Hospital Laboratory Requirements

(1) The laboratory must be licensed in accordance with the Tennessee Medical Laboratory Act. All technical laboratory staff must be licensed in accordance with the Tennessee Medical Laboratory Act and must be qualified by education, training and experience for the types of services rendered. (2) A written and signed report of each laboratory test and examination must be made a part of the patient’s record. There must be a procedure established to allow for effective and immediate communication with the attending physician and other department/services regarding test results, inappropriate specimens, or other consultations. (3) Laboratory facilities must be provided in keeping with services rendered by the hospital. Documentation and record keeping must be maintained for tracking and performance monitoring. (4) Where facilities for performance of post mortem examinations are not available in the hospital, arrangement are to be made with a local undertaker or another hospital where examination may be made. (5) Provisions through contractual services with a licensed laboratory for specific laboratory services may be granted if the contract source is approved and licensed in accordance with the rules and regulations under the Tennessee Medical Laboratory Act. (6) All laboratory personnel must have an orientation in infection control policies and employee health at the time of employment. Prior to beginning laboratory studies, the lab personnel must check the readiness, cleanliness and working condition of laboratory equipment. All single service articles will be disposed of after one use. Storage of all laboratory equipment in a clean environment is essential. All personnel involved in laboratory procedures will undergo on-the-job orientation and training with the opportunity for continuing education or they may demonstrate competence in hygiene, infection control, proper cleaning and safe operation of equipment and proper waste disposal. The laboratory must define a traffic control plan.