Clinical Laboratory Policy and Procedure Manual

The Clinical Laboratory Policy and Procedure Manual contains over 400 comprehensive policies, procedures and forms to help you comply with the latest Joint Commission Laboratory standards and CLIA regulations. Each template gives you a roadmap to effective department management, clinical procedures and operations that you can make specific to your organization.

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Table of Contents - TJC Standards and CLIA RegulationsCopyrightDisclaimerApproval/Signature SheetIntroduction
SECTION 01 - DOCUMENT AND PROCESS CONTROL
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 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 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