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F-QM-002-B-V0 — Master Document Register, Retention Schedule, and Staff Reading Acknowledgment

Type: Form · Version: V0 · Status: DRAFT — UNAPPROVED · Served read-only from the bundled QMS copies. The Drive master is untouched.

Parent document: LAB-QM-002 — Document Control Policy (parent is encoded in the form number)

Rendered in-browser from the project's Word file F-QM-002-B-V0-master-document-and-records-control-register.docx (policies-docx / forms-docx — the file Junry reviews). Formatting is faithful, not pixel-perfect; the DOCX is the official copy.

Document #	F-QM-002-B-V0	Parent Document	LAB-QM-002 — Document Control Policy

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Part 1 — Controlled Policies & Standard Operating Procedures Master Register

Maintained by the Chief Medical Technologist / Laboratory Quality Manager as the master inventory of all 37 contiguous active policies and technical SOPs:

Document No.	Document Title	Section / Discipline	Current Ver.	Effective Date	Next Review Date	Author / Owner	Primary Controlled Storage Location	Status
LAB-QM-001	Quality Management Manual	General QM	V0	MM-DD-YYYY	Annual	Chief Med Tech	Master Quality Binder / Lab Drive	Active (Draft)
LAB-QM-002	Document Control Policy	General QM	V0	MM-DD-YYYY	Annual	Chief Med Tech	Master Quality Binder / Lab Drive	Active (Draft)
LAB-QM-003	Continual Improvement and Performance Improvement Program Policy	General QM	V0	MM-DD-YYYY	Annual	Chief Med Tech	Master Quality Binder / Lab Drive	Active (Draft)
LAB-QM-004	Scope of Service and Laboratory User Information Policy	General QM	V0	MM-DD-YYYY	Annual	Chief Med Tech	Master Quality Binder / Lab Drive	Active (Draft)
LAB-QM-005	Confidentiality Policy	General QM	V0	MM-DD-YYYY	Annual	Chief Med Tech	Master Quality Binder / Lab Drive	Active (Draft)
LAB-QM-006	Internal Laboratory Rules and Regulations Policy	General QM	V0	MM-DD-YYYY	Annual	Chief Med Tech	Master Quality Binder / Lab Drive	Active (Draft)
LAB-QM-007	Control of Records	General QM	V0	MM-DD-YYYY	Annual	Chief Med Tech	Master Quality Binder / Lab Drive	Active (Draft)
LAB-QM-008	Organization and Governance	General QM	V0	MM-DD-YYYY	Annual	Chief Med Tech	Master Quality Binder / Lab Drive	Active (Draft)
LAB-QM-009	Risk Management	General QM	V0	MM-DD-YYYY	Annual	Chief Med Tech	Master Quality Binder / Lab Drive	Active (Draft)
LAB-QM-010	Occurrence Management Policy	General QM	V0	MM-DD-YYYY	Annual	Chief Med Tech	Master Quality Binder / Lab Drive	Active (Draft)
LAB-QM-011	Corrective and Preventive Action Policy	General QM	V0	MM-DD-YYYY	Annual	Chief Med Tech	Master Quality Binder / Lab Drive	Active (Draft)
LAB-QM-012	Internal Audit	General QM	V0	MM-DD-YYYY	Annual	Chief Med Tech	Master Quality Binder / Lab Drive	Active (Draft)
LAB-QM-013	Management Review	General QM	V0	MM-DD-YYYY	Annual	Chief Med Tech	Master Quality Binder / Lab Drive	Active (Draft)
LAB-QM-PRE-001	Specimen Collection Policy	Pre-Analytic	V0	MM-DD-YYYY	Annual	Chief Med Tech	Specimen Receiving / Lab Drive	Active (Draft)
LAB-QM-PRE-002	Referral Laboratory Policy	Pre-Analytic	V0	MM-DD-YYYY	Annual	Chief Med Tech	Specimen Receiving / Lab Drive	Active (Draft)
LAB-QM-PRE-003	Specimen Handling, Packaging and Transportation Policy	Pre-Analytic	V0	MM-DD-YYYY	Annual	Chief Med Tech	Specimen Receiving / Lab Drive	Active (Draft)
LAB-QM-ANA-001	Quality Control Policy	Analytic	V0	MM-DD-YYYY	Annual	Chief Med Tech	Testing Benches / Lab Drive	Active (Draft)
LAB-QM-ANA-002	Reagent Management Policy	Analytic	V0	MM-DD-YYYY	Annual	Chief Med Tech	Testing Benches / Lab Drive	Active (Draft)
LAB-QM-ANA-003	Method Validation Policy	Analytic	V0	MM-DD-YYYY	Annual	Chief Med Tech	Testing Benches / Lab Drive	Active (Draft)
LAB-QM-ANA-004	Proficiency Testing Policy	Analytic	V0	MM-DD-YYYY	Annual	Chief Med Tech	Testing Benches / Lab Drive	Active (Draft)
LAB-QM-ANA-005	Equipment and Temperature Monitoring Policy	Analytic	V0	MM-DD-YYYY	Annual	Chief Med Tech	Testing Benches / Lab Drive	Active (Draft)
LAB-QM-ANA-006	Calibration and Verification of Ancillary Measuring Devices and Labware Policy	Analytic	V0	MM-DD-YYYY	Annual	Chief Med Tech	Testing Benches / Lab Drive	Active (Draft)
LAB-QM-ANA-007	Purchasing, Receipt and External Provider Management Policy	Analytic	V0	MM-DD-YYYY	Annual	Chief Med Tech	Testing Benches / Lab Drive	Active (Draft)
LAB-QM-POST-001	Laboratory Reporting Policy	Post-Analytic	V0	MM-DD-YYYY	Annual	Chief Med Tech	Result Releasing / Lab Drive	Active (Draft)
LAB-QM-POST-002	Reporting Critical Values Policy	Post-Analytic	V0	MM-DD-YYYY	Annual	Chief Med Tech	Result Releasing / Lab Drive	Active (Draft)
LAB-QM-POST-003	Turnaround Time and STAT Testing Policy	Post-Analytic	V0	MM-DD-YYYY	Annual	Chief Med Tech	Result Releasing / Lab Drive	Active (Draft)
LAB-QM-POST-004	Laboratory Retention Schedule Policy	Post-Analytic	V0	MM-DD-YYYY	Annual	Chief Med Tech	Result Releasing / Lab Drive	Active (Draft)
LAB-QM-POC-001	Point-of-Care Testing Policy	POCT	V0	MM-DD-YYYY	Annual	Chief Med Tech	POCT Sites / Lab Drive	Active (Draft)
LAB-QM-HR-001	Orientation Policy	Human Resources	V0	MM-DD-YYYY	Annual	Chief Med Tech	Personnel File / Lab Office	Active (Draft)
LAB-QM-HR-002	Competency Assessment Policy	Human Resources	V0	MM-DD-YYYY	Annual	Chief Med Tech	Personnel File / Lab Office	Active (Draft)
LAB-QM-HR-003	Recruitment, Qualification and Appointment Policy	Human Resources	V0	MM-DD-YYYY	Annual	Chief Med Tech	Personnel File / Lab Office	Active (Draft)
LAB-QM-HR-004	Personnel Records Policy	Human Resources	V0	MM-DD-YYYY	Annual	Chief Med Tech	Personnel File / Lab Office	Active (Draft)
LAB-QM-SAF-001	Laboratory Safety Policy	Safety & Biorisk	V0	MM-DD-YYYY	Annual	Chief Med Tech	Safety Station / Lab Drive	Active (Draft)
LAB-QM-SAF-002	Facilities and Environmental Conditions	Safety & Biorisk	V0	MM-DD-YYYY	Annual	Chief Med Tech	Safety Station / Lab Drive	Active (Draft)
LAB-QM-IC-001	Hand Hygiene and Infection Control Policy	Infection Control	V0	MM-DD-YYYY	Annual	Chief Med Tech	IPC Station / Lab Drive	Active (Draft)
LAB-QM-IT-001	Laboratory Information Management and Security Policy	Information Tech	V0	MM-DD-YYYY	Annual	Chief Med Tech	IT Office / Lab Drive	Active (Draft)
LAB-QM-IT-002	Computer and Power Downtime and Disaster Recovery Plan	Information Tech	V0	MM-DD-YYYY	Annual	Chief Med Tech	IT Office / Lab Drive	Active (Draft)
SOP-P-001	Phlebotomy Section Reception, Unacceptable Specimen Management, and Adverse Reaction First Aid SOP	Phlebotomy SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Phlebotomy Station / Lab Drive	Active (Draft)
SOP-P-002	Adult and Pediatric Venipuncture Procedure SOP	Phlebotomy SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Phlebotomy Station / Lab Drive	Active (Draft)
SOP-P-003	Capillary (Skin Puncture) and Neonatal Heel-Stick Blood Collection Procedure SOP	Phlebotomy SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Phlebotomy Station / Lab Drive	Active (Draft)
SOP-H-001	Hematology Section Workflow, Quality Control, Interference Management, and Result Validation SOP	Hematology SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Hematology Bench / Lab Drive	Active (Draft)
SOP-H-002	HORIBA ABX Pentra XL 80 Complete Blood Count (CBC), 5-Part Differential, and Analyzer Maintenance SOP	Hematology SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Hematology Bench / Lab Drive	Active (Draft)
SOP-H-003	Peripheral Blood Smear Preparation, Wright-Giemsa Staining, Manual Differential, and Reticulocyte Count SOP	Hematology SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Hematology Bench / Lab Drive	Active (Draft)
SOP-H-004	Erythrocyte Sedimentation Rate (ESR — Modified Westergren Method) SOP	Hematology SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Hematology Bench / Lab Drive	Active (Draft)
SOP-H-005	ABO and Rh(D) Blood Typing (Slide and Tube Method) SOP	Hematology SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Hematology Bench / Lab Drive	Active (Draft)
SOP-H-006	Bleeding Time and Clotting Time (Capillary and Slide Method) Procedure SOP	Hematology SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Hematology Bench / Lab Drive	Active (Draft)
SOP-S-001	Serology Section Workflow, Specimen Processing, Quality Control, and Result Reporting SOP	Serology SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Serology Bench / Lab Drive	Active (Draft)
SOP-S-002	Hepatitis B Surface Antigen (HBsAg) Rapid Qualitative Immunoassay and Confirmatory Referral SOP	Serology SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Serology Bench / Lab Drive	Active (Draft)
SOP-S-003	Syphilis Rapid Qualitative Treponemal Antibody and RPR Screening Procedure SOP	Serology SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Serology Bench / Lab Drive	Active (Draft)
SOP-S-004	Dengue Duo (NS1 Ag and IgM/IgG) and Salmonella typhi (IgM/IgG) Rapid Immunoassay SOP	Serology SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Serology Bench / Lab Drive	Active (Draft)
SOP-S-005	Serum Qualitative Beta-hCG Pregnancy Test SOP	Serology SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Serology Bench / Lab Drive	Active (Draft)
SOP-CM-001	Clinical Microscopy Section Workflow, Specimen Acceptance, Quality Control, and Result Reporting SOP	Clinical Microscopy SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Microscopy Bench / Lab Drive	Active (Draft)
SOP-CM-002	Routine Urinalysis (Physical Examination, Sysmex UC-1000 / MEDITAPE UC-10S Chemical Strip and Visual Backup, and Microscopic Sediment Examination) SOP	Clinical Microscopy SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Microscopy Bench / Lab Drive	Active (Draft)
SOP-CM-003	Routine Fecalysis (Macroscopic Inspection and Direct Fecal Smear — Saline and Lugol's Iodine Wet Mount) SOP	Clinical Microscopy SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Microscopy Bench / Lab Drive	Active (Draft)
SOP-CM-004	Urine Qualitative Beta-hCG Pregnancy Test SOP	Clinical Microscopy SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Microscopy Bench / Lab Drive	Active (Draft)
SOP-CM-005	Stool Rapid Immunochromatographic Tests (Helicobacter pylori Stool Antigen and Qualitative Fecal Occult Blood Test / FOBT) SOP	Clinical Microscopy SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Microscopy Bench / Lab Drive	Active (Draft)
SOP-C-001	Clinical Chemistry Section Workflow, Pre/Post-Examination, Quality Control, and Result Validation SOP	Clinical Chemistry SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Chemistry Bench / Lab Drive	Active (Draft)
SOP-C-002	Mindray BS-240 Clinical Chemistry Analyzer Operation, Calibration, and Maintenance SOP	Clinical Chemistry SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Chemistry Bench / Lab Drive	Active (Draft)
SOP-C-003	Routine Photometric Chemistry Procedures on Mindray BS-240 (Glucose, Lipid Profile, Renal Panel, and Liver Enzymes) SOP	Clinical Chemistry SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Chemistry Bench / Lab Drive	Active (Draft)
SOP-C-004	Serum Electrolytes (Sodium, Potassium, and Chloride) Testing on Sensa Core ISE Electrolyte Analyzer SOP	Clinical Chemistry SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Chemistry Bench / Lab Drive	Active (Draft)
SOP-C-005	Glycated Hemoglobin (HbA1c) Testing on Wondfo Finecare FIA Meter SOP	Clinical Chemistry SOP	V0	MM-DD-YYYY	Annual	Chief Med Tech	Chemistry Bench / Lab Drive	Active (Draft)

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Part 2 — Controlled Laboratory Blank Forms & Logs Master Inventory

Controlled register of active blank form masters, worksheets, and logs in clinical use:

Form No.	Form Title	Parent Policy	Current Ver.	Point-of-Use Location	Retention Category	Status
F-QM-001-A-V0	Laboratory Strategic & Quality Master Plan	LAB-QM-001	V0	Quality Office / Lab Drive	5 Years	Active (Draft)
F-QM-002-A-V0	Document Change, Annual Review, and Disposal Request Form	LAB-QM-002	V0	Quality Office / Lab Drive	Permanent	Active (Draft)
F-QM-002-B-V0	Master Document Register, Retention Schedule, and Staff Reading Acknowledgment	LAB-QM-002	V0	Quality Office / Lab Drive	Permanent	Active (Draft)
F-QM-003-A-V0	Quality Indicator Register, CQI Schedule, and Performance Improvement Log	LAB-QM-003	V0	Quality Office / Lab Drive	5 Years	Active (Draft)
F-QM-003-B-V0	Continuous Quality Improvement (CQI) Project Charter and Committee Minutes	LAB-QM-003	V0	Quality Office / Lab Drive	5 Years	Active (Draft)
F-QM-004-A-V0	Client Feedback, Satisfaction Survey, and Complaint Log	LAB-QM-004	V0	Reception / OPD / Lab Drive	3 Years	Active (Draft)
F-QM-005-A-V0	Confidentiality Agreement Form	LAB-QM-005	V0	Personnel Files / Quality Binder	5 Years	Active (Draft)
F-QM-007-A-V0	Laboratory Department Personnel Audit Trail and Signature Register	LAB-QM-007	V0	Reception / Testing Benches	5 Years	Active (Draft)
F-QM-008-A-V0	Clinical Laboratory Organizational Chart	LAB-QM-008	V0	Laboratory Office Bulletin Board	5 Years	Active (Draft)
F-QM-008-B-V0	Official Delegation of Duties, Authority & Leave Coverage Form	LAB-QM-008	V0	Quality Office / Lab Drive	5 Years	Active (Draft)
F-QM-009-A-V0	Laboratory Risk Register, Assessment, and Treatment Plan	LAB-QM-009	V0	Quality Office / Lab Drive	5 Years	Active (Draft)
F-QM-010-A-V0	Incident, Occurrence, and Deviation Report & Log	LAB-QM-010	V0	All Testing Areas / Lab Drive	5 Years	Active (Draft)
F-QM-011-A-V0	Corrective and Preventive Action (CAPA) Record & Master Log	LAB-QM-011	V0	Quality Office / Lab Drive	5 Years	Active (Draft)
F-QM-012-A-V0	Annual Internal Audit Schedule, Plan, Report & Follow-Up Log	LAB-QM-012	V0	Quality Office / Lab Drive	5 Years	Active (Draft)
F-QM-013-A-V0	Management Review Record & Action Follow-Up Log	LAB-QM-013	V0	Quality Office / Lab Drive	3 Years	Active (Draft)
F-QM-PRE-001-A-V0	Clinical Laboratory Request Form	LAB-QM-PRE-001	V0	Reception / OPD / Wards	5 Years	Active (Draft)
F-QM-PRE-002-A-V0	Referral Laboratory Register, Annual Evaluation & Send-Out Log	LAB-QM-PRE-002	V0	Specimen Dispatch / Lab Drive	5 Years	Active (Draft)
F-QM-PRE-003-A-V0	Specimen Receipt, Transport, Rejection & Recollection Log	LAB-QM-PRE-003	V0	Specimen Receiving Station	5 Years	Active (Draft)
F-QM-ANA-004-A-V0	Proficiency Testing Survey Master Packet & Alternative Assessment Register	LAB-QM-ANA-004	V0	Quality Office / Lab Drive	5 Years	Active (Draft)
F-QM-ANA-005-A-V0	Critical Equipment List and Downtime Log	LAB-QM-ANA-005	V0	Testing Areas / Lab Drive	5 Years	Active (Draft)
F-QM-POST-001-A-V0	Laboratory Reporting, Validation, and Correction Record	LAB-QM-POST-001	V0	Result Release / Lab Drive	5 Years	Active (Draft)
F-QM-POST-002-A-V0	Critical Values and Notifiable Disease Notification Log	LAB-QM-POST-002	V0	Releasing / All Benches	5 Years	Active (Draft)
F-QM-POST-003-A-V0	Turnaround Time Exception and Verbal Orders Documentation Sheet	LAB-QM-POST-003	V0	Releasing / All Benches	3 Years	Active (Draft)
F-QM-HR-001-A-V0	Personnel Orientation and Safety Training Checklist	LAB-QM-HR-001	V0	Personnel Files / Lab Office	5 Years	Active (Draft)
F-QM-HR-002-A-V0	Staff Competency Assessment Record and Development Plan	LAB-QM-HR-002	V0	Personnel Files / Lab Office	5 Years	Active (Draft)
F-QM-HR-002-B-V0	Personnel Authorization Matrix and Staff Roster	LAB-QM-HR-002	V0	Quality Office / Lab Drive	5 Years	Active (Draft)
F-QM-HR-003-A-V0	Position Descriptions — Clinical Laboratory Positions	LAB-QM-HR-003	V0	Personnel Files / Lab Office	5 Years	Active (Draft)
F-QM-HR-003-B-V0	Workload and Staffing Review / Additional Manpower Request Record	LAB-QM-HR-003	V0	Quality Office / Lab Office	5 Years	Active (Draft)
F-QM-HR-004-A-V0	Personnel Dossier Verification, Appointment, and Exit Checklist	LAB-QM-HR-004	V0	Personnel Files / Lab Office	Duration + 5 Yrs	Active (Draft)
F-QM-SAF-001-A-V0	Chemical Inventory & SDS Master Register	LAB-QM-SAF-001	V0	Safety Station / Lab Drive	5 Years	Active (Draft)
F-QM-SAF-001-B-V0	Safety Inspection Checklist, Drill Attendance, and Recall Record	LAB-QM-SAF-001	V0	Safety Station / Lab Drive	5 Years	Active (Draft)
F-QM-SAF-002-A-V0	Daily Facility, Environment, and Safety Check Log	LAB-QM-SAF-002	V0	Safety Station / Testing Areas	3 Years	Active (Draft)
F-QM-SAF-002-B-V0	Facility Maintenance Request and Visitor Access Record	LAB-QM-SAF-002	V0	Reception / Lab Office	3 Years	Active (Draft)
F-QM-IC-001-A-V0	Infection Prevention & Control Audit Checklist and Spill Response Log	LAB-QM-IC-001	V0	Safety Station / IPC Area	3 Years	Active (Draft)
F-QM-IT-001-A-V0	Laboratory IT Systems Maintenance, Backup, and Recovery Log	LAB-QM-IT-001	V0	IT Office / Lab Drive	5 Years	Active (Draft)
F-QM-IT-002-A-V0	Computer and Power Downtime Pending-Work Log	LAB-QM-IT-002	V0	Testing Areas / Releasing	5 Years	Active (Draft)
F-H-002-A-V0	HORIBA ABX Pentra XL 80 Hematology Analyzer Maintenance Checklist	SOP-H-002	V0	Hematology Bench	5 Years	Active (Draft)
F-C-002-A-V0	Mindray BS-240 Clinical Chemistry Analyzer Maintenance Checklist	SOP-C-002	V0	Chemistry Bench	5 Years	Active (Draft)

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Work Instructions & Posted Bench Aids (WI-* — 16 Active Visual Aids)

Controlled master register of 16 active visual work instructions and posted bench aids displayed at laboratory testing stations and phlebotomy areas:

Work Instruction Code	Title	Parent Document	Location
WI-P-002-A-V0	BD Vacutainer Order of Draw, Tube Additives & Inversion Chart	SOP-P-002	illustrations/SOP-P-002/
WI-P-003-A-V0	Capillary Finger-Stick & Neonatal Heel-Stick Safe Puncture Card	SOP-P-003	illustrations/SOP-P-003/
WI-H-002-A-V0	HORIBA ABX Pentra XL 80 Daily Startup, Difftrol QC & Shutdown Card	SOP-H-002	illustrations/SOP-H-002/
WI-H-003-A-V0	Peripheral Blood Smear Wedge, Wright-Giemsa Staining & Reticulocyte Card	SOP-H-003	illustrations/SOP-H-003/
WI-H-005-A-V0	ABO & Rh(D) Slide and Immediate-Spin Tube Reaction Grading Card	SOP-H-005	illustrations/SOP-H-005/
WI-CM-002-A-V0	Sysmex UC-1000 / MEDITAPE UC-10S Operation, Visual Backup & Sediment Card	SOP-CM-002	illustrations/SOP-CM-002/
WI-CM-004-A-V0	Abbott Bioline hCG Urine & Serum Pregnancy Test Rapid Bench Card	SOP-CM-004	illustrations/SOP-CM-004/
WI-CM-005-A-V0	Stool Rapid Tests (RightSign H. pylori Antigen & Immunochemical FOBT) Card	SOP-CM-005	illustrations/SOP-CM-005/
WI-C-002-A-V0	Mindray BS-240 Daily Startup, Calibration, IQC & Special Wash Bench Card	SOP-C-002	illustrations/SOP-C-002/
WI-C-004-A-V0	Sensa Core ISE Electrolyte Analyzer Operation & Daily Cleaning Bench Card	SOP-C-004	illustrations/SOP-C-004/
WI-C-005-A-V0	Wondfo Finecare FIA Meter HbA1c Testing & ID Chip Verification Bench Card	SOP-C-005	illustrations/SOP-C-005/
WI-S-002-A-V0	HBsAg Rapid Qualitative Immunoassay & Confirmatory Referral Bench Card	SOP-S-002	illustrations/SOP-S-002/
WI-S-003-A-V0	Syphilis Rapid Treponemal Cassette & RPR Flocculation Card Bench Aid	SOP-S-003	illustrations/SOP-S-003/
WI-S-004-A-V0	Dengue Duo (NS1 Ag + IgM/IgG) & Typhoid IgM/IgG Rapid Test Bench Card	SOP-S-004	illustrations/SOP-S-004/
WI-QM-POST-002-A-V0	Critical Value Panic Thresholds & 15-Minute Read-Back Wall Chart	LAB-QM-POST-002	illustrations/LAB-QM-POST-002/
WI-QM-SAF-001-A-V0	Biological Spill Response & Sharps/Splash First Aid Wall Poster	LAB-QM-SAF-001	illustrations/LAB-QM-SAF-001/

Visual Annexes — Infographics (IG-* — 27 Controlled Annexes to Parent Policies)

Controlled register of the Laboratory's 27 infographics. Each infographic is a visual annex of its parent policy under LAB-QM-002 Section 5.2.6 — it carries no independent document number, is approved, revised, and retired together with its parent, and contains no requirement beyond the parent's text. Master files (PNG, print PDF, and editable HTML) are stored in infographics/ and cited in each parent policy's Section 7.0:

Annex Code	Title	Parent Document	Location
IG-01	QMS at a Glance	LAB-QM-001	infographics/
IG-02	Quality Indicators at a Glance	LAB-QM-003	infographics/
IG-03	Do Not Accept — Specimen Rejection	LAB-QM-PRE-001	infographics/
IG-04	Test Menu	LAB-QM-004	infographics/
IG-05	Waste Segregation	LAB-QM-IC-001	infographics/
IG-06	Specimen Handling and Transport	LAB-QM-PRE-003	infographics/
IG-07	Occurrence to CAPA	LAB-QM-010 and LAB-QM-011	infographics/
IG-08	The Quality Year	LAB-QM-012 and LAB-QM-013	infographics/
IG-09	Who Does What	LAB-QM-008	infographics/
IG-10	Risk Matrix	LAB-QM-009	infographics/
IG-11	Hand Hygiene and PPE	LAB-QM-IC-001	infographics/
IG-12	Turnaround Times	LAB-QM-POST-003	infographics/
IG-13	Keep It How Long — Retention at a Glance	LAB-QM-POST-004	infographics/
IG-14	Notifiable Results	LAB-QM-POST-002	infographics/
IG-15	Records Done Right	LAB-QM-007	infographics/
IG-16	IQC Westgard Troubleshooting	LAB-QM-ANA-001	infographics/
IG-17	POCT Governance and QC	LAB-QM-POC-001	infographics/
IG-18	Sharps Injury & Exposure Response	LAB-QM-SAF-001	infographics/
IG-19	LIS & Power Downtime	LAB-QM-IT-002	infographics/
IG-20	NEQAS Proficiency Testing Cycle	LAB-QM-ANA-004	infographics/
IG-21	Amended Reports	LAB-QM-POST-001	infographics/
IG-22	Competency Assessment	LAB-QM-HR-002	infographics/
IG-23	Equipment Tagout & Return to Service	LAB-QM-ANA-005	infographics/
IG-24	Referral Specimens	LAB-QM-PRE-002	infographics/
IG-25	Reagent Receiving & Lot Release	LAB-QM-ANA-007	infographics/
IG-26	Method Verification	LAB-QM-ANA-003	infographics/
IG-27	New Staff Onboarding	LAB-QM-HR-001	infographics/

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Part 3 — Authorized Personnel for Document Preparation, Review, and Approval

Document Category	Authorized Author / Originator	Authorized Technical Reviewer	Authorized Approver
Quality Management Manual (QM-001)	Chief Medical Technologist / LQM	Pathologist / Head of Laboratory	Hospital Director
Laboratory Policies (LAB-QM-###)	Chief Medical Technologist / Assigned RMT	Pathologist / Head of Laboratory	Hospital Director
Technical SOPs (Analytical & Sectional)	Registered Medical Technologist (RMT)	Chief Medical Technologist / LQM	Pathologist / Head of Laboratory
Laboratory Controlled Forms & Logs	Registered Medical Technologist (RMT)	Chief Medical Technologist / LQM	Pathologist / Head of Laboratory
Equipment Manuals & External Standards	Equipment Manufacturer / DOH / HFSRB	Chief Medical Technologist / LQM	Pathologist / Head of Laboratory

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Part 4 — Records Retention Schedule & Archiving Rules

Retention periods follow DOH Department Circular No. 2021-0226 (which superseded D.C. No. 70 s.1996), DOH A.O. 2021-0037, and ISO 15189:2022 Clause 8.4.3 per Laboratory Retention Schedule Policy:

Record Classification	Record Title / Description	Mandatory Retention Period	Archiving & Storage Method	Authorized Disposal Method
Patient Test Reports (General)	Routine CBC, Clinical Microscopy, Clinical Chemistry	2 Years for issued reports; 5 Years for laboratory-held result records	Electronic Lab-LIS database + Printed copy	Secure confidential shredding / Electronic purge
Serology & Transmissible Disease Records	HBsAg, Syphilis, Dengue, infectious disease results	5 Years for laboratory-held result records; results filed in the patient chart follow chart retention (in-patient 10 years after discharge)	Electronic Lab-LIS + Sealed annual archive	Secure confidential shredding
Quality Control (IQC) Data	Daily LJ charts, calibration logs, control run sheets	2 Years	QC Binder / Digital Excel archive	Shredding after review
External Quality Assessment (EQAP / PT)	NEQAS survey packets, evaluation reports, certificates	5 Years	Dedicated EQAP binder per program	Secure shredding after Pathologist approval
Maintenance & Service Records	Calibration certificates, service work orders, PM logs	2 Years after the equipment is declared unserviceable	Equipment Master File	Retained while instrument operational
Personnel Training & Competency	Orientation, annual competency, CEU certificates	3 Years after the employee's last day of employment	Individual Personnel Dossier (F-QM-HR-004-A)	Archiving / Controlled destruction
Quality System Documents (Obsolete)	Superseded policies, SOPs, forms, audit reports	2 Years from date of obsolescence	Obsolete Document Archive (Stamped OBSOLETE)	Controlled destruction

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Part 5 — Staff Reading and Training Acknowledgment Sign Page

5.1 Document Details

Field	Description
Document Number
Document Title
Version Number	Effective Date: YYYY-MM-DD
Section / Applicable Scope	[ ] All Staff [ ] Hematology [ ] Microscopy [ ] Chemistry [ ] Serology

5.2 Staff Acknowledgment and Undertaking

I confirm that I have read the controlled document above and received orientation on it. I understand it and will follow its requirements and procedures in my laboratory duties.

No.	Staff Name	Designation (MT / Laboratory Aide)	Date Read & Understood	Staff Signature	Orientation Conducted By (Initials)
1
2
3
4
5
6
7
8

5.3 Verification by Chief Medical Technologist / Laboratory Quality Manager

I verify that all staff in the section who must use this document have read and acknowledged it before it is implemented.

Signature: ____________________________________ Date: ________________________