Sync template from atomicqms-style deployment

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name: AtomicAI Pathology Assistant
on:
issue_comment:
types: [created]
issues:
types: [opened, assigned]
pull_request:
types: [opened, synchronize, assigned]
pull_request_review_comment:
types: [created]
jobs:
claude-assistant:
runs-on: ubuntu-latest
if: |
github.actor != 'atomicqms-service' &&
(
(github.event_name == 'issue_comment' && contains(github.event.comment.body, '@atomicai') && github.event.comment.user.login != 'atomicqms-service') ||
(github.event_name == 'issues' && github.event.action == 'opened' && contains(github.event.issue.body, '@atomicai')) ||
(github.event_name == 'pull_request' && github.event.action == 'opened' && contains(github.event.pull_request.body, '@atomicai')) ||
(github.event_name == 'pull_request_review_comment' && contains(github.event.comment.body, '@atomicai') && github.event.comment.user.login != 'atomicqms-service') ||
(github.event.action == 'assigned' && github.event.assignee.login == 'atomicai')
)
permissions:
contents: write
issues: write
pull-requests: write
steps:
- uses: actions/checkout@v4
with:
fetch-depth: 0
- name: Run AtomicAI Pathology Assistant
uses: https://beta.atomicqms.com/atomicqms-service/actions/claude-code-gitea-action-slim@main
with:
trigger_phrase: '@atomicai'
assignee_trigger: 'atomicai'
claude_git_name: 'AtomicAI'
claude_git_email: 'atomicai@atomicqms.local'
custom_instructions: |
You are AtomicAI, an AI assistant specialized in Pathology and Anatomic Pathology Quality Management.
## Your Expertise
- CAP (College of American Pathologists) accreditation
- CLIA laboratory standards
- Surgical pathology specimen handling
- Histology and tissue processing
- Immunohistochemistry protocols
- Cytology and FNA procedures
- Autopsy protocols and procedures
- Frozen section procedures
- Specimen identification and tracking
- Quality assurance and peer review
- Critical diagnosis communication
- Digital pathology and whole slide imaging
## Document Creation Guidelines
- Place Surgical Path SOPs in SOPs/Surgical-Pathology/
- Place Histology SOPs in SOPs/Histology/
- Place Cytology SOPs in SOPs/Cytology/
- Place QA Forms in Forms/Quality-Assurance/
- Place Specimen Forms in Forms/Specimen/
- Place Policies in Policies/
## Numbering Convention
- SOP-SP-XXX for Surgical Pathology SOPs
- SOP-HIS-XXX for Histology SOPs
- SOP-CYT-XXX for Cytology SOPs
- SOP-AUT-XXX for Autopsy SOPs
- POL-XXX for Policies
- FRM-XXX for Forms
Always create branches and submit changes as Pull Requests for review.
Prioritize specimen integrity, diagnostic accuracy, and turnaround time.
allowed_tools: 'Read,Edit,Grep,Glob,Write'
disallowed_tools: 'Bash,WebSearch'

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# Document Change Request Form
| Form ID | FRM-001 | Revision | 1.0 |
|---------|---------|----------|-----|
---
## Section 1: Request Information
| Field | Entry |
|-------|-------|
| Request Date | |
| Requested By | |
| Department | |
## Section 2: Document Information
| Field | Entry |
|-------|-------|
| Document Number | |
| Document Title | |
| Current Revision | |
## Section 3: Change Description
### Type of Change
- [ ] New Document
- [ ] Revision to Existing Document
- [ ] Document Obsolescence
### Description of Change
*(Describe the proposed change in detail)*
### Reason for Change
*(Explain why this change is needed)*
## Section 4: Impact Assessment
### Affected Areas
- [ ] Training Required
- [ ] Other Documents Affected
- [ ] Process Changes Required
- [ ] Validation Impact
### List Affected Documents
## Section 5: Approvals
| Role | Name | Signature | Date |
|------|------|-----------|------|
| Requester | | | |
| Document Owner | | | |
| Quality Assurance | | | |
---
*Form FRM-001 Rev 1.0*

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# Corrective and Preventive Action (CAPA) Form
| Form ID | FRM-003 | Revision | 1.0 |
|---------|---------|----------|-----|
---
## Section 1: CAPA Identification
| Field | Entry |
|-------|-------|
| CAPA Number | |
| Date Initiated | |
| Initiated By | |
| CAPA Owner | |
| Target Closure Date | |
## Section 2: Classification
### Type
- [ ] Corrective Action
- [ ] Preventive Action
### Source
- [ ] Customer Complaint
- [ ] Internal Audit
- [ ] External Audit
- [ ] Process Deviation
- [ ] Nonconforming Product
- [ ] Management Review
- [ ] Other: ____________
### Priority
- [ ] Critical (5 business days)
- [ ] Major (15 business days)
- [ ] Minor (30 business days)
## Section 3: Problem Description
*(Describe the nonconformity or potential nonconformity)*
## Section 4: Immediate Containment
*(Actions taken to contain the immediate impact)*
## Section 5: Root Cause Investigation
### Investigation Method Used
- [ ] 5 Whys
- [ ] Fishbone Diagram
- [ ] Fault Tree Analysis
- [ ] Other: ____________
### Root Cause Determination
## Section 6: Corrective/Preventive Actions
| Action | Responsible | Due Date | Status |
|--------|-------------|----------|--------|
| | | | |
| | | | |
| | | | |
## Section 7: Effectiveness Verification
| Criteria | Method | Result |
|----------|--------|--------|
| | | |
Verification Date: ____________
Verified By: ____________
## Section 8: Closure
| Role | Name | Signature | Date |
|------|------|-----------|------|
| CAPA Owner | | | |
| Quality Approval | | | |
---
*Form FRM-003 Rev 1.0*

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# Internal Audit Checklist
| Form ID | FRM-006 | Revision | 1.0 |
|---------|---------|----------|-----|
---
## Audit Information
| Field | Entry |
|-------|-------|
| Audit Number | |
| Audit Date | |
| Area/Process Audited | |
| Lead Auditor | |
| Auditee(s) | |
---
## Checklist Items
| # | Requirement/Question | Reference | C/NC/NA | Evidence/Notes |
|---|---------------------|-----------|---------|----------------|
| 1 | Are current versions of applicable procedures available? | SOP-001 | | |
| 2 | Are personnel trained on applicable procedures? | SOP-003 | | |
| 3 | Are training records current and complete? | SOP-003 | | |
| 4 | Are records properly maintained and retrievable? | SOP-001 | | |
| 5 | Are nonconformities being documented and addressed? | SOP-002 | | |
| 6 | Are CAPAs being completed on time? | SOP-002 | | |
| 7 | Is equipment calibrated and maintained? | | | |
| 8 | Are process controls being followed? | | | |
| 9 | Are quality objectives being monitored? | | | |
| 10 | | | | |
**Legend:** C = Conforming, NC = Nonconforming, NA = Not Applicable
---
## Findings Summary
| Finding # | Type | Description | Clause Reference |
|-----------|------|-------------|------------------|
| | | | |
| | | | |
---
## Auditor Signature
| Auditor | Signature | Date |
|---------|-----------|------|
| | | |
---
*Form FRM-006 Rev 1.0*

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# Specimen Receipt Log
| Form ID | FRM-PATH-001 | Revision | 1.0 |
|---------|-------------|----------|-----|
---
## Log Information
| Field | Entry |
|-------|-------|
| Date | |
| Shift | ☐ Day ☐ Evening ☐ Night |
| Accessioning Technician | |
| Technician ID | |
---
## Specimen Receipt Record
### Specimen 1
| Field | Entry |
|-------|-------|
| Time Received | |
| Received From | ☐ OR ☐ Clinic ☐ Courier ☐ Transport ☐ Other: |
| Accession Number | |
| Patient Name | |
| MRN | |
| DOB | |
| Specimen Type | |
| Specimen Site | |
| Number of Containers | |
| Fixative | ☐ Formalin ☐ Fresh ☐ Other: |
| Collection Date/Time | |
| Container Labeled Correctly? | ☐ Yes ☐ No |
| Requisition Complete? | ☐ Yes ☐ No |
| Specimen Condition | ☐ Acceptable ☐ Compromised (see notes) |
| Priority | ☐ Routine ☐ Rush ☐ STAT |
| Discrepancy? | ☐ No ☐ Yes (Resolution: _______) |
| Received By (Initials) | |
### Specimen 2
| Field | Entry |
|-------|-------|
| Time Received | |
| Received From | ☐ OR ☐ Clinic ☐ Courier ☐ Transport ☐ Other: |
| Accession Number | |
| Patient Name | |
| MRN | |
| DOB | |
| Specimen Type | |
| Specimen Site | |
| Number of Containers | |
| Fixative | ☐ Formalin ☐ Fresh ☐ Other: |
| Collection Date/Time | |
| Container Labeled Correctly? | ☐ Yes ☐ No |
| Requisition Complete? | ☐ Yes ☐ No |
| Specimen Condition | ☐ Acceptable ☐ Compromised (see notes) |
| Priority | ☐ Routine ☐ Rush ☐ STAT |
| Discrepancy? | ☐ No ☐ Yes (Resolution: _______) |
| Received By (Initials) | |
### Specimen 3
| Field | Entry |
|-------|-------|
| Time Received | |
| Received From | ☐ OR ☐ Clinic ☐ Courier ☐ Transport ☐ Other: |
| Accession Number | |
| Patient Name | |
| MRN | |
| DOB | |
| Specimen Type | |
| Specimen Site | |
| Number of Containers | |
| Fixative | ☐ Formalin ☐ Fresh ☐ Other: |
| Collection Date/Time | |
| Container Labeled Correctly? | ☐ Yes ☐ No |
| Requisition Complete? | ☐ Yes ☐ No |
| Specimen Condition | ☐ Acceptable ☐ Compromised (see notes) |
| Priority | ☐ Routine ☐ Rush ☐ STAT |
| Discrepancy? | ☐ No ☐ Yes (Resolution: _______) |
| Received By (Initials) | |
### Specimen 4
| Field | Entry |
|-------|-------|
| Time Received | |
| Received From | ☐ OR ☐ Clinic ☐ Courier ☐ Transport ☐ Other: |
| Accession Number | |
| Patient Name | |
| MRN | |
| DOB | |
| Specimen Type | |
| Specimen Site | |
| Number of Containers | |
| Fixative | ☐ Formalin ☐ Fresh ☐ Other: |
| Collection Date/Time | |
| Container Labeled Correctly? | ☐ Yes ☐ No |
| Requisition Complete? | ☐ Yes ☐ No |
| Specimen Condition | ☐ Acceptable ☐ Compromised (see notes) |
| Priority | ☐ Routine ☐ Rush ☐ STAT |
| Discrepancy? | ☐ No ☐ Yes (Resolution: _______) |
| Received By (Initials) | |
### Specimen 5
| Field | Entry |
|-------|-------|
| Time Received | |
| Received From | ☐ OR ☐ Clinic ☐ Courier ☐ Transport ☐ Other: |
| Accession Number | |
| Patient Name | |
| MRN | |
| DOB | |
| Specimen Type | |
| Specimen Site | |
| Number of Containers | |
| Fixative | ☐ Formalin ☐ Fresh ☐ Other: |
| Collection Date/Time | |
| Container Labeled Correctly? | ☐ Yes ☐ No |
| Requisition Complete? | ☐ Yes ☐ No |
| Specimen Condition | ☐ Acceptable ☐ Compromised (see notes) |
| Priority | ☐ Routine ☐ Rush ☐ STAT |
| Discrepancy? | ☐ No ☐ Yes (Resolution: _______) |
| Received By (Initials) | |
---
## Special Handling/Fresh Specimens
*Document any specimens requiring immediate processing (frozen sections, special studies, etc.)*
| Accession # | Specimen Type | Special Handling Required | Time to Grossing | Pathologist Notified |
|-------------|---------------|---------------------------|------------------|---------------------|
| | | | | ☐ Yes |
| | | | | ☐ Yes |
---
## Discrepancy Log
| Time | Accession # | Discrepancy Type | Description | Resolution | Resolved By |
|------|-------------|------------------|-------------|------------|-------------|
| | | ☐ Labeling ☐ Requisition ☐ Condition ☐ Other | | | |
| | | ☐ Labeling ☐ Requisition ☐ Condition ☐ Other | | | |
---
## Shift Summary
| Field | Count |
|-------|-------|
| Total Specimens Received | |
| Surgical Pathology | |
| Cytology | |
| Frozen Sections | |
| STAT/Rush Cases | |
| Specimens with Discrepancies | |
| Specimens Held/Not Accessioned | |
---
## Quality Notes
*Document any quality issues, equipment problems, or unusual occurrences:*
---
## Shift Handoff
| Field | Entry |
|-------|-------|
| Pending Issues for Next Shift | |
| Outstanding Discrepancies | |
| Equipment Issues | |
| Shift Sign-Off | |
| Date/Time | |
---
## Supervisor Review
| Field | Entry |
|-------|-------|
| Reviewed By | |
| Date | |
| Comments | |
| Signature | |
---
*Form FRM-PATH-001 Rev 1.0 - Specimen Receipt Log*

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# Training Record Form
| Form ID | FRM-004 | Revision | 1.0 |
|---------|---------|----------|-----|
---
## Section 1: Employee Information
| Field | Entry |
|-------|-------|
| Employee Name | |
| Employee ID | |
| Department | |
| Job Title | |
## Section 2: Training Information
| Field | Entry |
|-------|-------|
| Training Title | |
| Training Date | |
| Training Duration | |
| Trainer Name | |
| Trainer Qualification | |
### Training Type
- [ ] Initial Training
- [ ] Retraining
- [ ] Refresher
- [ ] Procedure Update
### Delivery Method
- [ ] Classroom
- [ ] On-the-Job
- [ ] Self-Study
- [ ] Computer-Based
- [ ] Other: ____________
## Section 3: Training Content
*(List topics covered or attach training materials)*
## Section 4: Assessment
### Assessment Method
- [ ] Written Test
- [ ] Practical Demonstration
- [ ] Verbal Assessment
- [ ] Observation
### Assessment Results
| Metric | Result |
|--------|--------|
| Score (if applicable) | |
| Pass/Fail | |
## Section 5: Signatures
| Role | Name | Signature | Date |
|------|------|-----------|------|
| Trainee | | | |
| Trainer | | | |
| Supervisor | | | |
---
*Form FRM-004 Rev 1.0*

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# Quality Policy
| Document ID | POL-001 |
|-------------|---------|
| Title | Quality Policy |
| Revision | 1.0 |
| Effective Date | [DATE] |
| Author | [AUTHOR] |
| Approved By | [APPROVER] |
---
## 1. Policy Statement
[ORGANIZATION NAME] is committed to providing products and services that consistently meet customer requirements and applicable regulatory requirements. We strive for continual improvement of our Quality Management System to enhance customer satisfaction.
## 2. Quality Objectives
Our organization commits to:
1. **Customer Focus**: Understanding and meeting customer needs and expectations
2. **Regulatory Compliance**: Maintaining compliance with all applicable regulations and standards
3. **Continuous Improvement**: Continually improving the effectiveness of our QMS
4. **Employee Engagement**: Ensuring all employees understand their role in quality
5. **Risk-Based Thinking**: Identifying and addressing risks and opportunities
## 3. Management Commitment
Top management demonstrates commitment to the QMS by:
- Ensuring the quality policy is appropriate to the organization's purpose
- Ensuring quality objectives are established and compatible with strategic direction
- Ensuring integration of QMS requirements into business processes
- Promoting the use of the process approach and risk-based thinking
- Ensuring resources needed for the QMS are available
- Communicating the importance of effective quality management
- Ensuring the QMS achieves its intended results
- Engaging, directing, and supporting persons to contribute to QMS effectiveness
## 4. Scope
This policy applies to all employees, contractors, and processes within the scope of our Quality Management System.
## 5. Communication
This policy shall be:
- Communicated and understood within the organization
- Available to relevant interested parties as appropriate
- Reviewed for continuing suitability
---
## Revision History
| Rev | Date | Description | Author |
|-----|------|-------------|--------|
| 1.0 | [DATE] | Initial release | [AUTHOR] |

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README.md
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# pathology # Pathology & Laboratory Medicine Quality Management System
A comprehensive QMS template designed for anatomic pathology, clinical pathology, and laboratory medicine departments. A comprehensive QMS template designed for anatomic pathology, clinical pathology, and laboratory medicine departments.
## 🔬 Designed For
- **Anatomic Pathology** - Surgical pathology, cytopathology, autopsy
- **Clinical Pathology** - Chemistry, hematology, microbiology, transfusion medicine
- **Reference Laboratories** - Specialized testing services
- **Molecular Pathology** - Genetic and molecular diagnostics
- **Forensic Pathology** - Medical examiner and coroner services
- **Dermatopathology** - Skin biopsy interpretation
- **Neuropathology** - Brain and nervous system pathology
## 📋 Regulatory Framework
This template supports compliance with:
- **CAP** - College of American Pathologists accreditation
- **CLIA** - Clinical Laboratory Improvement Amendments
- **The Joint Commission** - Hospital accreditation (laboratory chapter)
- **FDA** - IVD and LDT regulations
- **AABB** - Blood bank standards (if applicable)
- **State Clinical Laboratory Licensing** - State-specific requirements
- **OSHA** - Bloodborne pathogens, chemical safety
- **HIPAA** - Patient information privacy
- **ASCP** - Pathologist and technologist standards
- **CAP Biorepository** - Tissue banking requirements (if applicable)
## Repository Structure
```
├── SOPs/
│ ├── Specimen-Handling/ # Accessioning, processing, storage
│ ├── Histology/ # Tissue processing, embedding, sectioning, staining
│ ├── Cytology/ # Cytology preparation and screening
│ ├── Autopsy/ # Post-mortem examination procedures
│ ├── Molecular/ # Molecular testing, NGS, PCR
│ └── General/ # Document control, training, CAPA
├── Forms/
│ ├── Requisition-Forms/ # Specimen submission, clinical history
│ ├── Grossing-Templates/ # Specimen dictation templates
│ ├── QC-Records/ # Staining QC, reagent logs, instrument checks
│ ├── Report-Templates/ # Synoptic and narrative report templates
│ ├── Competency/ # Technologist and pathologist assessments
│ └── Incident-Reports/ # Specimen quality, labeling errors
├── Policies/ # Department policies
├── Work-Instructions/ # Step-by-step procedures
└── Templates/ # Document templates
```
## Document Numbering Convention
- **POL-XXX**: Policies
- **SOP-SP-XXX**: Specimen Handling SOPs
- **SOP-HIS-XXX**: Histology SOPs
- **SOP-CYT-XXX**: Cytology SOPs
- **SOP-AUT-XXX**: Autopsy SOPs
- **SOP-MOL-XXX**: Molecular SOPs
- **WI-XXX**: Work Instructions
- **FRM-XXX**: Forms and Records
## 🤖 AI-Powered Assistance
This repository includes **AtomicAI**, your pathology QMS assistant. Mention `@atomicai` in any issue or pull request to:
- Draft specimen handling and processing SOPs
- Create histology and staining procedures
- Generate grossing templates for specimen types
- Develop molecular testing protocols
- Create quality control procedures
- Review documents for CAP/CLIA compliance
### Example Prompts
- "@atomicai create an SOP for surgical specimen grossing and sampling"
- "@atomicai draft a tissue processor validation procedure"
- "@atomicai write an immunohistochemistry staining and QC protocol"
- "@atomicai create a synoptic report template for breast cancer"
- "@atomicai develop a frozen section procedure with turnaround time standards"
- "@atomicai create a specimen labeling and identification policy"
## Getting Started
1. **Establish Specimen Policies** - Define accessioning and handling requirements
2. **Standardize Processing** - Document histology and cytology procedures
3. **Implement QC Programs** - Set up staining, reagent, and instrument QC
4. **Define Reporting Standards** - Create synoptic and narrative templates
5. **Train Staff** - Use competency assessment forms
## Key Documents to Create First
1. **Specimen Accessioning SOP** - Receiving, labeling, and logging specimens
2. **Tissue Processing SOP** - Fixation, processing, embedding procedures
3. **H&E Staining Protocol** - Routine hematoxylin and eosin procedure
4. **Immunohistochemistry SOP** - IHC staining and controls
5. **Frozen Section SOP** - Intraoperative consultation procedure
6. **Grossing Manual** - Specimen-specific grossing guidelines
7. **Critical Values Policy** - Urgent result communication
## Special Considerations for Pathology
### Specimen Integrity
- Specimen identification and labeling
- Fixation timing and adequacy
- Cold ischemia documentation
- Tissue banking considerations
- Chain of custody (legal cases)
### Quality Control
- H&E and special stain QC
- IHC positive and negative controls
- Reagent expiration and storage
- Instrument calibration and maintenance
- Proficiency testing participation
### Reporting
- Turnaround time standards
- Synoptic reporting (CAP protocols)
- Critical/unexpected results
- Amendment and addendum procedures
- Second opinion and consultation
### Safety
- Formalin handling and exposure limits
- Xylene substitutes and ventilation
- Infectious specimen handling
- Sharps safety (microtome blades)
- Prion precautions (CJD)
---
*This template is maintained by AtomicQMS. For questions, open an issue in this repository.*

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# Standard Operating Procedure: Document Control
| Document ID | SOP-001 |
|-------------|---------|
| Title | Document Control |
| Revision | 1.0 |
| Effective Date | [DATE] |
| Author | [AUTHOR] |
| Approved By | [APPROVER] |
| Department | Quality Assurance |
---
## 1. Purpose
To establish a procedure for the creation, review, approval, distribution, and control of documents within the Quality Management System.
## 2. Scope
This procedure applies to all controlled documents including:
- Policies
- Standard Operating Procedures (SOPs)
- Work Instructions
- Forms and Templates
- Specifications
- External documents of external origin
## 3. Responsibilities
### 3.1 Document Owner
- Responsible for document content and accuracy
- Initiates document creation and revision
- Ensures periodic review is performed
### 3.2 Quality Assurance
- Maintains the document control system
- Assigns document numbers
- Manages document distribution
- Archives obsolete documents
### 3.3 Approvers
- Review and approve documents before release
- Ensure documents are adequate for intended purpose
## 4. Procedure
### 4.1 Document Creation
1. Identify the need for a new document
2. Request document number from Quality Assurance
3. Draft document using appropriate template
4. Include all required header information
5. Submit for review and approval
### 4.2 Document Review and Approval
1. Route document to appropriate reviewers
2. Reviewers provide comments within 5 business days
3. Author addresses all comments
4. Final approval by designated approver
5. Quality Assurance releases document
### 4.3 Document Numbering
Documents shall be numbered according to the following convention:
| Type | Prefix | Example |
|------|--------|---------|
| Policy | POL | POL-001 |
| SOP | SOP | SOP-001 |
| Work Instruction | WI | WI-001 |
| Form | FRM | FRM-001 |
### 4.4 Revision Control
1. All changes require documented justification
2. Changes follow same review/approval process as new documents
3. Revision number increments with each approved change
4. Revision history maintained in document footer
### 4.5 Document Distribution
1. Current versions available in document control system
2. Obsolete versions marked and archived
3. Training on new/revised documents as needed
### 4.6 Periodic Review
1. Documents reviewed at least every 2 years
2. Review documented even if no changes made
3. Reviews may result in revision or reaffirmation
## 5. Related Documents
- FRM-001 Document Change Request Form
- FRM-002 Document Review Record
## 6. Definitions
| Term | Definition |
|------|------------|
| Controlled Document | Document managed under document control system |
| Obsolete | Document no longer valid for use |
| Revision | Updated version of a document |
---
## Revision History
| Rev | Date | Description | Author |
|-----|------|-------------|--------|
| 1.0 | [DATE] | Initial release | [AUTHOR] |

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# Standard Operating Procedure: Corrective and Preventive Action (CAPA)
| Document ID | SOP-002 |
|-------------|---------|
| Title | Corrective and Preventive Action |
| Revision | 1.0 |
| Effective Date | [DATE] |
| Author | [AUTHOR] |
| Approved By | [APPROVER] |
| Department | Quality Assurance |
---
## 1. Purpose
To establish a systematic process for identifying, investigating, correcting, and preventing nonconformities and potential nonconformities.
## 2. Scope
This procedure applies to:
- Product and process nonconformities
- Customer complaints
- Audit findings
- Process deviations
- Potential nonconformities identified through risk analysis
## 3. Definitions
| Term | Definition |
|------|------------|
| Corrective Action | Action to eliminate the cause of a detected nonconformity |
| Preventive Action | Action to eliminate the cause of a potential nonconformity |
| Root Cause | Fundamental reason for a nonconformity |
| Effectiveness Check | Verification that implemented actions achieved desired results |
## 4. Responsibilities
### 4.1 CAPA Owner
- Investigates the issue
- Identifies root cause
- Develops and implements corrective/preventive actions
- Verifies effectiveness
### 4.2 Quality Assurance
- Manages CAPA system
- Assigns CAPA numbers
- Tracks CAPA status
- Reviews and approves CAPAs
- Reports CAPA metrics to management
### 4.3 Management
- Provides resources for CAPA implementation
- Reviews CAPA trends
- Ensures timely closure
## 5. Procedure
### 5.1 CAPA Initiation
1. Identify nonconformity or potential nonconformity
2. Document issue on CAPA Form (FRM-003)
3. Classify severity and priority
4. Assign CAPA owner
### 5.2 Investigation
1. Gather relevant data and evidence
2. Interview personnel involved
3. Review related documents and records
4. Use appropriate investigation tools:
- 5 Whys
- Fishbone Diagram
- Failure Mode Analysis
### 5.3 Root Cause Analysis
1. Identify potential root causes
2. Verify root cause through evidence
3. Document root cause determination
4. Consider systemic implications
### 5.4 Action Development
1. Develop corrective/preventive actions
2. Assign responsibilities and due dates
3. Assess actions for:
- Appropriateness to problem severity
- Impact on other processes
- Resource requirements
### 5.5 Implementation
1. Execute approved actions
2. Document implementation evidence
3. Update affected documents/processes
4. Provide training as needed
### 5.6 Effectiveness Verification
1. Define effectiveness criteria
2. Allow sufficient time for actions to take effect
3. Collect and analyze data
4. Document verification results
5. If ineffective, reopen CAPA for further action
### 5.7 Closure
1. Review all CAPA documentation
2. Verify all actions completed
3. Confirm effectiveness verified
4. Obtain approval for closure
## 6. CAPA Metrics
Quality Assurance shall track and report:
- Number of open CAPAs
- CAPA aging
- On-time closure rate
- Effectiveness rate
- CAPAs by category/source
## 7. Related Documents
- FRM-003 CAPA Form
- SOP-003 Nonconforming Product Control
- SOP-004 Customer Complaints
---
## Revision History
| Rev | Date | Description | Author |
|-----|------|-------------|--------|
| 1.0 | [DATE] | Initial release | [AUTHOR] |

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# Standard Operating Procedure: Training and Competence
| Document ID | SOP-003 |
|-------------|---------|
| Title | Training and Competence |
| Revision | 1.0 |
| Effective Date | [DATE] |
| Author | [AUTHOR] |
| Approved By | [APPROVER] |
| Department | Human Resources / Quality |
---
## 1. Purpose
To ensure personnel performing work affecting product quality are competent based on appropriate education, training, skills, and experience.
## 2. Scope
This procedure applies to:
- All employees performing quality-affecting activities
- Contractors and temporary personnel
- Personnel requiring GxP training
## 3. Responsibilities
### 3.1 Supervisors/Managers
- Identify training needs for their personnel
- Ensure training is completed before performing tasks
- Evaluate competence of personnel
- Maintain department training records
### 3.2 Human Resources
- Coordinate training programs
- Maintain central training database
- Track training compliance
- Archive training records
### 3.3 Quality Assurance
- Develop QMS-related training
- Approve training curricula for GxP activities
- Audit training compliance
### 3.4 Employees
- Complete assigned training on time
- Maintain current qualifications
- Report training needs to supervisor
## 4. Procedure
### 4.1 Training Needs Assessment
1. Identify competence requirements for each role
2. Document requirements in job descriptions
3. Assess current competence of personnel
4. Identify training gaps
### 4.2 Training Curriculum Development
1. Define learning objectives
2. Develop training materials
3. Identify delivery method:
- Classroom
- On-the-job
- Self-study
- Computer-based
4. Define assessment criteria
5. Obtain approval from Quality (for GxP training)
### 4.3 Training Delivery
1. Schedule training session
2. Document attendance
3. Deliver training per curriculum
4. Assess comprehension through:
- Written test (minimum 80% passing)
- Practical demonstration
- Supervisor observation
### 4.4 Training Documentation
Training records shall include:
- Employee name and ID
- Training title and date
- Trainer name and qualifications
- Assessment results
- Signatures
### 4.5 Retraining Requirements
Retraining is required when:
- Significant document revisions occur
- Performance deficiencies identified
- Extended absence from job function
- Periodic requalification due
### 4.6 New Employee Orientation
All new employees shall complete:
1. Company orientation
2. Quality system overview
3. Job-specific training
4. SOP read and understand for applicable procedures
## 5. Training Records Retention
- Training records maintained for duration of employment
- Records retained 3 years after employee departure
- Records available for regulatory inspection
## 6. Related Documents
- FRM-004 Training Record Form
- FRM-005 Training Assessment Form
- Job Descriptions
---
## Revision History
| Rev | Date | Description | Author |
|-----|------|-------------|--------|
| 1.0 | [DATE] | Initial release | [AUTHOR] |

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# Standard Operating Procedure: Internal Audit
| Document ID | SOP-004 |
|-------------|---------|
| Title | Internal Audit |
| Revision | 1.0 |
| Effective Date | [DATE] |
| Author | [AUTHOR] |
| Approved By | [APPROVER] |
| Department | Quality Assurance |
---
## 1. Purpose
To establish a systematic approach for conducting internal audits to verify the effectiveness of the Quality Management System.
## 2. Scope
This procedure covers:
- QMS process audits
- Compliance audits
- Product audits
- System audits
## 3. Definitions
| Term | Definition |
|------|------------|
| Audit | Systematic, independent examination to determine conformance |
| Auditor | Person qualified to perform audits |
| Finding | Observation of conformance or nonconformance |
| Observation | Noted item not rising to level of finding |
## 4. Responsibilities
### 4.1 Lead Auditor
- Plans and schedules audits
- Prepares audit checklists
- Conducts audit activities
- Reports audit findings
### 4.2 Quality Manager
- Maintains audit program
- Qualifies auditors
- Reviews audit reports
- Reports to management
### 4.3 Auditee
- Provides access to areas/records
- Responds to findings
- Implements corrective actions
## 5. Procedure
### 5.1 Annual Audit Schedule
1. Develop annual audit schedule considering:
- Previous audit results
- Process criticality
- Regulatory requirements
- Changes to processes
2. Ensure all QMS processes audited at least annually
3. Obtain management approval
4. Communicate schedule to affected areas
### 5.2 Auditor Qualification
Auditors shall:
- Complete auditor training course
- Conduct at least 2 audits under supervision
- Be independent of area being audited
- Maintain competence through ongoing audits
### 5.3 Audit Preparation
1. Review applicable procedures and standards
2. Review previous audit reports
3. Prepare audit checklist
4. Notify auditee of audit scope and schedule
5. Confirm auditor availability
### 5.4 Conducting the Audit
1. Hold opening meeting with auditee
2. Execute audit checklist
3. Gather objective evidence:
- Document review
- Personnel interviews
- Process observation
4. Document findings with evidence
5. Classify findings:
- Major Nonconformance
- Minor Nonconformance
- Observation
6. Hold closing meeting
### 5.5 Audit Reporting
1. Complete audit report within 5 business days
2. Report shall include:
- Audit scope and criteria
- Personnel interviewed
- Findings with evidence
- Recommendations
3. Distribute report to auditee and management
### 5.6 Finding Resolution
1. Auditee responds with corrective action plan within 10 business days
2. Quality reviews and approves plan
3. Auditee implements corrective actions
4. Auditor verifies effectiveness
5. Close finding upon verification
## 6. Audit Records
Maintain for 5 years:
- Audit schedules
- Checklists
- Reports
- Corrective action records
## 7. Related Documents
- FRM-006 Audit Checklist Template
- FRM-007 Audit Report Template
- SOP-002 CAPA
---
## Revision History
| Rev | Date | Description | Author |
|-----|------|-------------|--------|
| 1.0 | [DATE] | Initial release | [AUTHOR] |

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# Standard Operating Procedure: Management Review
| Document ID | SOP-005 |
|-------------|---------|
| Title | Management Review |
| Revision | 1.0 |
| Effective Date | [DATE] |
| Author | [AUTHOR] |
| Approved By | [APPROVER] |
| Department | Quality Assurance |
---
## 1. Purpose
To ensure top management reviews the Quality Management System at planned intervals to ensure its continuing suitability, adequacy, and effectiveness.
## 2. Scope
This procedure applies to the periodic management review of the QMS, including all processes and quality objectives.
## 3. Frequency
Management reviews shall be conducted:
- At least annually
- More frequently if significant changes occur
- As needed based on quality performance
## 4. Responsibilities
### 4.1 Quality Manager
- Prepares management review agenda and materials
- Facilitates the meeting
- Documents meeting minutes and action items
- Tracks completion of action items
### 4.2 Top Management
- Attends management review meetings
- Reviews QMS performance data
- Makes decisions on QMS improvements
- Allocates resources as needed
### 4.3 Department Managers
- Provides input data for their areas
- Attends management review
- Implements assigned action items
## 5. Management Review Inputs
The following shall be considered:
### 5.1 Actions from Previous Reviews
- Status of action items
- Effectiveness of implemented actions
### 5.2 Changes in Context
- Internal changes (organization, resources)
- External changes (regulations, market)
### 5.3 QMS Performance
- Customer satisfaction and feedback
- Quality objectives achievement
- Process performance metrics
- Nonconformities and corrective actions
- Audit results
- Supplier performance
### 5.4 Resource Adequacy
- Personnel
- Infrastructure
- Work environment
### 5.5 Risk and Opportunities
- Risk assessment results
- Effectiveness of risk controls
- New opportunities identified
### 5.6 Improvement Opportunities
- Process improvements
- Product improvements
- QMS enhancements
## 6. Management Review Outputs
Decisions and actions related to:
- Improvement of QMS and processes
- Product improvement
- Resource needs
- Changes to quality policy or objectives
## 7. Documentation
### 7.1 Meeting Minutes
- Date and attendees
- Items discussed
- Decisions made
- Action items with owners and due dates
### 7.2 Record Retention
- Management review records retained for 5 years
- Available for regulatory inspection
## 8. Related Documents
- FRM-008 Management Review Agenda Template
- FRM-009 Management Review Minutes Template
---
## Revision History
| Rev | Date | Description | Author |
|-----|------|-------------|--------|
| 1.0 | [DATE] | Initial release | [AUTHOR] |

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# Standard Operating Procedure: Pathology Specimen Accessioning
| Document ID | SOP-PATH-001 |
|-------------|-------------|
| Title | Pathology Specimen Accessioning and Processing |
| Revision | 1.0 |
| Effective Date | [DATE] |
| Author | [AUTHOR] |
| Approved By | [APPROVER] |
| Department | Anatomic Pathology |
---
## 1. Purpose
To establish standardized procedures for the receipt, accessioning, and initial processing of pathology specimens to ensure proper identification, optimal preservation, and regulatory compliance.
## 2. Scope
This procedure applies to all anatomic pathology specimens including:
- Surgical pathology specimens
- Cytology specimens
- Skin biopsies
- Bone marrow biopsies
- Autopsy specimens
## 3. Responsibilities
### 3.1 Accessioning Staff
- Receive and log specimens
- Verify specimen-requisition match
- Assign case numbers
- Distribute to appropriate areas
### 3.2 Histology Technician
- Process tissue specimens
- Embed and section specimens
- Prepare slides for pathologist review
### 3.3 Pathologist
- Perform gross examination
- Dictate gross description
- Review slides and render diagnosis
### 3.4 Laboratory Director
- Ensure quality standards
- Review policies and procedures
- Oversee accreditation compliance
## 4. Definitions
| Term | Definition |
|------|------------|
| Accession | Process of receiving and logging specimens |
| Fixation | Chemical preservation of tissue |
| Grossing | Macroscopic examination and description |
| Cassette | Container for tissue during processing |
| Block | Paraffin-embedded tissue section |
## 5. Equipment and Materials
- Specimen containers (various sizes)
- 10% neutral buffered formalin (NBF)
- Requisition forms
- Barcoded labels
- Cassettes
- Tissue processor
- Embedding station
- Microtome
- Slides and coverslips
## 6. Procedure
### 6.1 Specimen Receipt
#### 6.1.1 Verification at Receipt
Upon receiving each specimen:
- [ ] Container properly labeled with patient identifiers
- [ ] Requisition form accompanies specimen
- [ ] Container intact without leakage
- [ ] Specimen in appropriate fixative (if applicable)
- [ ] Time of collection documented
#### 6.1.2 Label Verification
**Minimum required on container:**
| Element | Present |
|---------|---------|
| Patient name | ☐ |
| Second identifier (MRN, DOB) | ☐ |
| Specimen type/site | ☐ |
| Date of collection | ☐ |
| Collector identification | ☐ |
**Requisition must include:**
| Element | Present |
|---------|---------|
| Patient name and identifiers | ☐ |
| Ordering physician | ☐ |
| Specimen source/site | ☐ |
| Clinical history | ☐ |
| Date/time of collection | ☐ |
| Date/time of receipt in lab | ☐ |
#### 6.1.3 Discrepancy Handling
If discrepancies exist:
1. Do NOT accessioned until resolved
2. Contact ordering physician/collector
3. Document resolution in LIS
4. Complete discrepancy log
| Discrepancy Type | Required Action |
|------------------|-----------------|
| Name mismatch | Contact collector, do not process |
| Missing information | Request completion before accessioning |
| Damaged container | Document, assess specimen integrity |
| No requisition | Hold specimen, request requisition |
| Unlabeled specimen | Do not process until properly labeled |
### 6.2 Accessioning
#### 6.2.1 Case Number Assignment
1. Log specimen into Laboratory Information System (LIS)
2. System assigns unique accession number
3. Format: [Year]-S[Sequential#] (e.g., 2024-S12345)
4. Generate specimen labels
#### 6.2.2 Labeling
1. Apply barcoded labels to:
- Specimen container
- Cassettes
- All associated paperwork
2. Verify label matches requisition
3. Apply orientation labels if applicable
#### 6.2.3 Specimen Categorization
| Category | Description | Priority |
|----------|-------------|----------|
| Routine | Standard turnaround | 2-3 days |
| Rush | Expedited processing | 24-48 hours |
| STAT | Emergency | Same day |
| Intraoperative | Frozen section | Immediate |
### 6.3 Fixation Assessment
#### 6.3.1 Optimal Fixation Times
| Specimen Type | Minimum | Optimal | Maximum |
|---------------|---------|---------|---------|
| Small biopsy (≤5mm) | 6 hours | 6-12 hours | 24 hours |
| Medium tissue (5-15mm) | 12 hours | 12-24 hours | 48 hours |
| Large specimen (>15mm) | 24 hours | 24-48 hours | 72 hours |
#### 6.3.2 Fixative Requirements
- Standard: 10% neutral buffered formalin (10:1 ratio)
- Breast tissue for biomarkers: Cold ischemia <1 hour, fixed within 1 hour
- Special fixatives per protocol (e.g., Bouin's, B5)
Document:
- Time of collection (if available)
- Time of receipt in fixative
- Time placed in processor
### 6.4 Gross Examination (Grossing)
#### 6.4.1 Pre-Grossing Preparation
1. Verify specimen identity
2. Review clinical history and prior pathology
3. Gather appropriate supplies
4. Photograph specimen (if indicated)
#### 6.4.2 Gross Description Components
**Standard elements:**
- [ ] Specimen type and site
- [ ] How received (container, fixative)
- [ ] Dimensions (3 measurements)
- [ ] Weight (if applicable)
- [ ] External appearance
- [ ] Cut surface appearance
- [ ] Lesion description (size, location, margins)
- [ ] Sections submitted summary
**For resection specimens:**
- [ ] Orientation (sutures, clips, inks)
- [ ] Margin assessment
- [ ] Lymph node identification
- [ ] Relationship of lesion to margins
#### 6.4.3 Inking Protocol
| Color | Common Usage |
|-------|--------------|
| Black | Anterior/superficial |
| Blue | Posterior/deep |
| Green | Superior |
| Orange | Inferior |
| Red | Medial |
| Yellow | Lateral |
Document inking scheme in gross description.
#### 6.4.4 Section Submission
| Specimen Type | Standard Sections |
|---------------|-------------------|
| Small biopsy | Entire specimen |
| Skin ellipse | 3mm cross-sections, all margins |
| Breast lumpectomy | Lesion, margins (6 directions), representative |
| Colon resection | Tumor (4 sections), margins, nodes, mucosa |
### 6.5 Tissue Processing
#### 6.5.1 Processing Steps
1. Dehydration (graded alcohols)
2. Clearing (xylene)
3. Infiltration (paraffin)
4. Total processing time: 8-14 hours
#### 6.5.2 Processing Schedules
| Schedule | Duration | Specimen Types |
|----------|----------|----------------|
| Routine overnight | 12-14 hours | Standard specimens |
| Extended | 16-20 hours | Fatty tissue, large specimens |
| Rapid | 2-4 hours | Urgent specimens |
| Rush microwave | 1-2 hours | STAT specimens |
### 6.6 Embedding
1. Orient tissue in cassette per protocol
2. Embed in paraffin at 60°C
3. Cool on cold plate
4. Verify block identity
### 6.7 Microtomy
1. Face block until full tissue visible
2. Cut at specified thickness (typically 4-5 µm)
3. Float sections on warm water bath
4. Pick up on labeled slide
5. Dry slides before staining
### 6.8 Slide Preparation
1. H&E staining (routine)
2. Special stains per request/protocol
3. Immunohistochemistry as ordered
4. Coverslip slides
5. Verify slide-block-patient match
## 7. Quality Control
### 7.1 Daily QC
- [ ] Reagent checks
- [ ] Processor function verification
- [ ] Temperature monitoring
- [ ] Staining controls
### 7.2 Specimen Quality Metrics
| Metric | Target |
|--------|--------|
| Specimen rejection rate | <2% |
| Accessioning errors | <0.5% |
| Lost specimens | 0 |
| Turnaround time (routine) | ≤48 hours |
| Block/slide discrepancies | <0.1% |
## 8. Documentation
- FRM-PATH-001 Specimen Receipt Log
- FRM-PATH-002 Gross Description Template
- FRM-PATH-003 Processing Log
- Discrepancy reports
- QC logs
## 9. References
- CAP Laboratory Accreditation Checklist
- ASCO/CAP Guidelines for Biomarker Testing
- CLIA regulations
- Institutional policies
---
## Revision History
| Rev | Date | Description | Author |
|-----|------|-------------|--------|
| 1.0 | [DATE] | Initial release | [AUTHOR] |

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# Standard Operating Procedure: [Title]
| Document ID | SOP-XXX |
|-------------|---------|
| Title | [Title] |
| Revision | 1.0 |
| Effective Date | [DATE] |
| Author | [AUTHOR] |
| Approved By | [APPROVER] |
| Department | [DEPARTMENT] |
---
## 1. Purpose
[State the purpose of this procedure]
## 2. Scope
[Define the scope and applicability]
## 3. Responsibilities
### 3.1 [Role 1]
- [Responsibility]
- [Responsibility]
### 3.2 [Role 2]
- [Responsibility]
- [Responsibility]
## 4. Definitions
| Term | Definition |
|------|------------|
| | |
## 5. Procedure
### 5.1 [Section Title]
[Procedure steps]
### 5.2 [Section Title]
[Procedure steps]
## 6. Related Documents
- [List related procedures, forms, etc.]
## 7. References
- [External standards, regulations, etc.]
---
## Revision History
| Rev | Date | Description | Author |
|-----|------|-------------|--------|
| 1.0 | [DATE] | Initial release | [AUTHOR] |

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# Work Instruction: [Title]
| Document ID | WI-001 |
|-------------|--------|
| Title | [Title] |
| Revision | 1.0 |
| Effective Date | [DATE] |
| Author | [AUTHOR] |
| Approved By | [APPROVER] |
| Department | [DEPARTMENT] |
---
## 1. Purpose
[Describe the purpose of this work instruction]
## 2. Scope
[Define what activities this instruction covers]
## 3. Safety Precautions
- [List any safety requirements]
- [Personal protective equipment needed]
- [Hazards to be aware of]
## 4. Equipment/Materials Required
| Item | Specification |
|------|---------------|
| | |
| | |
## 5. Procedure
### Step 1: [Title]
[Detailed instructions]
### Step 2: [Title]
[Detailed instructions]
### Step 3: [Title]
[Detailed instructions]
## 6. Acceptance Criteria
[Define what constitutes successful completion]
## 7. Records
| Record | Location | Retention |
|--------|----------|-----------|
| | | |
## 8. References
- [Related SOPs]
- [Specifications]
- [Standards]
---
## Revision History
| Rev | Date | Description | Author |
|-----|------|-------------|--------|
| 1.0 | [DATE] | Initial release | [AUTHOR] |