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CAP Home > CAP Accreditation and Laboratory Improvement > Procedure Manual Review

  Revised Checklist Question


Posted April 7, 2011

Review of New Policies and Procedures     Phase II

The director reviews and approves all new policies and procedures, as well as substantial changes to existing documents, before implementation.

Note: Current practice must match the policy and procedure documents.

This change is in alignment with 42CFR493.1251(d), Code of Federal Register. Centers for Medicare and Medicaid Services, which states: “Procedures and changes in procedures must be approved, signed, and dated by the current laboratory director before use”, the director whose name is on the CLIA certification must perform the task.




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