[Histonet] Procedure manual review

Tench, Bill Bill.Tench <@t> pph.org
Mon Nov 15 10:30:56 CST 2010

All procedures must be reviewed annually (and that means WITHIN 12
months, not just once a calender year)
This may be done by the appropriate supervisor or pathologist, not
necessarily the Director (Director must review all new or changed
The review should confirm that the procedure in operation matches what
really happens.
The laboratory must have in place a mechanism that demonstrates that the
users of those procedures are familiar with them (and without digging up
the CAP standards, i rely on my memory that this must also be documented
in some format on an annual basis).  I believe we accomplish this with
an annual signed statement from the employees confirming they are
familiar with the procedures they use. 
Bill Tench
Associate Dir. Laboratory Services
Chief, Cytology Services
Palomar Medical Center
555 E. Valley Parkway
Escondido, California  92025
Bill.Tench <@t> pph.org
Voice: 760- 739-3037
Fax: 760-739-2604

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