/Immunology4032 - Performance Evaluation - Population-Specific/Age-Related Competency - Medical Technologist - Serology/Immunology4033 - Annual Competency Clinical Skills Assessment - Medical Technologist - Serology/Immunology4034 - Position Description/Performance Evaluation - Medical Laboratory Technician4035 - Annual Competency Clinical Skills Assessment - Medical Laboratory Technician4036 - Position Description/Performance Evaluation - Phlebotomist4037 - Performance Evaluation - Population-Specific/Age-Related Competency - Phlebotomist4038 - Annual Competency Skills Assessment - Phlebotomist4039 - Position Description/Performance Evaluation - Clinical Laboratory Secretary/Clerk4040 - Performance Evaluation - Population-Specific/Age-Related Competency - Clinical Laboratory Secretary/Clerk4041 - Annual Competency Skills Assessment - Clinical Laboratory Secretary/Clerk4042 - Position Description/Performance Evaluation - Clinical Laboratory Assistant4043 - Annual Competency Skills Assessment - Clinical Laboratory Assistant4044 - Annual Competency - Joint Commission National Patient Safety Goals
SECTION 05 - INFECTION PREVENTION AND CONTROL
5001 - Infection Prevention and Control - Clinical Laboratory5002 - Standard Precautions5003 - Hand Hygiene - CDC Guidelines5004 - Transmission-Based Precautions (Isolation Precautions)5005 - Personal Protective Equipment - Clinical Laboratory5006 - Personal Protective Equipment - Training5007 - Order for Putting On and Removing PPE5008 - N95 Fit-Testing5009 - Biological Safety Cabinets5010 - Dress Code - Clinical Laboratory5011 - Exposure of Staff to Mycobacterium Tuberculosis and Pathogenic Fungi5012 - TB - Exposure Control Plan5013 - Handling of Biohazardous Waste5014 - Response to an Influx of Infectious Patients5015 - Cleaning Clinical Laboratory5016 - Exposure Control Plan5017 - Sharps Injury Protection Plan5018 - Sharps Injury Log Form5019 - Management of Accidental Blood or Body Fluid Exposure/Contamination5020 - Hepatitis B Vaccine Program
SECTION 06 - INFORMATION MANAGEMENT
6001 - Confidentiality of Information - General Issues6002 - Data Protection and Confidentiality Guidelines for Departments6003 - Change of Lab Results in the Medical Record6004 - Documentation and the Use of Abbreviations, Acronyms and Symbols6005 - Unacceptable Abbreviation and Symbol List6006 - Clinical Laboratory Resource Library
SECTION 07 - LEADERSHIP
7001 - Mission7002 - Vision Statement7003 - Goals7004 - CLIA Certificate(s)7005 - Certification of Accreditation7006 - Scope of Services - Clinical Laboratory7007 - Outside Reference Laboratory Authorization7008 - Processing of Specimens for Reference Labs7009 - Leadership Responsibilities7010 - Communication Between the Lab and LIPs7011 - Compliance Plan for Clinical Laboratories7012 - Sentinel Event
SECTION 08 - PERFORMANCE IMPROVEMENT
8001 - Performance Improvement Plan - Clinical Laboratory8002 - Clinical Laboratory PI Monitoring and Evaluation Plan8003 - Clinical Laboratory PI Trending Sheet8004 - Clinical Laboratory PI Outcome Evaluation8005 - Clinical Laboratory PI Volume Measures/Statistics8006 - Clinical Laboratory - Blood Usage PI Monitoring and Evaluation Plan8007 - Clinical Laboratory - Blood Usage PI Trending Sheet8008 - Criteria for Transfusion Review8009 - Service Specific Blood Usage Summary - General Staff Report Form8010 - Conducting Root Cause Analysis8011 - Incident Reporting Staff Questionnaire
SECTION 09 - QUALITY SYSTEM ASSESSMENT FOR NON-WAIVED TESTING
9001 - Proficiency Testing for Non-Waived Testing9002 - Laboratory Staff Competency9003 - Sending and Receiving Proficiency Testing Samples9004 - When Compatible Proficiency Testing Samples Are Not Available9005 - Establishment and Verification of Performance Specifications9006 - Comparison of Test Results9007 - Cytologic Examinations9008 - Cytology Workload Limits9009 - Antibacterial, Antimycobacterial and Antifungal Susceptibility Testing9010 - Provider Performed Microscopy Procedures (PPMPs)9011 - Blood Gases - Quality Control
SECTION 10 - TRANSPLANT SAFETY
10001 - Tissue and Cell Acquisition10002 - Receiving, Inspecting and Documentation of Tissue and Cells Verification10003 - Storage of Tissue and Cells10004 - Tissue Refrigerator/Freezer Maintenance Procedures10005 - Storage of Tissue in the Event of the Loss of Refrigeration10006 - Request for Tissue10007 - Documentation of Tissue Implantation10008 - Reporting Adverse Tissue Reactions
SECTION 11 - WAIVED TESTING
SECTION 12 - GENERAL DEPARTMENT POLICIES
SECTION 13 - AUTOLOGOUS DONATIONS
13001 - Autologous Blood Donor Program Protocol, Phlebotomy, Patient Care13002 - Autologous Blood Donation Form13003 - Autologous Blood Donor Record Form13004 - Facts about Autologous Blood Transfusion13005 - Autologous Blood Bank Discharge Instructions13006 - Labeling of Autologous Units13007 - Autologous Units - Clinical Laboratory Processing13008 - Autologous Units - Storage13009 - Charges for Autologous Donor Procedure13010 - Transfer of Autologous Blood13011 - Autologous Units That Are Shipped13012 - Blood Shaker/Weight Monitor
SECTION 14 - BLOOD BANK
14001 - Blood Bank Policies and Procedures14002 - Blood/Blood Components - Inventory14003 - Inspection and Criteria for Rejection of Stored Blood14004 - Blood Bank Refrigerator14005 - Blood Bank Refrigerator and Freezer Quality Control14006 - Blood Bank Refrigeration and Freezer Alarms14007 - Storage of Blood Components in the Event of the Loss of Monitored Refrigeration14008 - Blood/Blood Components - Patient's Guide to Blood Transfusions14009 - Blood/Blood Component - Informed Consent14010 - Blood/Blood Component Transfusion Consent Form14011 - Refusal of Blood/Blood Component Transfusion14012 - Refusal to Permit Blood/Blood Component Transfusion Form14013 - Blood Bank Requisitions14014 - Collection and Labeling of Blood Specimens14015 - Identification of Blood Samples in the Blood Bank14016 - Criteria for Rejection of Specimens for Blood Bank and Serologies14017 - Comparison of Past Blood Bank Records14018 - Type/Screen Protocol14019 - Blood Bank Panic Values14020 - Pretransfusion Protocol14021 - Selection of Donor ABO/Rh14022 - Cross Agglutination Report Form14023 - Platelet Concentrate Form14024 - Sign-Out Protocol for Blood/Blood Components14025 - Blood/Blood Components - Transfusion14026 - Blood Transfusion Record14027 - Transfusion Reaction14028 - Request for Investigation of Transfusion Reaction Form14029 - Release of Blood in Emergency Situations14030 - Blood Bank Emergency Release Form14031 - Hemolytic Disease of the Newborn14032 - Antibody Screening and Crossmatch Results/Interpretation14033 - Reset-Up of Previously Crossmatched and Released Blood14034 - Massive Transfusion14035 - Multiple Transfusions14036 - Releasing Directed Donors for General Use14037 - Retention of Blood Bank Specimen and Donor Samples14038 - Retesting of Donor Units14039 - Return and Reissue of Blood for Transfusion14040 - Filtration Protocol14041 - ABO Group Testing of Red Cells and Serum - Test Tube14042 - Resolving ABO Discrepancies14043 - Agglutination Interpretation of Tube Antibody/Antigen Reactions14044 - Antibody Screen/Indirect Antiglobulin Test (IAT)14045 - Antibody Identification14046 - Auto Control14047 - Cold Reactive Autoantibodies14048 - Direct Antiglobulin Test (DAT)14049 - Immediate Spin Compatibility Testing and Saline IAT (Crossmatch)14050 - Fresh Frozen Plasma (FFP)14051 - Thawing Fresh Frozen Plasma14052 - Cryoprecipitate AHF14053 - Frozen Red Blood Cells, Thawed, Deglycerolized14054 - Granulocytes14055 - Packed Red Blood Cells (PRBCs)14056 - Platelets - Single Unit14057 - Plateletpheresis14058 - Rh Immune Globulin (RhoGAM)14059 - Rh Testing of Red Cells for "D" and "Weak D" Test Tube Method14060 - Rouleaux vs. Agglutination Determinations14061 - Whole Blood14062 - Quality Control Testing - Reagents, Equipment14063 - Functional Calibration of Blood Bank Serologic Centrifuges14064 - Centrifuge Calibration Form14065 - Blood Warmers14066 - Blood Bank Reagent Quality Control14067 - Out-of-Control Plan (Blood Bank)14068 - Disposition of Expired Blood14069 - Blood Supply and Look-Back14070 - Notification of Recipients of Possible Infectious Blood/Blood Components14071 - Creutzfeldt-Jakob Disease14072 - Suppliers of Blood Bank Products/Services
SECTION 15 - CHEMISTRY
15001 - Specimen Requirements15002 - Criteria for Rejection of Specimens for Chemistry15003 - Verification of Clinical Chemistry Test System15004 - Method Linearity15005 - Supporting Information - Linearity Testing on Du Pont Systems15006 - Coronary Risk Profile15007 - Authorization for CK-MB on Normal CK15008 - Troponin Levels15009 - LDH Isoenzymes15010 - Gentamicin Discrepancies15011 - Digoxin Levels15012 - Iron Studies15013 - Serum Acetone15014 - Swallowed Blood Syndrome (APT Test)15015 - Oliguria Profile15016 - Creatinine Clearance Calculations15017 - 24-Hour Urine Calculations15018 - Glucose Tolerance Preparation15019 - Glucose Tolerance Test (Oral)15020 - Drugs of Abuse Screen for Urine15021 - Test Instrumentation and Back-Up15022 - Insert Clinical Chemistry System Equipment Test15023 - Test Specifications Form (Example)15024 - Calibration Frequency15025 - Quality Control - Out-of-Control15026 - Quality Control Updating15027 - Quality Control Monthly Reports15028 - Control Product Inserts15029 - Maintenance Log Form15030 - Daily ISE and System Check Log Form15031 - Na+ K+ Analyzer Log Form15032 - Daily Maintenance Log Form - Discrete Clinical Analyzer15033 - Weekly and Monthly Maintenance Log Form - Clinical Analyzer15034 - Shift Log Form
SECTION 16 - COAGULATION/SEROLOGY
16001 - Specimen Collection List16002 - Patient Preparation List16003 - Panic Values - Coagulation16004 - Coagulation Panel16005 - Cold Agglutination Test16006 - Lee and White Clotting Time16007 - Tests for Circulating Anti-Coagulants16008 - Thrombin Time16009 - RPR - Syphilis Screening Test16010 - Coagulation Quality Control Guidelines16011 - Coagulation Out-of-Control Form16012 - Out-of-Control Plan (Reagents)16013 - Parallel Testing - Serology Kits16014 - HIV Antibody Test and Results16015 - Authorization for Disclosure of the Results of the HIV Antibody Blood Test Form
SECTION 17 - HEMATOLOGY
17001 - Criteria for Rejection of Specimens for Hematology Workups17002 - Hematology Quality Control Guidelines17003 - Hematology Panic Values17004 - Abnormal Presurgical Results17005 - Correction of RBCs and RBC Parameters for Over Range WBCs17006 - Pre-Op CBC17007 - Guidelines for Manual Differential17008 - Blood Cell Differential17009 - Pathologist Smear Review Criteria17010 - Hematology Slides and Reports to be Reviewed by Pathologist17011 - Average Normal Blood Values At Different Ages (Birth - 12 Years of Age) - Chart17012 - Mean Hematologic Values (Infant through Adult) - Chart17013 - Thalassemia Trait Versus Iron Deficiency17014 - Bone Marrow Procedure17015 - Eosinophil Count17016 - Hemacytometer17017 - Microhematocrit Centrifuge Quality Control17018 - Hematocrit17019 - Mucin Clot Test17020 - Nasal Smear - Granulocytes17021 - Red Blood Cell Indices17022 - Reticulocyte Count17023 - Sugar Water Screening for Paroxysmal Nocturnal Hemoglobinuria17024 - Erythrocyte Sedimentation Rate (Modified Westergren)17025 - Wintrobe Sedimentation Rate17026 - Platelet Clumping Cold Agglutinin Procedure17027 - Lipemic CBC - HGB Correction17028 - Morphologic Characteristics of the Myeloid and Non-Myeloid Cells (Wright's Stain) Chart17029 - Correction of White Count for Nucleated RBCs 17030 - Automated Differential Check17031 - Sample Analysis
SECTION 18 - MICROBIOLOGY
18001 - Bacteriology Hazards18002 - Microbiological Spills or Contamination18003 - Disposal of Contaminated Materials18004 - Quality Control - Laboratory Equipment18005 - Equipment Quality Control Log Form18006 - Thermometer Record Form18007 - Autoclave18008 - Quality Control - Autoclave18009 - Autoclave Quality Control Log Form18010 - Quality Control - Calibrated Loops18011 - Calibrated Loop Quality Control Log Form18012 - Calibration of the Ocular Micrometer18013 - Calibration of Ocular Micrometer Diagram18014 - Quality Control - Media18015 - Control Organisms to be Used for Media Performance Testing18016 - Quality Control - Reagents18017 - Reagent Information Log Form18018 - Reagent Quality Control Log Form18019 - Microbiology Reagent Quality Control Log Form18020 - Quality Control Organisms - Stock Organisms Maintenance and Use18021 - CTA Medium (For Maintenance of Stock Organisms)18022 - Stock Cultures - Methods of Maintenance18023 - Working Stock Cultures - Maintenance18024 - Microbiology Specimen - Collection, Ordering and Reporting18025 - Receiving Laboratory Specimens18026 - Criteria for Rejection of Specimens - Microbiology18027 - Criteria for Rejection of Stool for Ova and Parasites18028 - Out-of-Control Plan - Microbiology18029 - Panic Values in Microbiology18030 - Department of Health Services: Submitting and Reporting Cultures18031 - Aerobic Bacteria Identification - General Culture Procedure18032 - Aerobic Identification - Enteric Gram Negative Bacilli18033 - Aerobic Identification - Gram Positive Bacilli18034 - Aerobic Identification - Gram Positive Cocci18035 - Aerobic Identification - Gram Negative and Gram Variable Cocci and Coccobacilli18036 - Gram Positive Rods18037 - Gram Positive Rods Flowchart18038 - AFB Cultures and Fungus - Reference Lab18039 - Mycobacteriology, Mycology and Fungus Serology Test18040 - Anaerobic Cultures - Ordering and Collection18041 - Anaerobic Cultures - Identifying and Reporting18042 - Infections Commonly Involving Anaerobes - Chart18043 - Sites of Anaerobic Infection - Chart18044 - Beta Strep18045 - GC Cultures18046 - Identification of Neisseria (From the Urogenital Tract, Eye and Body Fluids)18047 - Blood Cultures - Ordering and Collection18048 - Blood Cultures - Processing and Reporting18049 - Campylobacter Cultures18050 - Catheter Tip Cultures (CVPs)18051 - Body Fluid Cultures - Ordering and Collection18052 - Body Fluid Cultures - Identifying and Reporting18053 - Fungus Cultures and Direct Examination of Specimens for Fungus18054 - Respiratory Cultures - Ordering and Collection18055 - Respiratory Cultures - Identifying and Reporting18056 - Spinal Fluid Cultures - Ordering and Collection18057 - Spinal Fluid Cultures - Processing and Reporting18058 - Sputum Cultures - Ordering and Collection18059 - Sputum Cultures - Processing and Reporting18060 - Stool Cultures18061 - Urine Cultures - Ordering and Collection18062 - Urine Cultures (Colony Count) - Identifying and Reporting18063 - Urogenital Tract Cultures - Ordering and Collection18064 - Urogenital Tract Cultures - Identifying and Reporting18065 - Viral Specimens - Collection, Transport, Storage - Chart18066 - OF Basal Medium with Dextrose18067 - Bile Esculin Agar Slants18068 - Ornithine Motility Indole Medium (OMI)18069 - Salt Tolerance Test18070 - Simmons Citrate Agar Slants18071 - Cytology Preparation18072 - Catalase Test18073 - Floxin (Ofloxacin) Procedure18074 - Germ Tube Test18075 - Gram Stain18076 - Haemophilus Identification Test18077 - Hippurate Hydrolysis Test18078 - India Ink Method for Cryptococcus Detection in CSF18079 - Wet Mounts18080 - Plating Protocol for Clinical Microbiology Specimens18081 - Media Used for Plating Microbiology Specimens18082 - Streak Plate Technique (For Plating Culture Specimens)18083 - Multiple-Resistant Organisms18084 - Antibiotic Susceptibility18085 - Susceptibility with Streptococcus Pneumoniae18086 - Sensitivity Testing - Kirby-Bauer Method18087 - Quality Control of Antimicrobial Susceptibility Disks (Kirby-Bauer Method)18088 - CSF and Body Fluid Counts18089 - Cellophane Tape Preparation for Enterobius Vermicularis (Pin Worm)18090 - Semen Analysis18091 - Stool - Wright's Stain for Polys18092 - Synovial Fluid Crystal Analysis
SECTION 19 - URINALYSIS
19001 - Urine Collection by Patients19002 - Routine Urinalysis19003 - Criteria for Rejection of Specimens for Urinalysis19004 - Preoperative Patient Macro Urines19005 - Microscopic Urinalysis19006 - Urinalysis - Ranges of Values and Definition of Ranges19007 - Twenty-Four (24) Hour Urine Collection19008 - 24-Hour Urine Collection Guide19009 - Specific Gravity of Urine19010 - Daily Urine Quality Control Guidelines19011 - Action Log Form19012 - Urine - Storage19013 - Collection and Processing of Employment Drug Tests19014 - Checklist Procedure for Pre-Employment Drug Testing