University Policy


3364-107-101 Phlebotomy on Outpatients
3364-107-102 Specimens Unacceptable for Testing
3364-107-104 Blood Transfusion Identification Wristbands
3364-107-105 Unauthorized Testing on UTMC Employees
3364-107-106 Cancellation and Correction of Resulted Lab Tests
3364-107-107 STAT Tests Critical Tests and Critical Limits
3364-107-108 Written Confirmation of Verbal Orders
3364-107-109 Phlebotomy Guidelines
3364-107-110 Release of a Body From the Morgue
3364-107-112 Specimen Collection and Acceptance
3364-107-113 Documentation and Communication at Change of Shift
3364-107-114 Reporting of Infectious Diseases
3364-107-116 Specimen Handling in the Laboratory
3364-107-117 Physician and Patient Satisfaction
3364-107-118 Reactions to Venipunctures on Outpatients and Inpatients
3364-107-119 Confirmation of Unclear Written Laboratory Orders
3364-107-120 Reconciling Orders With Specimens
3364-107-121 Report Format/Content Review
3364-107-122 Specimen Quality Feedback
3364-107-125 Point of Care (POC) Glucose Testing on Critically Ill Patients
3364-107-127 Non-conforming Events in Laboratory
3364-107-201 CLIA '88 Testing Personnel Requirements
3364-107-202 Overtime
3364-107-203 Officer of the Day Protocol
3364-107-204 Planned Absence from Campus
3364-107-205 Travel/Seminar Policy
3364-107-206 Filling Staff Vacancies
3364-107-207 Reporting Absence from Work
3364-107-208 Training and Annual Competency Documentation
3364-107-210 Posted Overtime Hours and Extra Hours
3364-107-301 Organizational Issues: Design, Implementation and Review of Quality Plan
3364-107-302 Quality Control
3364-107-303 Process Control
3364-107-304 Authorized Users of Laboratory Computer System
3364-107-305 Authorized Use of Computers
3364-107-306 Reports of Incidents and Accidents
3364-107-307 Proficiency Test Protocol
3364-107-308 Accuracy and Reliability of Tests Not Covered by Proficiency Testing
3364-107-309 Retention of Laboratory Records and Materials
3364-107-310 External Audits
3364-107-311 Documentation/Record-Keeping/Record Review
3364-107-312 Selection of Reference Laboratories
3364-107-313 Laboratory Downtime Procedure
3364-107-314 Communication of Concerns Regarding Quality and Safety
3364-107-315 Proficiency Test Protocol - Ungraded Exception Codes
3364-107-316 Document Management System
3364-107-317 Laboratory Compliance w/CAP Terms of Accreditation
3364-107-318 Temperature Monitoring
3364-107-319 Minimizing Large Volume Blood Draws
3364-107-401 Pathology Safety Training
3364-107-402 Lab Coats in Lounge
3364-107-403 Laser and UV Light Safety
3364-107-404 Formaldehyde
3364-107-405 Monitoring Pathology Safety
3364-107-406 Authorized Access to Laboratory
3364-107-407 Packaging and Shipping of Infectious Materials
3364-107-408 Adherence to Federal, State and Local Laws and Regulations
3364-107-409 Bi-Annual Review of Chemical Hygiene Plan
3364-107-410 Handling of CSF with Known or Suspected Creutzfeldt-Jakob Disease (CJD)

3364-107-411 Automatic Infectious Disease Consultation in Select Patients with Positive Blood Cultures 



Last Updated: 6/27/22