QSP 2 - Clause 4.3 Document Control
QSP 2 - Clause 4.3 Document Control
QSP 2 - Clause 4.3 Document Control
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 1 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
AMENDMENT SHEET
SI Page Clause Date of Amendment Reasons Signature Signature
No No Amendment Of QM Of Lab
Director
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 2 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
Purpose: - To assure that quality system documents used by Molecular Laboratory at Zydus
Medical College and Hospital, Microbiology department employees are properly developed,
approved, current, located where needed, and archived properly. Quality system documents
include the following: manuals, procedures, work Instructions (WIs), policies, biological
reference intervals, and their origins, and documents of external origin such as regulations,
standards, etc.
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 3 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
All policies and procedures that are currently in use and all documents that were previously
used and are still retained by the laboratory should be managed using a document control
system.
Scope: This procedure applies to the control of documents including electronic and external,
which calls for quality requirements or prescribes activities affecting quality such as methods,
regulations, directives, procedures, and instructions, pertaining to the Molecular Laboratory,
Zydus Medical College and Hospital, Dahod laboratory’s Quality Management System
(QMS).
Responsibility:
Quality Manual:
Author: Dr. NiteshKumar Jaiswal (Quality Manager)
Amendment/Annual Review-Dr. Rekha Kishori (Technical Expert/ Section Head –
Assistant Professor)
Approve: Dr. Deepak Deshkar (Laboratory Director)
Issue: 2.0
Quality System Procedures:
Author: Dr. NiteshKumar Jaiswal (Quality Manager)
Amendment/Annual Review- Dr. Rekha Kishori (Technical Expert/ Section Head –
Assistant Professor)
Approve: Dr. Deepak Deshkar (Laboratory Director)
Issue: 2.0
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 4 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
It is the responsibility of the concerned Section Head/ HOD to read and implement this SOP.
It is the responsibility of the Quality Manager (QM) to implement and maintain a document
control system, coordinate reviews and revisions of quality system documents, maintain an
electronic document log sheet to ensure active and revised documents are provided to staff,
and archive superseded or obsolete documents
Procedure: Policies and procedures under document control follow a defined cycle. The
general flow of document control is as follows:
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 5 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
All the laboratory documents are controlled (as per the Table below). Only one hard
copy (Controlled Copy) of QUALITY documents is printed and is available in the
Quality department. Only one hard copy (Controlled Copy) of Standard Operating
Procedures is printed and is available with respective sections. Master copy
(Electronic) of QUALITY documents (Quality Manual, Quality System Procedures,
etc) & SOPs is available with the Quality Assurance department
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 6 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
copy number,
page number
to the total
number of
pages,
reviewed on
the date, and
appropriate
signatures.
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 7 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
number to
total number
of pages,
reviewed on
date and
appropriate
signatures.
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 8 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
Header & Footer of document: The header contains the name and logo of the laboratory and
the document name/title. The Footer of the document contains the laboratory name and
location, type of document (SOP, QSP, etc.), version number, and the page number.
In case a new procedure or revision (in the old procedure) is required by the department the
concerned department Section Head Laboratory Quality Manager/ laboratory Director writes
or revises (existing ) procedure by referring product broacher of the kit.
The completed document is then forwarded to the QUALITY Assurance department for
formatting.
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 9 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
The approver reads and evaluates the document. Concerns and changes are noted and
discussed with the author. After changes and identification, if any, of additional training and
resources or impact on customers, the following actions are taken.
If the document is approved, then the name and date are entered and the document is issued.
The concerned staff is trained (self-reading) on the document and it is implemented.
If the document is not approved; the reason is identified and the QUALITY Assurance
department is notified which in turn notifies the author. If any conflicts are there then these
are resolved between both the author and the approver.
Approver reads and reviews the document. Changes and concerns are noted and discussed
with the authors. The approver determines the final action. After resolution, the document is
forwarded to the QUALITY department for formatting and the above-mentioned procedure is
followed.
All new documents and the documents that have undergone a substantial revision are
approved by the Head of the respective department or appropriate laboratory authority. The
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 10 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
approval of new documents and revisions to current documents is done before the procedures
are used by laboratory personnel.
The substantial revision designation is applied to any revision that impacts the performance
of the procedure, for example, changes in procedural steps, quality control, reaction times and
temperatures, and sample size.
Documents with substantial revisions are released with version changes and are approved by
the head of the department or appropriate laboratory authority and reviewed by testing
personnel.
The minor revision designation is applied for the correction of typos and spelling mistakes,
the addition of a new logo, or other purely display issues.
Minor revisions are included as amendments to the document without changing the version.
External Documents:
Documents from external sources are controlled using listings to track the use of versions as
part of
the quality system. The date and version are to appear on these lists. Lists are maintained for
the
reference documents (CLSI documents, NABL documents, etc.)
External electronic documents available and maintained online (few NABL documents) are
checked and controlled by periodically [annually] checking the appropriate website.
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 11 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
Lab Records
Manual entries
All the manual entries are done using a black/blue ball-point pen. Care is taken to minimize
errors while writing. In case of an error, erroneous data is struck out (making sure that it is
still visible clearly) and the correct value or figure is entered. This is authenticated by the date
and initials of the person involved in making changes and the reason for making changes
(e.g., wrong entry, calculation error, interpretation error, etc)
Equipment logs
All analytical equipment should essentially have the following two log sheets:
Maintenance & calibration log
QC failure log
Minor equipment that would not adversely affect the sample analysis (e.g. Vortex, shaker,
dry bath, sonicator, etc.) need not have any of the above log sheets.
General instructions:
After completion of the log sheets, they should be handed over to QUALITY for
archival and new log sheets should be taken from QUALITY personnel before the
completion of the log sheets which are in use.
Every log sheet should contain the Equipment Record number.
Every log sheet should be given through QUALITY and authenticated for the utility.
Log sheet should be withdrawn immediately by QUALITY if the equipment or the log
sheet itself is no more used.
Every log sheet should have the user-specified or equipment-customized format which
should be approved by QUALITY.
Archival of log sheets: After completion of the log sheet or in case of removal of the
equipment from service, these log sheets should be archived.
Maintenance and calibration log: There should be equipment dedicated file to record all the
details of the maintenance and calibrations done each time. The maintenance includes that
has to be performed as per the respective equipment SOP along with the preventive
maintenance if any.
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 12 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
QC failure log: Whenever a QC is an outlier, it should be logged in this log sheet with
necessary elements like the corrective action taken, user signature, and date. Replace with a
new log sheet, on completion.
Equipment Files
All analytical equipment should essentially have the following documents but not limited to:
Control & calibrator insert
IQ /OQ /PQ records
L.J. printouts
Control reconstitution records
Daily maintenance records
Calibration printout records
Control printout records
Service report & breakdown records
Preventive maintenance records
Installation/calibration on certificate service report
Operation/user manual
Validation records
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 13 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
Outsourcing of the archived data: Should be done for a period of two years except for
the molecular diagnostic gel pictures, histopathology, and cytopathology test reports
which should be retained for ten years.
Data destruction
The archived data should be destroyed after retaining it for the required time period, using a
shredder (hard copy) or by deletion (soft copy).
Definitions
Activity: A defined set of work. The output of one activity or set of activities becomes the
input to another activity or set of activities.
Controlled copy - A controlled copy is a formal copy of the latest, correct issue of a
document; an identified issue of a document to an individual or location of the record. The
controlled copy is officially tracked, updated, and destroyed to assure that it is current.
Document - Any recorded information or object which can be treated as a unit. Records are
considered a subset of documents that have specific attributes.
Master Copy - The original records or archival materials that are preserved and used to make
access copies.
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 14 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
Minor revision: A revision that does not affect the nature of a policy or the way in which a
procedure is conducted. The revision would not affect patient results or patient outcomes. For
example, a spelling or grammatical correction would be a minor revision.
Policy: A defined course of action that is intended to guide current and future decisions.
Policies are established by individuals within the organization and are endorsed by the
management.
Procedure: The specific instructions that must be followed to complete activities within a
process.
Record: Data that is generated when policies, procedures, or processes are followed.
Substantial revision: A change that affects the nature of a policy or the way in which a
procedure is conducted that could impact patient test results or patient outcome.
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 15 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
Annexure1
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 16 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 17 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager:
QSP:2
MOLECULAR LABORATORY, ZYDUS MEDICAL COLLEGE, AND
HOSPITAL, DAHOD, GUJARAT
References
Ref. Title
No.
Molecular Laboratory, Zydus Medical College and Hospital Dahod, Gujarat 38915
Doc. No.: QSP 02 Document Control
Issue No.: 02 Issue Date: 11- Amendment No.: Nil Amendment Date: - Page 18 of 18
Oct-2022
Copy: Prepared By: Reviewed By: Quality Issued By: Laboratory Director:
Section Head: Manager: