DEPARTMENT OF PATHOLOGY GENERAL POLICY MANUAL

Table of Contents

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

 

PATHOLOGY MISSION STATEMENT

Provision of Laboratory Services

  1. ADMINISTRATIVE POLICIES
    1. Quality Management
      1. Quality Management System
      2. Quality Management Program
        1. Pathology Organizational Chart
      3. Proficiency Testing
        1. Proficiency Testing Policy
        2. Alternative Proficiency Assessment Methods
        3. Proficiency Test Procedure
        4. Proficiency Checklist
    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 * (9/2009) (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. Weather Emergency Plan
      1. Pathology Department Plan
      2. Hopkins' Medicine Weather Emergency Policies
    5. HOPKINS OnAlert (CEPAR)
    6. Laboratory Safety Information
      1. Laboratory Safety Manual
      2. Johns Hopkins Safety Policies
      3. Materials Safety Data Sheets (MSDS)
      4. Cryogenic Liquid Policy
      5. Ergonomic Program
  2. HUMAN RESOURCES
    1. New Employee Orientation Checklist
      1. Student and Volunteer Orientation Checklist
    2. Employee Compensation / Payroll Policies
    3. Laboratory Conduct
      1. Institutional Code of Conduct
      2. Laboratory Standards of Conduct
    4. Staff Request not to Participate in Patient Care
    5. Pathology Appearance Standards and Image Policy
  3. PATIENT SAFETY
    1. Patient/Visitor Event or Service Concern Reporting Policy
      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 Reporting*
    5. Procedure for Correction of Patient Records
    6. Infection Control Guidelines
    7. Laboratory Superstat Reporting (01/07/09)
  4. MISCELLANEOUS
    1. Information Management
      1. Retention Times, for Records, Reports and Specimens
      2. Reference Laboratory Services Policy * and JHH Reference Laboratories List
      3. Reflex Testing
      4. Test Add-on and Verbal Order Policy (9/2009)
    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. Reagent and Solution Labeling Policy
      4. Testing of Reagent Water in the Clinical Laboratory
    3. Venipuncture Procedure
  5. COMPLIANCE POLICIES
    1. Compliance Billing Policy
    2. Compliance Policy on Auditing and Monitoring Activities