Sync template from atomicqms-style deployment
This commit is contained in:
79
.gitea/workflows/atomicai.yml
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79
.gitea/workflows/atomicai.yml
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name: AtomicAI Pathology Assistant
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on:
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issue_comment:
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types: [created]
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issues:
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types: [opened, assigned]
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pull_request:
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types: [opened, synchronize, assigned]
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pull_request_review_comment:
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types: [created]
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jobs:
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claude-assistant:
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runs-on: ubuntu-latest
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if: |
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github.actor != 'atomicqms-service' &&
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(
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(github.event_name == 'issue_comment' && contains(github.event.comment.body, '@atomicai') && github.event.comment.user.login != 'atomicqms-service') ||
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(github.event_name == 'issues' && github.event.action == 'opened' && contains(github.event.issue.body, '@atomicai')) ||
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(github.event_name == 'pull_request' && github.event.action == 'opened' && contains(github.event.pull_request.body, '@atomicai')) ||
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(github.event_name == 'pull_request_review_comment' && contains(github.event.comment.body, '@atomicai') && github.event.comment.user.login != 'atomicqms-service') ||
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(github.event.action == 'assigned' && github.event.assignee.login == 'atomicai')
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)
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permissions:
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contents: write
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issues: write
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pull-requests: write
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steps:
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- uses: actions/checkout@v4
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with:
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fetch-depth: 0
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- name: Run AtomicAI Pathology Assistant
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uses: https://beta.atomicqms.com/atomicqms-service/actions/claude-code-gitea-action-slim@main
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with:
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trigger_phrase: '@atomicai'
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assignee_trigger: 'atomicai'
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claude_git_name: 'AtomicAI'
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claude_git_email: 'atomicai@atomicqms.local'
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custom_instructions: |
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You are AtomicAI, an AI assistant specialized in Pathology and Anatomic Pathology Quality Management.
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## Your Expertise
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- CAP (College of American Pathologists) accreditation
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- CLIA laboratory standards
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- Surgical pathology specimen handling
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- Histology and tissue processing
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- Immunohistochemistry protocols
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- Cytology and FNA procedures
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- Autopsy protocols and procedures
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- Frozen section procedures
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- Specimen identification and tracking
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- Quality assurance and peer review
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- Critical diagnosis communication
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- Digital pathology and whole slide imaging
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## Document Creation Guidelines
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- Place Surgical Path SOPs in SOPs/Surgical-Pathology/
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- Place Histology SOPs in SOPs/Histology/
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- Place Cytology SOPs in SOPs/Cytology/
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- Place QA Forms in Forms/Quality-Assurance/
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- Place Specimen Forms in Forms/Specimen/
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- Place Policies in Policies/
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## Numbering Convention
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- SOP-SP-XXX for Surgical Pathology SOPs
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- SOP-HIS-XXX for Histology SOPs
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- SOP-CYT-XXX for Cytology SOPs
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- SOP-AUT-XXX for Autopsy SOPs
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- POL-XXX for Policies
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- FRM-XXX for Forms
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Always create branches and submit changes as Pull Requests for review.
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Prioritize specimen integrity, diagnostic accuracy, and turnaround time.
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allowed_tools: 'Read,Edit,Grep,Glob,Write'
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disallowed_tools: 'Bash,WebSearch'
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0
Forms/Competency/.gitkeep
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0
Forms/Competency/.gitkeep
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64
Forms/FRM-001-Document-Change-Request.md
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64
Forms/FRM-001-Document-Change-Request.md
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# Document Change Request Form
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| Form ID | FRM-001 | Revision | 1.0 |
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|---------|---------|----------|-----|
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---
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## Section 1: Request Information
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| Field | Entry |
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|-------|-------|
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| Request Date | |
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| Requested By | |
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| Department | |
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## Section 2: Document Information
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| Field | Entry |
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|-------|-------|
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| Document Number | |
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| Document Title | |
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| Current Revision | |
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## Section 3: Change Description
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### Type of Change
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- [ ] New Document
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- [ ] Revision to Existing Document
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- [ ] Document Obsolescence
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### Description of Change
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*(Describe the proposed change in detail)*
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### Reason for Change
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*(Explain why this change is needed)*
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## Section 4: Impact Assessment
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### Affected Areas
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- [ ] Training Required
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- [ ] Other Documents Affected
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- [ ] Process Changes Required
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- [ ] Validation Impact
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### List Affected Documents
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## Section 5: Approvals
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| Role | Name | Signature | Date |
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|------|------|-----------|------|
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| Requester | | | |
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| Document Owner | | | |
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| Quality Assurance | | | |
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---
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*Form FRM-001 Rev 1.0*
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91
Forms/FRM-003-CAPA-Form.md
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91
Forms/FRM-003-CAPA-Form.md
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# Corrective and Preventive Action (CAPA) Form
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| Form ID | FRM-003 | Revision | 1.0 |
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|---------|---------|----------|-----|
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---
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## Section 1: CAPA Identification
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| Field | Entry |
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|-------|-------|
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| CAPA Number | |
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| Date Initiated | |
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| Initiated By | |
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| CAPA Owner | |
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| Target Closure Date | |
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## Section 2: Classification
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### Type
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- [ ] Corrective Action
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- [ ] Preventive Action
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### Source
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- [ ] Customer Complaint
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- [ ] Internal Audit
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- [ ] External Audit
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- [ ] Process Deviation
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- [ ] Nonconforming Product
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- [ ] Management Review
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- [ ] Other: ____________
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### Priority
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- [ ] Critical (5 business days)
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- [ ] Major (15 business days)
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- [ ] Minor (30 business days)
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## Section 3: Problem Description
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*(Describe the nonconformity or potential nonconformity)*
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## Section 4: Immediate Containment
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*(Actions taken to contain the immediate impact)*
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## Section 5: Root Cause Investigation
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### Investigation Method Used
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- [ ] 5 Whys
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- [ ] Fishbone Diagram
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- [ ] Fault Tree Analysis
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- [ ] Other: ____________
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### Root Cause Determination
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## Section 6: Corrective/Preventive Actions
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| Action | Responsible | Due Date | Status |
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|--------|-------------|----------|--------|
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| | | | |
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| | | | |
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| | | | |
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## Section 7: Effectiveness Verification
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| Criteria | Method | Result |
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|----------|--------|--------|
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| | | |
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Verification Date: ____________
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Verified By: ____________
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## Section 8: Closure
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| Role | Name | Signature | Date |
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|------|------|-----------|------|
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| CAPA Owner | | | |
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| Quality Approval | | | |
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---
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*Form FRM-003 Rev 1.0*
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56
Forms/FRM-006-Audit-Checklist.md
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56
Forms/FRM-006-Audit-Checklist.md
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# Internal Audit Checklist
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| Form ID | FRM-006 | Revision | 1.0 |
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|---------|---------|----------|-----|
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---
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## Audit Information
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| Field | Entry |
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|-------|-------|
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| Audit Number | |
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| Audit Date | |
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| Area/Process Audited | |
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| Lead Auditor | |
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| Auditee(s) | |
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---
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## Checklist Items
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| # | Requirement/Question | Reference | C/NC/NA | Evidence/Notes |
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|---|---------------------|-----------|---------|----------------|
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| 1 | Are current versions of applicable procedures available? | SOP-001 | | |
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| 2 | Are personnel trained on applicable procedures? | SOP-003 | | |
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| 3 | Are training records current and complete? | SOP-003 | | |
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| 4 | Are records properly maintained and retrievable? | SOP-001 | | |
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| 5 | Are nonconformities being documented and addressed? | SOP-002 | | |
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| 6 | Are CAPAs being completed on time? | SOP-002 | | |
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| 7 | Is equipment calibrated and maintained? | | | |
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| 8 | Are process controls being followed? | | | |
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| 9 | Are quality objectives being monitored? | | | |
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| 10 | | | | |
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**Legend:** C = Conforming, NC = Nonconforming, NA = Not Applicable
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---
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## Findings Summary
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| Finding # | Type | Description | Clause Reference |
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|-----------|------|-------------|------------------|
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| | | | |
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| | | | |
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---
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## Auditor Signature
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| Auditor | Signature | Date |
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|---------|-----------|------|
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| | | |
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---
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*Form FRM-006 Rev 1.0*
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0
Forms/Grossing-Templates/.gitkeep
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0
Forms/Grossing-Templates/.gitkeep
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0
Forms/Incident-Reports/.gitkeep
Normal file
0
Forms/Incident-Reports/.gitkeep
Normal file
0
Forms/QC-Records/.gitkeep
Normal file
0
Forms/QC-Records/.gitkeep
Normal file
0
Forms/Report-Templates/.gitkeep
Normal file
0
Forms/Report-Templates/.gitkeep
Normal file
0
Forms/Requisition-Forms/.gitkeep
Normal file
0
Forms/Requisition-Forms/.gitkeep
Normal file
196
Forms/Specimen-Tracking/FRM-PATH-001-Specimen-Receipt-Log.md
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196
Forms/Specimen-Tracking/FRM-PATH-001-Specimen-Receipt-Log.md
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# Specimen Receipt Log
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| Form ID | FRM-PATH-001 | Revision | 1.0 |
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|---------|-------------|----------|-----|
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---
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## Log Information
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| Field | Entry |
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|-------|-------|
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| Date | |
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| Shift | ☐ Day ☐ Evening ☐ Night |
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| Accessioning Technician | |
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| Technician ID | |
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---
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## Specimen Receipt Record
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### Specimen 1
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| Field | Entry |
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|-------|-------|
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| Time Received | |
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| Received From | ☐ OR ☐ Clinic ☐ Courier ☐ Transport ☐ Other: |
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| Accession Number | |
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| Patient Name | |
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| MRN | |
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| DOB | |
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| Specimen Type | |
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| Specimen Site | |
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| Number of Containers | |
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| Fixative | ☐ Formalin ☐ Fresh ☐ Other: |
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| Collection Date/Time | |
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| Container Labeled Correctly? | ☐ Yes ☐ No |
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| Requisition Complete? | ☐ Yes ☐ No |
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| Specimen Condition | ☐ Acceptable ☐ Compromised (see notes) |
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| Priority | ☐ Routine ☐ Rush ☐ STAT |
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| Discrepancy? | ☐ No ☐ Yes (Resolution: _______) |
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| Received By (Initials) | |
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### Specimen 2
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| Field | Entry |
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|-------|-------|
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| Time Received | |
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| Received From | ☐ OR ☐ Clinic ☐ Courier ☐ Transport ☐ Other: |
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| Accession Number | |
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| Patient Name | |
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| MRN | |
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| DOB | |
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| Specimen Type | |
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| Specimen Site | |
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| Number of Containers | |
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| Fixative | ☐ Formalin ☐ Fresh ☐ Other: |
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| Collection Date/Time | |
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| Container Labeled Correctly? | ☐ Yes ☐ No |
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| Requisition Complete? | ☐ Yes ☐ No |
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| Specimen Condition | ☐ Acceptable ☐ Compromised (see notes) |
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| Priority | ☐ Routine ☐ Rush ☐ STAT |
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| Discrepancy? | ☐ No ☐ Yes (Resolution: _______) |
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| Received By (Initials) | |
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### Specimen 3
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| Field | Entry |
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|-------|-------|
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| Time Received | |
|
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| Received From | ☐ OR ☐ Clinic ☐ Courier ☐ Transport ☐ Other: |
|
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| Accession Number | |
|
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| Patient Name | |
|
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| MRN | |
|
||||
| DOB | |
|
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| 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*
|
||||
72
Forms/Training/FRM-004-Training-Record.md
Normal file
72
Forms/Training/FRM-004-Training-Record.md
Normal file
@@ -0,0 +1,72 @@
|
||||
# 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*
|
||||
57
Policies/POL-001-Quality-Policy.md
Normal file
57
Policies/POL-001-Quality-Policy.md
Normal file
@@ -0,0 +1,57 @@
|
||||
# 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] |
|
||||
134
README.md
134
README.md
@@ -1,3 +1,133 @@
|
||||
# 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.*
|
||||
|
||||
0
SOPs/Autopsy/.gitkeep
Normal file
0
SOPs/Autopsy/.gitkeep
Normal file
0
SOPs/Cytology/.gitkeep
Normal file
0
SOPs/Cytology/.gitkeep
Normal file
112
SOPs/General/SOP-001-Document-Control.md
Normal file
112
SOPs/General/SOP-001-Document-Control.md
Normal file
@@ -0,0 +1,112 @@
|
||||
# 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] |
|
||||
134
SOPs/General/SOP-002-CAPA.md
Normal file
134
SOPs/General/SOP-002-CAPA.md
Normal file
@@ -0,0 +1,134 @@
|
||||
# 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] |
|
||||
123
SOPs/General/SOP-003-Training.md
Normal file
123
SOPs/General/SOP-003-Training.md
Normal file
@@ -0,0 +1,123 @@
|
||||
# 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] |
|
||||
136
SOPs/General/SOP-004-Internal-Audit.md
Normal file
136
SOPs/General/SOP-004-Internal-Audit.md
Normal file
@@ -0,0 +1,136 @@
|
||||
# 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] |
|
||||
114
SOPs/General/SOP-005-Management-Review.md
Normal file
114
SOPs/General/SOP-005-Management-Review.md
Normal file
@@ -0,0 +1,114 @@
|
||||
# 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] |
|
||||
0
SOPs/Histology/.gitkeep
Normal file
0
SOPs/Histology/.gitkeep
Normal file
0
SOPs/Molecular/.gitkeep
Normal file
0
SOPs/Molecular/.gitkeep
Normal file
1
SOPs/Safety/.gitkeep
Normal file
1
SOPs/Safety/.gitkeep
Normal file
@@ -0,0 +1 @@
|
||||
# Placeholder
|
||||
0
SOPs/Specimen-Handling/.gitkeep
Normal file
0
SOPs/Specimen-Handling/.gitkeep
Normal file
293
SOPs/Specimen-Handling/SOP-PATH-001-Specimen-Accessioning.md
Normal file
293
SOPs/Specimen-Handling/SOP-PATH-001-Specimen-Accessioning.md
Normal file
@@ -0,0 +1,293 @@
|
||||
# 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] |
|
||||
62
Templates/SOP-Template.md
Normal file
62
Templates/SOP-Template.md
Normal file
@@ -0,0 +1,62 @@
|
||||
# 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] |
|
||||
68
Work Instructions/WI-001-Template.md
Normal file
68
Work Instructions/WI-001-Template.md
Normal file
@@ -0,0 +1,68 @@
|
||||
# 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] |
|
||||
Reference in New Lab Ticket
Block a user