Standard Operating Procedure- SOP
Name of institution
Document Management
ID Code:
Ap 22
Topic & Purpose:
Review Period:
Explains the overall management of all
documents
1 year
Location:
Distribution:
Version number:
Annex:
V 1.0
None
Written by:
Name(s), Date(s) and Signature(s) of the Author(s)
Reviewed by:
Name(s), Date(s) and Signature(s)
Authorized by:
Name, Date and Signature
Replaces the version:
Not applicable (1st version)
Changes to the last authorized version:
Not applicable (1st version)
Institution:
Version: 1.0
Date:
Number of pages: Name of
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procedure:
Document
Management
Procedure
ID Code: Ap 22
QM chapter: 13
Document Management Procedure
Application ..................................................................................................................... 2
Objective ........................................................................................................................ 2
Definitions ...................................................................................................................... 2
References..................................................................................................................... 2
Responsibilities .............................................................................................................. 2
Operating mode ............................................................................................................. 3
Methodology ............................................................................................................... 3
Creation and receipt ................................................................................................... 3
Maintenance and use ................................................................................................. 5
Archiving..................................................................................................................... 6
Disposal ..................................................................................................................... 6
Related documents ........................................................................................................ 6
Application
This procedure ensures document management.
Objective
This procedure explains the overall management of all documents.
Definitions
Document: Information and its supporting medium; digital or physical.
Record: Document stating results achieved or providing evidence of activities
performed. Information captured on worksheets, forms and charts.
References
To be filled in if necessary
Responsibilities
The Quality Manager is responsible for:
 overseeing the document management;
 assigning an ID Code to all new laboratory documents, completing the
distribution list detailed in SOP Document Distribution, and controlling
documents, as detailed in SOP Document Control;
 establishing safeguards against the loss or unauthorized removal of documents,
and making requirements and penalties for not following these requirements
known to staff;
 overseeing laboratory test reports and records;
 assuring that staff meet their responsibilities of keeping work records in the
appropriate testing areas;
 verifying that the required document archiving procedure is followed;
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procedure:
Document
Management
Procedure
ID Code: Ap 22
QM chapter: 13
following established procedures for ensuring new or current validated
documents are correctly used in place of any previous versions;
reviewing this document management procedure annually and revising it if
necessary.
Operating mode
Methodology
The goal of document management is to:
 contribute to the smooth operation of the laboratory’s activities by ensuring quick
and easy access to information contained in documents;
 protect documents from inappropriate and unauthorized access;
 meet statutory and regulatory requirements including archival, audit and
oversight activities for documents;
 provide documents as reference for protection and support in litigation;
 improve the laboratory’s efficiency in obtaining and using information from files;
 free up laboratory’s space by moving inactive records to storage facilities.
The life cycle of documents usually consists of four stages:
 creation and receipt
 maintenance and use
 archiving
 disposal.
Creation and receipt
1. Employees are responsible for making records of their work. They create the records
needed to their laboratory work. They will record decisions and actions taken and
document the activities for which they are responsible.
2. Supporting documentation of laboratory test records includes but is not limited to the
following:
 Media/reagent preparation records
 Media and chemical control number records
 Quality Control records including but not limited to the following:
o Quality assurance records
o Performance and sterility check of media records
o Autoclave sterilization records
o Timers’ and hygrometers’ calibration certificates
o Micropipette calibration records
o Point check calibration of laboratory thermometers records
o Thermometer calibration certificates
o Temperature records for incubators, refrigerators and freezers
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Institution:
Version: 1.0
Date:
Number of pages: Name of
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procedure:
Document
Management
Procedure
ID Code: Ap 22
QM chapter: 13
o Records for laboratory equipment, such as autoclaves, dishwashers,
microscopes, spectrophotometers, etc.
The Quality Manager shall date stamp these documents, when received, and check
that these documents are properly filed.
3. It is important that employees take proper care of documents so that information can
be found when needed. This includes:
 setting up clearly defined directories and files;
 regularly filing materials in a manner that ensures safe storage and efficient
retrieval.
4. The minimum requirements for the unique identification of documents are:
 Title
 ID Code
 One or more of: version, current revision date, or revision number
 Number of pages
 Designated staff with authority to issue the document
 Database identification, if applicable.
5. The ID Code given to all documents may include, as an example:
 B XXX for books
 R XXX for reviews
 E XXX for equipment notices
 MN XXX for manufacturer notices
 ELB XXX for equipment logbooks
 IQCLB XXX for Internal Quality Control logbooks
 FLT XXX for forms, records, files, lists, tables and reports
 P XXX for policies
 PR XXX for processes
 SOP XXX for Standard Operating Procedures
XXX is the number given according to:
o the referring chapter in the Quality Manual for P, PR, SOP, FLT, IQCLB
and ELB
o the time of arrival
6. A list, which identifies the current valid revisions and their distribution, is maintained.
This list is also referred to as the document control logbook.
7. Classifying laboratory documents involves gathering and maintaining the required
documents in specific files according to their ID Code. As examples:
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procedure:
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Management
Procedure
ID Code: Ap 22
QM chapter: 13
Personnel files (ID Code: FLT) – includes job application form, training checklist,
copies of diplomas or certifications, performance evaluations and continuing
education for each laboratory employee. These files are kept in the Laboratory
Director office with restricted access.
Procedure manual (ID Code: SOP) – includes procedures for every test
performed in the laboratory, with each procedure describing the pre-analytical,
analytical and post-analytical phases of testing.
Equipment maintenance logbooks (ID Code: ELB) – includes documentation of
maintenance. Note: Instrument manufacturers provide a maintenance schedule
and often provide a master form to use.
Temperature logs (ID Code: IQCLB) – includes daily logs of the room
temperature, and, if in use, incubator, refrigerators and freezers temperature
logs.
Quality control logs (ID Code: IQCLB) – includes documentation of all quality
controls for all tests performed in the laboratory.
Proficiency testing (PT) records (ID Code: FLT) – includes ordering information,
copies of results and evaluations, and all other PT related documentation (e.g.,
corrective actions, correspondence with PT providers).
Patient test management (ID Code: FLT) – includes requisitions and reporting
mechanisms.
Calibration verification logs (ID Code: IQCLB).
Method verification logs (ID Code: IQCLB).
Maintenance and use
1. New procedures are distributed to affected staff and a distribution list is kept, as
indicated in SOP Document Distribution.
2. Safeguards are established by the Quality Manager against the loss or unauthorized
removal of documents.
3. Laboratory records are maintained. They include quality performance test reports,
biosafety reports, and other test reports produced by the laboratory.
4. Documents are controlled as indicated in the SOP Document Control.
5. Copies of laboratory test records are kept (the record of a laboratory test is the final
printed data report). These records are arranged by date in file room XXX. Only
authorized personnel have access to these files. Records are kept for at least XXX
years. After XXX years, record copies are retired to the Record Center due to space
limitations.
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Institution:
Version: 1.0
Date:
Number of pages: Name of
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procedure:
Document
Management
Procedure
ID Code: Ap 22
QM chapter: 13
Archiving
There should be appropriate archiving procedures for laboratory documents (e.g. SOP
Short Term Archiving and SOP Long Term Archiving).
Disposal
When a published and distributed document has been revised, the previous version
should be stored in an archive for XXX (time) and later discarded. This includes both
the hardcopy and any electronic copies of the document.
Related documents
SOP Document Control Ref XXX, provided in this QM template as Ap 24
SOP Document Distribution Ref XXX
SOP Long Term Archiving Ref XXX
SOP Short Term Archiving Ref XXX, provided in this QM template as Ap 23
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