Note: Files marked with an asterisk (*) are only available from on-campus computers.

PATHOLOGY MISSION STATEMENT

A. ADMINISTRATIVE POLICIES

1. Quality Management
   1. Laboratory Structure and Function*
      1. Pathology Organizational Chart*
   2. Quality Assessment Programs
   3. Proficiency Testing


2. HIPAA Policies
   1. Release of Anatomic Pathology Medical Records
   2. Paper Documents Policy
   3. Faxed Documents Procedure
      1. Fax Verification Form
      2. Fax Cover Sheet
   4. Telephone Inquiry Policy


3. Pathology Disaster Plan (7/2007 updated) * (Code Yellow ED, Hospital, Chemical, Radiation)
   1. Disaster Call Roster Exhibit I *
   2. Pathology Contact Phone List Exhibit II *
   3. Disaster Fast Facts * (Poster)
   4. JHM Staff Emergency Response Reference
   5. High Winds Policy


4. Bioterrorism Plan* and Communication Plan (Code Yellow Bio)*



5. Weather Emergency Plan



6. HOPKINS OnAlert (CEPAR)

B. HUMAN RESOURCES

1. New Employee Orientation Checklist
   1. Student and Volunteer Orientation Checklist


2. Employee Compensation / Payroll Policies



3. Laboratory Standards of Conduct



4. Staff Request not to Participate in Patient Care



5. Pathology Appearance Standards and Image Policy

C. PATIENT SAFETY

1. Patient Safety Net Policy and Procedure
   1. Laboratory PSN Event Grid
   2. Morgue PSN Event Grid


2. Mislabeled or Unidentified Patient Specimens Policy



3. Critical Action Laboratory Values



4. Critical Action Value Reporting*



5. Correction of Mis-registered Patients



6. Infection Control Guidelines



7. Laboratory SuperStat Test Reporting (7/01/07)

D. MISCELLANEOUS

1. Information Management
   1. Retention Times, for Records, Reports and Specimens
   2. Reference Laboratory Services Policy * and JHH Reference Laboratories List
   3. Reflex Test List
   4. Test Add-on and Verbal Order Policy



2. Environment
   1. Pathology Equipment Management Policy
   2. Isensix Procedure (Reference Guide)
      1. Isensix Equipment Standard Operating Procedure
      2. Isensix Troubleshooting Guide Appendix A
   3. Lab Safety Manual (revised 11/2007)
   4. Reagent and Solution Labeling Policy



3. Proficiency Testing Guide
   1. Proficiency Test Checklist
   2. Proficiency Test Order Checklist



4. Venipuncture Procedure

E. COMPLIANCE POLICIES

1. Compliance Billing Policy



2. Compliance Policy on Auditing and Monitoring Activities

F. JHMI Provider Performed Microscopy Procedures (PPMP)

1. Provider Performed Microscopy Testing Policy
   1. Specimen Collection Procedure
   2. KOH and Wet Prep Procedure
   3. Fern Test Procedure
   4. Urine Sediment Examination Procedure
   5. Postcoital Examination Procedure
   6. Scabies Identification Procedure
   7. Qualitative Semen Analysis Procedure