Pathology Policy and Procedure Manual
Pathology 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.
SECTION I - LEADERSHIP
Goals and ObjectivesScope of ServicesStaffingPatient ConfidentialityTissue Accession LogbookPrevention of Specimen MislabelingOutside Reference Laboratory AuthorizationOutside Reference Laboratory ServicesAutopsy Criteria and Next of Kin AuthorizationAuthorization for AutopsyAuthorization for Autopsy FormAutopsy ReportsRequesting Pathology ServicesElectronic ReportsRequesting Slides and/or BlocksDiscontinued ProceduresAddresses for Primary Standards
SECTION II - PERFORMANCE IMPROVEMENT
Pathology Department Performance Improvement PlanPerformance Measures and Outcomes - Pathology DepartmentPerformance Improvement Monitoring and Evaluation Plan - Transfusion CommitteePerformance Measures and Outcomes - Transfusion Committee (Blood/Blood Product Usage)Criteria for Transfusion ReviewTransfusion Reaction Reporting/InterventionRequest for Investigation of Transfusion Reaction FormPerformance Measures and Outcomes - Tissue CommitteeTissue Committee CriteriaSentinel EventConducting Root Cause Analysis
SECTION III - MANAGEMENT OF ENVIRONMENT OF CARE
Pathology Department SafetyElectrical SafetyHazard Surveillance Detection Survey - Clinical Laboratory ServicesLaboratory Safety QuizHazardous Materials and Waste TrainingChemical Training Record FormHow to Read Safety Data Sheets (SDS)Incompatible Chemicals - In Storage and ReactionsFormaldehyde PrecautionsFormaldehyde Monitor Record FormFormaldehyde Test KitFormaldehyde Spill - Emergency Action PlanHandling of Biohazardous WasteDisposal of Pathology ChemicalsDisposal of Anatomical WasteDisposal of Extremity AmputationsDisposal of FetusesDisposal of SharpsLatex SensitivityEmergency ManagementFire SafetyEquipment SafetyEquipment MaintenanceQuality Control - Equipment
SECTION IV - HUMAN RESOURCES
Position Description/Performance Evaluation - Medical Director of Clinical Laboratory/Pathology DepartmentAnnual Competency Clinical Skills Assessment - Medical Director of Clinical Laboratory/Pathology DepartmentPosition Description/Performance Evaluation - Director of Clinical LaboratoryPerformance Evaluation - Age-Related Competency - Director of Clinical LaboratoryAnnual Competency Clinical Skills Assessment - Director of Clinical LaboratoryPosition Description/Performance Evaluation - CytotechnologistPerformance Evaluation - Age-Related Competency - CytotechnologistAnnual Competency Clinical Skills Assessment - CytotechnologistPosition Description/Performance Evaluation - Histology Technician/Pathology SecretaryAnnual Competency Skills Assessment - Histology Technician/Pathology SecretaryNew Employee Orientation and TrainingContinuing EducationStaff Requests
SECTION V - SURVEILLANCE, PREVENTION AND CONTROL OF INFECTION
Standard PrecautionsHand HygieneExposure Control PlanSharps Injury Protection Plan - Addendum to Exposure Control PlanSharps Injury LogExposure to Blood or Body FluidsReport of Exposure to Bloodborne PathogensExposure of Personnel to Mycobacterium Tuberculosis and Pathogenic FungiBloodborne Pathogens/Infectious Disease and the Laboratory WorkerCreutzfeldt-Jacob Disease Precautions
SECTION VI - CYTOPATHOLOGY
Cytology RequisitionsCriteria for Accepting Cytology SpecimensCriteria for Rejection of Cytology SpecimensReport of Cytodiagnostic (Cervical Cytology) Examination FormCytology PreparationProcessing and Reporting of Cytology ExaminationsOutside Reference Laboratory Non-GYN CytologiesSpinal Fluid Cytology for Leukemia CellsSlide Volume RecordSlide Volume Record FormPap Smear LogPap Smear Log Form - GYN-CytologyPap Smear Log Form - Non-GYN-CytologyGYN-Pathology Quarterly ReviewsCytology Screening/RescreeningCytology Screening - Correlation LogDiagnostic Correlation Between Screener and Pathologist FormGYN Cytology - Cervical Histology Correlation LogCytology-Histology Correlation Studies FormProficiency Testing (PT) Program - Cytology: GYN ExaminationsCollege of American Pathologists - PAP Program
SECTION VII - HISTOPATHOLOGY
Tissue Examination and ExemptionsSpecimens Approved for ExemptionIdentification of SpecimensIdentification and Filing of Slides, Blocks and Wet TissuePathology ReportsTumor Case ReportingFrozen Section ProtocolIdentification and Filing of Frozen Section SlidesHistology Specimen Collection and FixativesFixation/Dehydration - Tissue ProcessorEmbeddingSectioningIdentifying Epithelial Surface on Small Biopsy SpecimensReprocessing Dried Tissue SpecimensPeer Education ProgramsPathology Code
SECTION VIII - STAINS
StainsPap Smear Staining ProcedureRestaining TechniqueAcid AlcoholDiff-Quik StainEosin-YGomori's Iron Reaction (Prussian Blue)Gomori's One-Step Trichrome StainHematoxylin - Eosin StainingQuality Control of Routine Hematoxylin and Eosin StainingPeriodic Acid-Schiff (PAS) StainZiehl-Neelson AFB StainCoverslippingBone Marrow ProcedureHistology Daily WorksheetQuality Control - Special StainsSpecial Stain Record FormSpecial Stain Control Record FormQuality Control Stains