Module overview
Section 2 of 6 · Open sections

Required section · Section 2 of 6

One hierarchy, one lifecycle

Federal and accreditor requirements set applicable obligations. The laboratory’s controlled-document hierarchy—policy, process, procedure, work instruction/job aid, form/template, and record—is its own managed structure. A procedure does not automatically outrank every job aid unless current local document control establishes that relationship.

A form or template is a blank capture tool, itself a controlled document. Once that form holds data, it is no longer a template; it is a record, evidence of what was actually done, and it is retained rather than edited.

CLSI QMS02, the consensus standard for developing and managing laboratory documents, frames a document-management program around this same idea: creating, reviewing, approving, maintaining, assessing, changing, and retiring documents, for both paper-based and electronic systems, across every level of the hierarchy from policy through form.

Every controlled document also moves through a lifecycle. Someone recognizes a need for a new or revised document. It is drafted, technically reviewed, and approved by the person with the authority to approve it. It becomes effective and is issued to the point of use. It stays accessible and current while it is periodically reviewed and, when a trigger occurs, revised. Eventually it is retired and archived. CLSI QMS02 describes this same evidence-based path, from recognition of need through use and control to retirement, for documents of any size or complexity laboratory, including point-of-care testing.

If an obsolete copy appears at point of use, stop using it, obtain the current approved version, and report it for removal, archiving, or other disposition under document control.

Before following an instruction, confirm that it is the current approved version under the laboratory’s document-control system; if it is obsolete, stop use and obtain the current version.

Illustrative drawing — this picture was drawn rather than captured.

Stacked laboratory controlled-document hierarchy from policy through record, shown separately from external federal and accreditor requirements. Local document control defines relationships among procedures and job aids.
Figure 1Laboratory controlled-document hierarchy, distinct from external federal and accreditor requirements.

Illustrative drawing — this picture was drawn rather than captured.

Lifecycle diagram from need through retirement. An obsolete copy at point of use routes to stop use, obtain the current approved version, and report the copy for removal, archiving, or other document-control disposition.
Figure 2Controlled-document lifecycle, including the obsolete-copy response.

The controlled document lifecycle, from recognizing a need to retiring the document.

  1. Need recognized

    A trigger such as a new test, an instrument change, or a manufacturer package-insert revision is identified and logged as a reason to create or revise a document.

  2. Drafted

    The document owner writes or revises the content, including any new acceptance criteria or steps the trigger requires.

  3. Reviewed

    A technical reviewer, such as a supervisor, checks the draft for accuracy and completeness before it goes to the approver.

  4. Approved by the director

    The current laboratory director signs and dates approval. This step cannot be delegated to any other role.

  5. Issued and effective

    The document becomes effective on a stated date, is placed at the point of use, and staff are notified before that date.

  6. Periodically or triggered review

    The document is checked on the laboratory's own schedule, or sooner if a reagent, instrument, or method change makes it out of date.

  7. Revised

    When a review finds the document out of step with current practice, a new version is drafted and re-enters review and approval.

  8. Retired and archived

    The superseded version is dated as discontinued, removed from the active point-of-use location, and archived under the retention policy so it cannot be mistaken for current.

Knowledge checks

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Knowledge check 1

A laminated card taped to an analyzer, telling a technologist which button starts the daily calibration sequence, sits at which level of the document hierarchy?

Choose one option.

Knowledge check 2

A blank calibration-verification log is filed in the document-control system as a controlled template. A technologist fills it in today after running calibration verification. What is the filled-in copy now?

Choose one option.

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