Mas Hem 08242023 1698728884598

Master
Hematology and
Coagulation Checklist
CAP Accreditation Program
College of American Pathologists

325 Waukegan Road
Northfield, IL 60093-2750
www.cap.org 08.24.2023
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Hematology and Coagulation Checklist 08.24.2023
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Hematology and
Coagulation Checklist
TABLE OF CONTENTS
SUMMARY OF CHANGES....................................................................................................................5
INTRODUCTION.................................................................................................................................... 7
QUALITY CONTROL............................................................................................................................. 7
WAIVED TESTS - GENERAL............................................................................................................................................. 7
NONWAIVED TESTS - GENERAL..................................................................................................................................... 8
HEMATOLOGY.................................................................................................................................... 12
SPECIMEN COLLECTION AND HANDLING....................................................................................................................12
COMPLETE BLOOD COUNT (CBC) INSTRUMENTS..................................................................................................... 14
CALIBRATION............................................................................................................................................................. 14
CBC INSTRUMENT QUALITY CONTROL................................................................................................................. 15
Stabilized Controls................................................................................................................................................ 16
Moving Averages...................................................................................................................................................17
Retained Patient Specimens.................................................................................................................................18
Error Detection and Verification............................................................................................................................ 18
MANUAL HEMATOCRIT....................................................................................................................................................21
MANUAL BLOOD COUNT.................................................................................................................................................22
AUTOMATED DIFFERENTIALS........................................................................................................................................24
MANUAL DIFFERENTIALS............................................................................................................................................... 25
BLOOD FILMS FOR MICROORGANISMS....................................................................................................................... 28
AUTOMATED RETICULOCYTES......................................................................................................................................30
MANUAL RETICULOCYTES............................................................................................................................................. 30
BODY FLUIDS................................................................................................................................................................... 31
MANUAL CELL COUNT- BODY FLUID..................................................................................................................... 31
AUTOMATED CELL COUNT - BODY FLUID.............................................................................................................33
NUCLEATED CELL DIFFERENTIALS - BODY FLUID.............................................................................................. 34
RESULT REPORTING - BODY FLUID.......................................................................................................................36
SEMEN ANALYSIS..................................................................................................................................................... 37
Requisitions, Specimen Receipt and Results Reporting...................................................................................... 37
Sperm Motility........................................................................................................................................................39
Stained Smear - Sperm Differential......................................................................................................................41
Biochemical Tests................................................................................................................................................. 43
Anti-sperm Antibody (ASA) Tests......................................................................................................................... 43
Automated Semen Analysis Instruments.............................................................................................................. 44
ABNORMAL HEMOGLOBIN DETECTION........................................................................................................................46
HIGH PERFORMANCE LIQUID CHROMATOGRAPHY (HPLC)............................................................................... 49
BONE MARROW PREPARATIONS..................................................................................................................................51
RESULTS REPORTING - HEMATOLOGY....................................................................................................................... 53
COAGULATION................................................................................................................................... 54
SPECIMEN COLLECTION AND HANDLING - COAGULATION...................................................................................... 54
QUALITY CONTROL - COAGULATION........................................................................................................................... 59
COAGULATION TESTS BASED ON DIRECT MEASUREMENT OF ANALYTES........................................................... 60
COAGULATION STUDIES.................................................................................................................................................66
PT/INR AND aPTT...................................................................................................................................................... 66
D-DIMER STUDIES..................................................................................................................................................... 71
MIXING STUDIES....................................................................................................................................................... 73
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COAGULATION FACTOR ASSAYS (EXCLUDING FIBRINOGEN BY IMMUNOLOGIC METHODS)........................74

PLATELET FUNCTION STUDIES.............................................................................................................................. 76
ELECTROPHORESIS - COAGULATION....................................................................................................................78
RESULTS REPORTING - VISCOELASTIC TESTING............................................................................................... 79
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ON-LINE CHECKLIST DOWNLOAD OPTIONS

Participants of the CAP accreditation programs may download the checklists from the CAP website (cap.org)
by logging into e-LAB Solutions Suite. They are available in different checklist types and formatting options,
including:
● Master — contains ALL of the requirements and instructions available in PDF, Word/XML or Excel
formats
● Custom — customized based on the laboratory's activity (test) menu; available in PDF, Word/XML or
Excel formats
● Changes Only — contains only those requirements with significant changes since the previous checklist
edition in a track changes format to show the differences; in PDF version only. Requirements that have
been moved or merged appear in a table at the end of the file.
CHECKLIST ACCREDITATION RESOURCES

CAP accredited laboratories have access to additional checklist accreditation tools and resources found on
the CAP website (cap.org) by logging into e-LAB Solutions Suite - Accreditation Resources. Content found in
Accreditation Resources includes:
● A library of past Focus on Compliance webinars and laboratory inspection preparation videos
● Answers to the most common checklist questions
● Customizable templates and forms (eg, competency assessment, personnel, validation/verification,
quality management)
● Proficiency testing (PT) frequently asked questions, forms, and troubleshooting guides
● IQCP eligibility, frequently asked questions, forms, templates, and examples
● Laboratory director education and resources
● Quality management resources
● Inspector training and inspection tip sheets
● Self and post inspection toolbox
SUMMARY OF CHECKLIST EDITION CHANGES

Hematology and Coagulation Checklist
08/24/2023 Edition
The information below includes a listing of checklist requirements with significant changes in the current edition
and previous edition of this checklist. The list is separated into three categories:
1. New
2. Revised:
● Modifications that may require a change in policy, procedure, or process for continued
compliance; or
● A change to the Phase
3. Deleted/Moved/Merged:
● Deleted
● Moved — Relocation of a requirement into a different checklist (requirements that have been
resequenced within the same checklist are not listed)
● Merged — The combining of similar requirements
NOTE: The requirements listed below are from the Master version of the checklist. The customized checklist
version created for inspections and self-evaluations may not list all of these requirements.
Previously Cited Checklist Requirements

● The inspector's version of the checklist contains a listing of previously cited checklist requirements.
Specific information on those citations, including the inspection date and inspector comments, is
included following each related requirement within the checklist.
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● Laboratories can access data on previously cited deficiencies by logging into e-LAB Solutions Suite on
cap.org and going to Accreditation Reports - Inspection Summation Report.
NEW Checklist Requirements
Requirement Effective Date

HEM.38700 08/24/2023
REVISED Checklist Requirements

HEM.20143 10/24/2022
HEM.22625 10/24/2022
HEM.25760 10/24/2022
HEM.25920 10/24/2022
HEM.34400 10/24/2022
HEM.34500 10/24/2022
HEM.34798 10/24/2022
HEM.35300 10/24/2022
HEM.35471 10/24/2022
HEM.35490 10/24/2022
HEM.35566 10/24/2022
HEM.35762 08/24/2023
HEM.35851 10/24/2022
HEM.35924 10/24/2022
HEM.36880 08/24/2023
HEM.36920 08/24/2023
HEM.37165 08/24/2023
HEM.37360 10/24/2022
HEM.37373 08/24/2023
HEM.37375 08/24/2023
HEM.37400 10/24/2022
HEM.37860 10/24/2022
HEM.37880 10/24/2022
HEM.37960 08/24/2023
HEM.38300 10/24/2022
HEM.38500 10/24/2022
DELETED/MOVED/MERGED Checklist Requirements

HEM.38450 10/23/2022
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INTRODUCTION
This checklist is used in conjunction with the All Common and Laboratory General Checklists to inspect a
hematology laboratory section or department.
Certain requirements are different for waived versus nonwaived tests. Refer to the checklist headings and
explanatory text to determine applicability based on test complexity. The current list of tests waived under CLIA
may be found at http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfClia/analyteswaived.cfm.
Laboratories not subject to US regulations: Checklist requirements apply to all laboratories unless a specific
disclaimer of exclusion is stated in the checklist. When the phrase "FDA-cleared/approved test (or assay)" is
used within the checklist, it also applies to tests approved by an internationally recognized regulatory authority
(eg, CE-marking).
QUALITY CONTROL
Inspector Instructions:
● Sampling of QC policies and procedures
● Sampling of QC records
● What do you do if controls are out of range?

● How does your laboratory verify or establish acceptable quality control ranges?
● What is your course of action when monthly precision data changes significantly from
the previous month's data?
● How is quality control performed for test procedures that do not have commercially
available calibration or control materials?
● Review a sampling of QC data over the previous two-year period. Select several
occurrences in which QC is out of range and follow records to determine if the steps
taken follow the laboratory procedure for corrective action
● Use QC data to identify nonwaived tests that utilize internal quality control processes
to confirm that any individualized quality control plan (IQCP) is used as approved by
the laboratory director.
WAIVED TESTS - GENERAL
HEM.18038 QC - Waived Tests Phase II

The laboratory follows manufacturer's instructions for quality control, reviews results, and
records acceptability prior to reporting patient results.
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NOTE: Quality control must be performed according to manufacturer's instructions. To detect

problems and evaluate trends, testing personnel or supervisory staff must review quality control
data on days when controls are run prior to reporting patient results. The laboratory director or
designee must review QC data at least monthly or more frequently if specified in the laboratory
QC policy.
With respect to internal controls, acceptable control results must be recorded, at a minimum,
once per day of patient testing for each device.*
*Acceptable internal control results need not be recorded, if (and only if) an unacceptable
instrument control automatically locks the instrument and prevents release of patient results.
Evidence of Compliance:
✓ Records showing confirmation of acceptable QC results
HEM.18691 QC Corrective Action - Waived Tests Phase II

The laboratory performs and records corrective action when control results exceed
defined acceptability limits.
HEM.18705 Calibration, Calibration/Verification - Waived Tests Phase II

For waived tests, the laboratory follows manufacturer's instructions for calibration,
calibration verification, and related functions.
✓ Records for calibration/calibration verification/related functions as required by the
manufacturer AND
✓ Records of recalibration or other appropriate corrective action when calibration verification is
unacceptable
NOTE: The remaining requirements in this checklist on controls, calibration, and reportable range do not apply
to waived tests.
NONWAIVED TESTS - GENERAL
The following group of requirements is applicable to nonwaived manual, automated, and semi-automated
testing, unless a separate checklist requirement exists in another checklist section that defines a specific QC
frequency (eg, CBC instrument, coagulation testing, manual cell counts).
HEM.19360 Daily QC - Nonwaived Tests Phase II

The laboratory performs controls for quantitative and qualitative tests each day of testing,
or more frequently if specified in manufacturer's instructions, laboratory procedure, or the
CAP Checklist, and when changes occur that may impact patient results.
NOTE: The laboratory must define the number and type of quality control used and the frequency
of testing in its quality control procedures. Control testing is not required on days when patient
testing is not performed.
Controls must be run prior to resuming patient testing when changes occur that may impact
patient results, including after a change of analytically critical reagents, major preventive
maintenance, change of a critical instrument component, or with software changes, as
appropriate.
Daily quality control must be run as follows:
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● Quantitative tests - two controls at different concentrations at least daily, except

for coagulation tests (two controls every eight hours), or unless otherwise required
elsewhere in this checklist
● Qualitative tests - a negative control and a positive control (when applicable) at least
daily
Controls should verify assay performance at relevant decision points. The selection of these
points may be based on clinical or analytical criteria.
If an internal quality control process (eg, electronic/procedural/built-in) is used instead of an
external control material to meet daily quality control requirements, the laboratory must have
an individualized quality control plan (IQCP) approved by the laboratory director defining the
control process, including the frequency and use of external and internal controls. At a minimum,
external control materials must be analyzed with new lots and shipments of reagents or more
frequently if indicated in the manufacturer's instructions. Please refer to the IQCP section of the
All Common Checklist for the eligibility of tests for IQCP and requirements for implementation
and ongoing monitoring of an IQCP.
✓ Records of QC results including external and internal control procedures AND
✓ Manufacturer product insert or manual
REFERENCES
1) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Clinical laboratory improvement
amendments of 1988; final rule. Fed Register. 2003(Jan 24):3708 [42CFR493.1256(d)(3)(ii)]
2) Clinical and Laboratory Standards Institute (CLSI). User Protocol for Evaluation of Qualitative Test Performance; 3rd ed. CLSI
document EP12. Clinical and Laboratory Standards Institute, Wayne, PA; 2023.
3) Koepke JA. Update on reticulocyte counting. Lab Med. 1999;30:339-343
4) Department of Health and Human Services, Centers for Medicare and Medicaid Services. S & C: 16-20-CLIA: Policy Clarification on
Acceptable Control Materials Used when Quality Control (QC) is Performed in Laboratories. April 8, 2016.
HEM.19380 Control Range Establishment or Verification Phase II

The laboratory establishes or verifies an acceptable control range for each lot of control
material.
NOTE: For unassayed control materials, the laboratory must establish an acceptable control
range by repetitive analysis in runs that include previously tested control material. For assayed
control materials, the laboratory must verify control ranges supplied by the manufacturer.
Control values supplied by the manufacturer may be used without verification for qualitative (eg,
positive or negative) testing.
✓ Records for control range establishment or verification of each lot
REFERENCES
1) Clinical and Laboratory Standards Institute. Evaluation of Precision Performance of Quantitative Measurement Methods; Approved
Guideline. 3rd ed. CLSI Document EP05-A3. Clinical and Laboratory Standards Institute, Wayne, PA; 2014.
2) Clinical and Laboratory Standards Institute. Statistical Quality Control for Quantitative Measurement Procedures, Principles and
Definitions. 4th ed. CLSI guideline C24. Clinical and Laboratory Standards Institute, Wayne, PA, 2016.
HEM.20050 Numeric QC Data Phase II

For numeric QC data, quality control statistics (eg, SD and CV) are calculated monthly to
define and monitor analytic imprecision.
NOTE: For CBC data where stabilized whole blood is not used for quality control, such statistics
may be generated from previous patient samples using the standard deviation of duplicate pairs.
✓ QC records showing monthly monitoring of imprecision
REFERENCES
1) Mukherjee KL. Introductory mathematics for the clinical laboratory. Chicago, IL: American Society of Clinical Pathology, 1979:81-94
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2) Barnett RN. Clinical laboratory statistics, 2nd ed. Boston, MA: Little, Brown, 1979
3) Weisbrodt IM. Statistics for the clinical laboratory. Philadelphia. PA: JB Lippincott, 1985
4) Matthews DF, Farewell VT. Understanding and using medical statistics. New York, NY: Karger, 1988
5) Cembrowski GS, et al. An optimized quality control procedure for hematology analyzers with the use of retained patient specimens.
Am J Clin Pathol. 1988;89:203-210
amendments of 1988; final rule. Fed Register. 2003(Jan 24):7146 [42CFR493. 1256(d)(10)(i)]
7) Ross JW, Lawson NS. Analytic goals, concentrations relationships, and the state of the art for clinical laboratory precision. Arch
Pathol Lab Med. 1995;119:495-513
8) Clinical and Laboratory Standards Institute (CLSI). Statistical Quality Control for Quantitative Measurement Procedures: Principles
and Definitions. 4th ed. CLSI guideline C24. Clinical and Laboratory Standards Institute, Wayne, PA, 2016.
HEM.20070 Precision Statistics Phase I

The laboratory has an action protocol when data from precision statistics change
significantly from previous data.
NOTE: As an example, if the laboratory's normal-level commercial control usually yields a

monthly CV of 2% for WBC, but the most recent month shows a 4% CV, then something has
caused increased imprecision, and investigation with records is required. Similarly, if the monthly
SD for MCV by moving averages is typically around 1.8 fL, but now is at 3.1 fL, the laboratory
must find a cause for this shift and take action. If commercially sponsored interlaboratory QC
data for the same control lot and instrument model show SD/CV values outside those of the peer
group, an explanation is required.
✓ Records of investigation and corrective actions taken
HEM.20090 Alternative Control Procedures Phase II

If the laboratory performs test procedures for which control materials are not
commercially available, the laboratory performs and records alternative control
procedures to detect immediate errors and monitor test system performance over time.
NOTE: "Performance" includes elements of accuracy, precision, and clinical discriminating

power. The following are examples of alternative procedures: split sample testing with another
method or with another laboratory, the testing of previously tested patient specimens in duplicate,
testing of patient specimens in duplicate, or other defined processes approved by the laboratory
director.
✓ Records of alternative control procedures
REFERENCES
amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1256(h)].
HEM.20120 QC Handling Phase II

The laboratory tests control specimens in the same manner and by the same personnel as
patient samples.
NOTE: Personnel who routinely perform patient testing must analyze QC specimens; however,
this does not imply that each operator must perform QC daily. Personnel must participate in QC
on a regular basis. To the extent possible, all steps of the testing process must be controlled.
✓ Records reflecting that QC is performed by the same personnel performing patient testing
REFERENCES
amendments of 1988; final rule. Fed Register. 2003(Jan 24):7166 [42CFR493.1256(d)(8)]
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HEM.20140 QC Confirmation of Acceptability Phase II

Personnel review control results for acceptability before reporting patient/client results.
✓ Records of control result approval
REFERENCES
amendments of 1988; final rule. Fed Register. 2003(Jan 24):7166 [42CFR493.1256(f)], and 2003(Oct 1):1046[42CFR493.1282(b)(2)]
**REVISED** 10/24/2022
HEM.20143 QC Corrective Action Phase II
The laboratory performs and records corrective action when control results exceed
defined acceptability limits.
NOTE: The actions taken must be consistent with the laboratory's quality control program
(GEN.30000). Patient test results obtained in an analytically unacceptable test run or since
the last acceptable test run must be re-evaluated to determine if there is a significant clinical
difference in patient/client results. Re-evaluation may or may not include re-testing patient
samples, depending on the circumstances.
Even if patient samples are no longer available, test results can be re-evaluated to search for
evidence of an out-of-control condition that might have affected patient results. For example,
evaluation could include comparison of patient means for the run in question to historical patient
means, and/or review of selected patient results against previous results to see if there are
consistent biases (all results higher or lower currently than previously) for the test(s) in question.
The corrective action for tests that have an IQCP approved by the laboratory director must
include an assessment of whether further evaluation of the risk assessment and quality control
plan is needed based on the problems identified (eg, trending for repeat failures, etc.).
✓ Records of corrective action for unacceptable control results
REFERENCES
amendments of 1988; final rule. Fed Register. 2003(Oct 1):1046[42CFR493.1282(b)(2)]
HEM.20146 Monthly QC Review Phase II

The laboratory director or designee reviews and assesses quality control data at least
monthly.
NOTE: The reviewer must record follow-up for outliers, trends, or omissions that were not
previously addressed.
The QC data for tests performed less frequently than once per month may be reviewed when the
tests are performed.
The review of quality control data for tests that have an IQCP approved by the laboratory director
must include an assessment of whether further evaluation of the risk assessment and quality
control plan is needed based on problems identified (eg, trending for repeat failures, etc.).
✓ Records of QC review including follow-up for outliers, trends or omissions
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HEMATOLOGY
SPECIMEN COLLECTION AND HANDLING

● Sampling of hematology specimen collection and handling policies and procedures
● Sampling of patient CBC specimens (anticoagulant, labeling, storage)
● How do you know if the CBC specimen is clotted, lipemic, or hemolyzed?

● How do you ensure the CBC sample is thoroughly mixed before analysis?
● What is your course of action when you receive unacceptable hematology
specimens?
HEM.22000 Collection in Anticoagulant Phase II

All blood specimens collected in anticoagulant for hematology testing are mixed
thoroughly immediately before analysis.
NOTE: Some rocking platforms may be adequate to maintain even cellular distribution of
previously well-mixed specimens, but are incapable of fully mixing a settled specimen. For
instruments with automated samplers, the laboratory must ensure that the automated mixing time
is sufficient to homogeneously disperse the cells in a settled specimen.
✓ Records of evaluation of each specimen mixing method (eg, rotary mixer, rocker, automated
sampler, or manual inversions) for reproducibility of results, as applicable
REFERENCES
1) Clinical and Laboratory Standards Institute. Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens. 7th
ed. CLSI standard GP42. Clinical and Laboratory Standards Institute, Wayne, PA, 2020.
2) Clinical and Laboratory Standards Institute. Collection of Diagnostic Venous Blood Specimens; 7th ed. CLSI standard GP41-ED7.
Clinical and Laboratory Standards Institute, Wayne, PA, 2017.
HEM.22050 CBC Anticoagulant Phase II

Samples for complete blood counts and blood film morphology are collected in potassium
EDTA.
NOTE: Blood specimens for routine hematology tests (eg, CBC, leukocyte differential) must
be collected in potassium EDTA to minimize changes in cell characteristics. Laboratories must
follow manufacturer's recommendations for use of alternative anticoagulants.
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REFERENCES
1) Cohle SD, et al. Effects of storage of blood on stability of hematologic parameters. Am J Clin Pathol. 1981;76:67-79
2) Savage RA. Pseudoleukocytosis due to EDTA-induced platelet clumping. Am J Clin Pathol. 1984;82:132-133
3) Rabinovitch A. Anticoagulants, platelets and instrument problems. Am J Clin Pathol. 1984;82:132
6) Broden PN. Anticoagulant and tube effect on selected blood cell parameters using Sysmex NE-series instruments. Sysmex J Intl.
1992;2:112-119
7) Brunson D, et al. Comparing hematology anticoagulants: K2EDTA vs K3EDTA. Lab Hematol. 1995;1:112-119
8) Boos MS, et al. Temperature- and storage-dependent changes in hematologic variable and peripheral blood morphology. Am J Clin
Pathol. 1998;110:537
9) Wood BL, et al. Refrigerated storage improves the stability of the complete blood cell count and automated differential. Am J Clin
Pathol. 1999;112:687-695
HEM.22100 Capillary Tube Collection Criteria Phase II

Samples collected in capillary tubes for microhematocrits or capillary/dilution systems are
obtained in duplicate whenever possible.
NOTE: Microspecimen containers such as those used for other capillary blood CBC parameter
determinations need not be collected in duplicate. Because of the risk of injury, the use of
glass capillary tubes is discouraged; if glass capillary tubes are used, measures have been
implemented to reduce risk or injury.
REFERENCES
2) Occupational Safety and Health Administration. Toxic and hazardous substances. Bloodborne pathogens. Washington, DC: US
Government Printing Office, 1999(Jul 1): [29CFR1910.1030].
HEM.22150 Specimen Quality Assessment - CBC Phase II

CBC specimens are checked for clots (visual, applicator sticks, or automated analyzer
histogram inspection/flags) before reporting results.
NOTE: This may be done visually or with applicator sticks before testing. Additionally, microclots
will often present themselves histographically on automated and semi-automated particle
counters or by flagging, and the testing personnel must become familiar with such patterns.
Finally, platelet clumps or fibrin may be microscopically detected if a blood film is prepared on the
same sample.
REFERENCES
1) Clinical and Laboratory Standards Institute. Validation, Verification, and Quality Assurance of Automated Hematology Analyzers;
Approved Standard. 2
nd ed. CLSI Document H26-A2. Clinical and Laboratory Standards Institute, Wayne, PA; 2010.
HEM.22200 Hemolyzed or Lipemic Specimens - CBC Phase II

CBC specimens are checked for significant in vitro hemolysis and possible interfering
lipemia before reporting results.
NOTE: Specimens for complete blood counts must be checked for in vitro hemolysis that may
falsely lower the erythrocyte count and the hematocrit, as well as falsely increase the platelet
concentration from erythrocyte stroma. Visibly red plasma in a tube of EDTA-anticoagulated
settled or centrifuged blood should trigger an investigation of in vivo hemolysis (in which case the
CBC data are valid) versus in vitro hemolysis (in which case some or all of the CBC data are not
valid and should not be reported). Lipemia may adversely affect the hemoglobin concentration
and the leukocyte count. This does not imply that every CBC specimen must be subjected
to centrifugation with visual inspection of the plasma supernatant, particularly if this would
significantly impair the laboratory's turnaround time. An acceptable alternative for high volume
laboratories with automated instrumentation is to examine the numeric data for anomalous
results (especially indices), as well as particle histogram inspection.
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REFERENCES
1) Cantero M, et al. Interference from lipemia in cell count by hematology. Clin Chem. 1996;42:987-988
**REVISED** 10/24/2022
HEM.22625 Storage and Stability - Hematology Phase I
The laboratory defines sample storage conditions and stability for all hematology
parameters.
NOTE: The laboratory must define sample storage conditions and stability for all hematology
parameters, as time- and temperature-dependent alterations can occur, creating spurious results.
REFERENCES
1) Boos MS, et al. Temperature- and storage-dependent changes in hematologic variable and peripheral blood morphology. Am J Clin
Pathol. 1998;110:537
2) Gulati GL, et al. Changes in automated complete blood cell count and differential leukocyte count results induced by storage of blood
at room temperature. Arch Pathol Lab Med. 2002;126:336-342
COMPLETE BLOOD COUNT (CBC) INSTRUMENTS
CALIBRATION
Commercially available calibrator materials represent a convenient way to ensure that CBC instruments yield
accurate results. Because of differences in technology, such calibrators are typically instrument-specific, and are
cleared by the Food and Drug Administration for such use. These calibrators have more rigorous assignment of
target values than ordinary commercial QC materials. Commercial control materials are not suitable for routine
instrument calibration.
● Sampling of CBC calibration policies and procedures
● Sampling of CBC calibration records
● What is your course of action if the CBC instrument fails to pass all calibration
parameters?
● When was the last time you performed a calibration procedure and how did you verify
the calibration?
HEM.25400 Precalibrated Instrument Verification Phase II

If precalibrated instruments are used, the manufacturer's calibrations are verified with
appropriate control materials for the system.
NOTE: This requirement does not apply to CBC instruments that can be calibrated by the
laboratory.
✓ Records of calibration verification following manufacturer's instructions
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REFERENCES
1) van Assendelft OW, Buursma A. Reference method for the measurement of hemoglobin. Lab Hematol. 1995;1:154-155
amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1255]
HEM.25700 Calibration Phase II

The laboratory follows defined criteria for periodic analyzer calibration using stabilized
materials with target values certified by the manufacturer using primary reference
procedures.
REFERENCES
1) Gilmer PR, Williams LJ. The status of methods of calibration in hematology. Am J Clin Pathol. 1980;74:600-605
2) Lewis SM, et al. Current concepts in haematology 3: blood count calibration. J Clin Pathol. 1991;144:881-884
3) Clinical and Laboratory Standards Institute (CLSI). Validation, Verification, and Quality Assurance of Automated Hematology
Analyzers; Approved Standard—Second Edition. CLSI document H26-A2 (ISBN 1-56238-728-6). Clinical and Laboratory Standards
Institute, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania 19087-1898 USA, 2010.
**REVISED** 10/24/2022
HEM.25760 Calibration Verification Criteria Phase II
Criteria for the frequency and acceptability of calibration verification are defined and
followed.
NOTE: Criteria for calibration verification include:

1. At complete changes of reagents (ie, change in type of reagent from same vendor, or
change to a different vendor)
2. When indicated by quality control data
3. After major maintenance or service
4. When recommended by the manufacturer
5. At least every six months
For automated CBC cell counting instruments, requirements for calibration verification may be
considered met if the laboratory follows the manufacturer's instructions for instrument operation
and tests two levels of control materials each day of testing. The control results must meet the
laboratory's criteria for acceptability. Linearity studies are not required.
✓ Records of calibration verification at defined frequency
REFERENCES
amendments of 1988; final rule. Fed Register. 2003(Jan 24):7165 [42CFR493.1255]
HEM.25780 Recalibration Phase II

The laboratory performs recalibration of parameters using stabilized whole blood or other
commercial preparations with parameters certified by the manufacturer.
CBC INSTRUMENT QUALITY CONTROL
Longitudinal process quality control (QC) procedures for individual instruments may include:
1. Use of preserved or stabilized whole blood controls
2. "Moving average" monitoring
3. Retained patient specimens, or
4. Some combination of the above
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At least two different controls must be assayed and evaluated every 24 hours. For each QC procedure
employed, the laboratory must have appropriate QC ranges. For example, expected recovery ranges for
commercial control materials are NOT the same as between-run SD ranges, and are probably too wide for daily
QC of a single instrument. The laboratory should calculate its own imprecision statistics for each instrument.
● Sampling of QC policies and procedures
● Sampling of QC records from the previous two-year period
● Sampling of CBC error detection policies and procedures
● How do you determine when QC is unacceptable and when corrective actions are
needed?
● How does your laboratory establish or verify acceptable QC ranges?
● How do you ensure results from CBC specimens with cold agglutinins, nucleated
RBCs and lipemia are reported accurately?
● Select a spurious result example and follow the process used to ensure the correct
results are reported
STABILIZED CONTROLS
HEM.25850 Stabilized Controls Phase II

The laboratory analyzes two different stabilized control specimens during each 24-hours
of analyzer use.
NOTE: Stabilized control materials must be at two different analytic levels (ie, "normal" and
"high"). Three levels of control is a conceptual carryover from clinical chemistry, and does not
apply to hematology particle counting. Dilute, "low-level" (eg, leukopenic and thrombocytopenic)
"oncology" controls are less informative indicators of calibration status and are neither required
nor recommended. For example, a 10% calibration bias will be numerically most apparent in a
high-level control, less apparent in a normal-level control, and perhaps inapparent in a low-level
control; it would be quite extraordinary for a low-level control to indicate a calibration problem that
is not revealed by the other controls. There should be some relationship between the frequency
of control runs and the numbers of patient specimens processed. If the frequency of commercial
control use is less than two control specimens per 24 hours, one or more of the additional
approaches to QC must be employed to produce a total of at least two different data points per
24 hours.
✓ Records of QC results
REFERENCES
1) Lott JA, et al. Synthetic materials for platelet quality control. Am J Med Technol. 1983;49:43-48
2) Yacko M, et al. Multiple methods for platelet enumeration. Observation of a newly introduced bias. Am J Clin Pathol. 1987;87:109112
amendments of 1988; final rule. Fed Register. 2003(Jan 24):7168 42CFR493.1256(d)]
4) Dotson MA. Methods to monitor and control systematic error. In: clinical hematology: principles, procedures, correlations, 2nd edition.
Stiene-Martin EA, et al, eds. Philadelphia, PA: Lippincott, 1998:579-590
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5) Fink NE, et al. Evaluation and additional recommendations for preparing a whole blood control material. Rev Saude Publica.
1998;32:107-111
6) Springer W, et al. Evaluation of a new reagent for preserving fresh blood samples and its potential usefulness for internal quality
control of multichannel hematology analyzers. Am J Clin Pathol. 1999;111:387-396
MOVING AVERAGES
The technique of weighted moving averages (derived from multiple batch analysis of patient samples) is
acceptably sensitive to drifts or shifts in analyzer calibration if a supplemental QC routine (stabilized control
material or retained patient specimens) is employed. The latter is needed to detect random error and to avoid
bias due to masking of drift by characteristics of the subpopulations within each individual batch.
Laboratories analyzing fewer than 100 CBC specimens daily (long term average) should not use moving
averages as the primary method for process control, as this would not generate sufficient data within a day to be
of value.
Depending on the particular instrument, there may be "on-board" moving average analyses for RBC indices
only. In such cases, additional QC techniques are required for WBC, PLT and WBC differential parameters.
However, some laboratories have found the mathematical logic of moving averages, modified average of
normals, etc., applicable to other CBC parameters, and some instruments have these capabilities built into their
software. Or, such calculations may be performed with an associated computer.
**REVISED** 10/24/2022
HEM.25920 QC - Moving Averages Phase II
Control limits for moving averages are appropriately sensitive.
NOTE: Control limits for moving averages must be appropriately sensitive such that significant
calibration alterations are always detected. The written procedures must define the method
used to establish the moving average, the frequency of calculation (batch size), and criteria for
selection of upper and lower limits.
Recalibration is not required for minor calibration variations of no clinical consequence. In
other words, there should be a high probability for error detection and a low probability for false
rejection.
REFERENCES
1) Bull BS, et al. A study of various estimators for the derivation of quality control procedures from patient erythrocyte indices. Am J Clin
Pathol. 1974;61:473-481
2) Talamo TS, et al. Microcomputer assisted hematology quality control using a modified average of normals program. Am J Clin
Pathol. 1981; 76:707-712
3) Bull BS, Korpman RA. Autocalibration of hematology analyzers. J Clin Lab Automation. 1983;3:111-116
4) Cembrowski GS, Westgard JO. Quality control of multichannel hematology analyzers: evaluation of Bull's algorithm. Am J Clin
Pathol. 1985;83:337-345
5) Bull BS, Hay KL. Are red blood cells indexes international? Arch Pathol Lab Med. 1985;109:604-606
6) Levy WC, et al. Preserved blood versus patient data for quality control - Bull's algorithm revisited. Am J Clin Pathol. 1986;85:719-721
7) Levy WC, et al. The incorporation of red blood cell index mean data into quality control programs. Am J Clin Pathol. 1986;86:193-199
8) Lunetzky ES, Cembrowski GS. Performance characteristics of Bull's multirule algorithm for the quality control of multichannel
hematology analyzers. Am J Clin Pathol. 1987;88:634-638
9) Clinical and Laboratory Standards Institute (CLSI). Validation, Verification, and Quality Assurance of Automated Hematology
Analyzers; Approved Standard—Second Edition. CLSI document H26-A2 (ISBN 1-56238-728-6). Clinical and Laboratory Standards
Institute, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania 19087-1898 USA, 2010.
HEM.25990 QC Procedure Phase II

If a "moving averages" system is combined with another control system (commercial
controls or retained patient specimens), the process is well defined and appropriately
sensitive to drift in analyzer calibration.
✓ Records of QC results using moving averages
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REFERENCES
1) Cembrowski GS, Clarke G. Quality control of automated cell counters. Clin Lab Med. 2015;35:59-71.
2) Verbrugge SE, Huisman A. Verification and standardization of blood cell counters for routine clinical laboratory tests. Clin Lab Med.
2015;35:183-96.
3) Vis JY, Huisman A. Verification and quality control of routine hematology analyzers. Int J Hematol. 2016;38(suppl 1):100-9.
RETAINED PATIENT SPECIMENS
Use of retained patient specimens alone is inadequate for routine QC of the primary CBC instrument, and
must be considered as a supplemental procedure, in combination with another QC system. Retained patient
specimens, while conveniently available, present some difficulties in mathematically defining "agreement"
between CBC results separated in time, as these are not stabilized samples. This is in contrast to commercial
control materials that have been treated to reduce time-dependent degradation.
HEM.26660 QC - Retained Patient Specimens Phase I

When the laboratory uses retained patient specimens, statistically defined limits are used
to determine agreement of sequential assays of a given specimen.
NOTE: Allowance should be made for time-dependent alterations in data from such labile
specimens.
✓ QC records for retained patient specimens
HEM.27330 QC - CBC Defined Range Phase I

There is a defined range of CBC values for which control limits used for retained patient
specimens are applicable.
NOTE: Because imprecision (standard deviation, coefficient of variation) is dependent upon the
hematologic target value, limits must be restricted to appropriate ranges of CBC values.
ERROR DETECTION AND VERIFICATION
HEM.30070 Sampling Mode Comparison Phase I

The laboratory compares all results obtained for patient specimens analyzed in the
multiple sampling modes of the CBC analyzer (eg, "primary" and "secondary" modes) at
least annually to ensure that they are in agreement.
NOTE: Different modes may involve a different sample path before analysis. When samples
are analyzed in more than one mode, it is important to ensure that all modes function properly.
Re-analysis of a previously analyzed sample must be performed in the alternate mode(s), and
results must agree with the initial mode within the tolerance limits established for agreement by
the hematology laboratory's quality control program, and any recommendations by the instrument
manufacturer. Mode-to-mode correlation is not necessary for those analyzers that use the same
pathway for all modes.
✓ Records of sampling mode comparison studies
HEM.30100 Detection/Correction Procedure - WBC Phase II

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The laboratory has a process to detect and correct automated WBC counts for the
presence of nucleated red cells or megakaryocytes.
NOTE: The effect of nucleated erythrocytes and blood megakaryocytes on the apparent WBC
count varies with the system used for analysis. Each laboratory must evaluate its system(s) and
develop appropriate detection and correction procedures. This is important to prevent reporting a
falsely high WBC concentration. With some automated CBC instruments, nucleated erythrocytes
or megakaryocytes may present themselves histographically or cytographically, and this can
serve as an indicator for careful inspection of a stained blood film. The laboratory must establish
if its particular instrument(s) includes some or all nucleated non-leukocytes in its apparent WBC
"count".
✓ Records showing actions taken to verify WBC concentration prior to reporting
REFERENCES
1) Zandecki M, Genevieve F, Gerard J, Gordon A. Spurious counts and spurious results on haematology analyzers: a review. Part II:
white blood cell, red blood cells, haemaglobin, red cell indices and reticulocytes. Int J Lab Hematol. 2007;29(1):21-41.
2) Barnes PW, McFadden SL, Machin SJ, Simson E. The international consensus group for hematology review: suggested criteria for
action following automated CBC and WBC differential analysis. Lab Hematol. 2005;11(2):83-90.
HEM.30150 Spurious CBC Results Phase II

The laboratory has a process to detect spurious CBC instrument results that may
be clinically significant (eg, pseudomacrocytosis from rouleaux or agglutinates;
pseudoleukocytosis with erroneous hemoglobin, falsely low erythrocyte count and
hematocrit; hyperlipemia) prior to reporting.
NOTE: Analytic sources of error with automated instruments depend on the type of instrument
and reagents used by the laboratory.
✓ Record of action taken when spurious CBC instrument results are detected
REFERENCES
2) Zandecki M, Genevieve F, Gerard J, Gordon A. Spurious counts and spurious results on haematology analyzers: a review. Part I:
platelets. Int J Lab Hematol. 2007;29(1):4-20.
3) Barnes PW, McFadden SL, Machin SJ, Simson E. The international consensus group for hematology review: suggested criteria for
action following automated CBC and WBC differential analysis. Lab Hematol. 2005;11(2):83-90.
4) Lee EJ, Lee AI. Thrombocytopenia. Prim Care. 2016;43:543-67.
HEM.30200 Red Cell Indices Phase I

The laboratory routinely monitors red cell indices (MCV, MCH, MCHC) to detect random
errors.
NOTE: Patient sample red cell indices (MCV, MCH, MCHC) must be monitored routinely
to detect random errors, instrument malfunction, or spurious results. On many automated
instruments, the MCHC is the most useful parameter to ensure accuracy of the red cell
parameters in individual patient samples. Since MCHC varies over a narrow range, an abnormal
MCHC will often flag potentially spurious red cell parameters. Truly elevated MCHCs may be
seen with spherocytosis, while decreased MCHCs can accompany a low MCV in severe iron
deficiency anemia. If such RBC abnormalities are not present on the blood film, one or more
of the measured RBC parameters is likely erroneous. Incorrect data may be due to instrument
malfunction or to problems with the blood sample itself. MCV and MCH are fairly constant for
each patient, and monitoring these indices in a delta check error detection program may provide
rapid patient-based detection of instrument malfunction or specimen misidentification.
✓ Record of action taken when RBC indices are in question, including the reporting of results
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REFERENCES
2) Barnes PW, et al. The international consensus group for hematology review: suggested criteria for action following automated CBC
and WBC differential analysis. Lab Hematol. 2005;11(2):83-90.
3) Cembrowski GS, Clarke G. Quality control of automated cell counters. Clin Lab Med. 2015;35:59-71.
4) Verbrugge SE, Huisman A. Verification and standardization of blood cell counters for routine clinical laboratory tests. Clin Lab Med.
2015;35:183-96.
5) Vis JY, Huisman A. Verification and quality control of routine hematology analyzers. Int J Hematol. 2016;38(suppl 1):100-9.
HEM.30250 Reportable Range Phase II

Upper and lower limits of all reportable parameters on the CBC instrument are defined,
and results that fall outside these limits are reported properly.
NOTE: The laboratory must initially establish or verify the reportable range for each parameter
of its automated or semi-automated CBC instrument. In particular, the laboratory must have
data on its instrument's accuracy with thrombocytopenic and leukopenic samples. Platelet
concentrations below the established lower limits must be reanalyzed by another method (eg,
manual hemocytometry, or semiquantitative blood film estimates, or fluorescence flow cytometry
using specific platelet monoclonal antibodies). Particle (WBC, RBC, PLT) concentrations above
the established upper limits must, as clinically needed, be reanalyzed by doing the minimum
dilution necessary to bring the counts into the instrument's analytic range. When clinically
appropriate, apparent analyte concentrations that are lower or higher than the reportable range
may be reported as "less than" the lower limit or "greater than" the higher limit.
✓ Record of action taken when limits are exceeded, including the reporting of results
REFERENCES
2) Hanseler E, et al. Estimation of the lower limits of manual and automated platelet counting. Am J Clin Pathol. 1996;105:782-787
3) Ault KA. Implementation of the immunological platelet count on a hematology analyzer - the Abbott Cell-Dyn 4000. Lab Hematol.
1997;3:125-128
HEM.30300 Platelet Abnormalities Phase II

The laboratory has a process (such as microscopic correlation with the blood film) to
prevent reporting of spurious thrombocytopenia when platelet clumps, giant platelets, or
platelet satellitism are present.
NOTE: When platelet satellitosis (satellitism), significant numbers of giant platelets and/or platelet
clumps are suspected/detected by cyto/histographic abnormalities or instrument rejection of
a platelet result, the platelet concentration must be independently verified. Correlation with a
well-prepared blood film must be made. If platelets are clumped after collection in an EDTA-
anticoagulated tube that was well-mixed at the time of collection, this may represent in vitro
EDTA-induced changes; platelets must be quantified from blood collected directly into a counting
diluent, by use of a different anticoagulant per manufacturer's recommendations, or by estimation
from a non-anticoagulated blood film.
✓ Record showing actions taken to verify platelet concentration prior to reporting
REFERENCES
1) Hyun BH, et al. Platelet satellitosis. Chicago, IL: American Society of Clinical Pathology Check Sample H-78, 1976
2) Veenhoven WA, et al. Pseudothrombocytopenia due to agglutinins. Am J Clin Pathol. 1979;72:1005-1008
3) Gloster ES, et al. Spurious platelet counts associated with bacteremia. Am J Hematol. 1985;18:329-332
4) Cunningham VL, Brandt JT. Spurious thrombocytopenia due to EDTA-independent cold-reactive agglutinins. Am J Clin Pathol.
1992;97:359-362
5) Hanseler E, et al. Estimation of the lower limits of manual and automated platelet counting. Am J Clin Pathol. 1996;105:782-787
6) Bridgen ML, Dalal BU. Cell counter-related abnormalities. Lab Med. 1999;30:325-334
7) Kunicka JE, et al. Improved platelet counting using two-dimensional laser light scatter. Am J Clin Pathol. 2000;114;114:283-289
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HEM.30350 Spuriously High WBC Concentration Phase II

If significant numbers of unlysed RBC, giant platelets and/or platelet clumps are
suspected/detected, the WBC concentration is rechecked by another method or blood
films are examined to prevent reporting spuriously high WBC concentrations.
NOTE: When unlysed RBC, PLT satellitosis, significant numbers of giant PLT and/or PLT clumps
are suspected/detected by histographic abnormalities or instrument rejection of the PLT result,
the WBC count must be verified manually, by automated counting after collection into a different
anticoagulant, by automated counting in a lyse-resistant mode, or by semiquantitative blood film
evaluation to prevent reporting spuriously high WBC concentrations.
Evidence of Compliance
✓ Record showing actions taken to verify WBC concentration prior to reporting
REFERENCES
2) Zandecki M, Genevieve F, Gerard J, Gordon A. Spurious counts and spurious results on haematology analyzers: a review. Part I:
platelets. Int J Lab Hematol. 2007;29(1):4-20.
HEM.30400 Platelet Count Verification Phase II

If significant numbers of microcytic erythrocytes and/or small cell fragments are detected/
suspected, the platelet count is determined or verified using an alternate method.
NOTE: When a significant number of interfering particles are identified at the upper or lower PLT
counting threshold (by inspection of the PLT histogram or instrument flag), the PLT concentration
must be determined or verified by an alternate method. Such methods could include alternate
instrumentation, hemocytometry, or blood film estimate, depending upon the PLT concentration
and the degree of clinical accuracy required.
✓ Records showing action taken to verify platelet concentration prior to reporting
REFERENCES
1) Morton BD, et al. Pappenheimer bodies: an additional cause for a spurious platelet count. Am J Clin Pathol. 1980;74:310-311
2) Akware AM, et al. Spuriously elevated platelet counts due to microspherocytosis. Am J Clin Pathol. 1982;77:220-221
3) Gloster ES, et al. Spurious elevated platelet counts associated with bacteremia. Am J Hematol. 1985;18:329-332
4) Bridgen ML, Dalal BI. Cell counter-related abnormalities. Lab Med. 1999;30:325-334
5) Li S, Salhany KE. Spurious elevation of automated platelet counts in secondary acute monocytic leukemia associated with tumor
lysis syndrome. Arch Pathol Lab Med. 1999;123:1111-1114
6) Kunicka JE, et al. Improved platelet counting using two-dimensional laser light scatter. Am J Clin Pathol. 2000;114;114:283-289
MANUAL HEMATOCRIT
● Hematocrit procedure
● Sampling of annual centrifuge speed checks
● Sampling of timer checks
HEM.32050 Microhematocrit Centrifuge Phase I

The speed of the microhematocrit centrifuge is checked at least annually.
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NOTE: Relative centrifugal field (RCF) must be sufficient to achieve maximum packing of cells.
The centrifuge must be capable of sustaining an RCF of 10,000 to 15,000 at the periphery for five
minutes.
If the centrifuge speed cannot be checked by the user, the laboratory must annually compare
centrifuge test results against another centrifuge with known speed and constant packing time. If
the laboratory does not have such an instrument, another laboratory or an outside vendor may be
used for this comparison.
✓ Records of microhematocrit centrifuge speed checks
REFERENCES
1) Clinical and Laboratory Standards Institute. Procedure for Determining Packed Cell Volume by the Microhematocrit Method;
Approved Standard; 3rd ed. CLSI document H07-A3. CLSI, Wayne, PA, 2000.
HEM.32100 Mechanical Timer Phase I

If a mechanical timer is used, its accuracy is checked at least annually.
NOTE: Not applicable to electronic timers.

✓ Records of mechanical timer checks
HEM.32150 Constant Packing Time Phase II

The laboratory establishes constant packing time (minimum spin to reach maximum
packing of cells) before initial use and reassesses when there has been a change in either
the speed or time.
✓ Records of initial and reassessment studies as appropriate
REFERENCES
1) Clinical and Laboratory Standards Institute. Procedure for Determining Packed Cell Volume by the Microhematocrit Method;
Approved Standard; 3rd ed. CLSI document H07-A3. CLSI, Wayne, PA, 2000.
MANUAL BLOOD COUNT
NOTE: Counting chamber RBC counts are not recommended because of the level of imprecision and inability to
verify results against a stained blood film.
● Manual cell counts procedure
● Sampling of QC logs
● How do you correlate counting chamber platelet counts?

● How do you ensure that your diluting fluids are free from contamination?
HEM.33200 Manual Counts - PLT/WBC Phase II

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If WBC or PLT counts are performed manually by pipette dilution and hemocytometer
chamber count, each sample is counted in duplicate, plating both chambers of the
hemocytometer.
NOTE: Performance of the counts in duplicate is required for all hemocytometers, whether glass
or disposable.
✓ Records or worksheets reflecting duplicate counts and corrective action when limits of
agreement are exceeded
REFERENCES
amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1269(a)(2)]
HEM.33250 Manual Counts - PLT/WBC Phase I

When there is leukopenia or thrombocytopenia, the laboratory uses a technique to
offset the increased error associated with counting smaller numbers of cells in the
hemocytometer.
NOTE: Counting an increased number of cells (eg, increased number of hemocytometer squares
enumerated or a lesser specimen dilution) when there is leukopenia or thrombocytopenia can
be used to avoid increasing the imprecision of particle counting, which is governed by binomial
distributions and Poisson statistics.
✓ Records or worksheets for manual counts on leukopenic or thrombocytopenic specimens
REFERENCES
1) Barnett RN. Clinical laboratory statistics, 2nd ed. Boston, MA: Little, Brown, 1979:30-33, 101-103
2) Miale JB. Laboratory medicine hematology, 6th ed. St Louis, MO: CV Mosby, 1982:373-374
3) Savage RA. Evaluate your practice for platelet counts. Northfield, IL: College of American Pathologists Summing Up, Fall 1987
HEM.33300 Contamination Checks Phase II

Dilution fluids and reagents are checked for contaminants that may spuriously change the
true cell counts.
NOTE: Suggested checks include pH, osmolality and background counts.

✓ Records of contamination checks on dilution fluids/reagents
HEM.33330 Cell Count Controls Phase II

The laboratory analyzes at least one cell count control specimen in duplicate, or uses a
procedural control, for each eight hours of patient testing.
NOTE: For WBC and PLT, this requirement can be met with assayed liquid control material,
a previously assayed patient sample, or comparison with a visual blood film concentration
estimate. Visual estimates are not appropriate for RBC hemocytometry. Liquid controls
performed in a hemocytometer must be run in duplicate.
✓ Records of cell count or procedural controls at defined frequency
REFERENCES
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HEM.33350 PLT Estimate Phase I

For platelet hemocytometry, the manual count is correlated with a platelet estimate from a
properly prepared blood film.
✓ Records of slide review/correlation
REFERENCES
1) Barnes PW, et al. The international consensus group for hematology review: suggested criteria for action following automated CBC
and WBC differential analysis. Lab Hematol. 2005;11(2):83-90.
2) Lee EJ, Lee AI. Thrombocytopenia. Prim Care. 2016;43:543-67.
AUTOMATED DIFFERENTIALS
● Automated differential procedure
● What action would you take when there is a flagged result?
HEM.34100 Acceptable Limits - WBC Phase II

Acceptable limits for quality control procedures for WBC subclasses using manually
counted blood films or commercial controls are defined.
NOTE: For automated analyzers, at least two approaches are reasonable: 1) comparison of
instrument differentials on fresh blood samples with a conventional manual differential count,
and/or 2) use of commercially available stabilized leukocytes and/or particle surrogate control
material. The automated instrument and reference determinations should be treated as replicate
manual differentials and evaluated using the ± 2 or 3 SD agreement limits of Rümke. For pattern
recognition microscopy systems, QC can be done by periodic processing of prepared control
slides and maintenance/analysis of Levey-Jennings charts.
For commercial controls, mixed leukocyte subclasses (eg, "mononuclear" or "large unclassified
cells") or "remainder" fractions do not need to be assessed with QC procedures. The commercial
material must contain surrogate particles to measure total neutrophils, total granulocytes, total
lymphoid cells, monocytes, eosinophils, and basophils, if these subtypes are enumerated by the
instrument and reported by the laboratory. If discrete populations of abnormal cells are identified
and enumerated by the instrument (eg, nucleated RBC, blasts), then the QC material must
contain surrogate particles to evaluate accuracy.
REFERENCES
1) Rümke CL. The statistically expected variability in differential leukocyte counts. In: Differential leukocyte counting, CAP conference/
Aspen. Northfield, IL: CAP, 1977:39-45
2) Kalish RJ, Becker K. Evaluation of the Coulter S-Plus V three-part differential in a community hospital, including criteria for its use.
Am J Clin Pathol. 1986;86:751-755
3) Etzell, JE. For WBC differentials reporting absolute numbers. CAP Today, March 2010
4) Richardson-Jones A, Twedt D, Hellman R. Absolute versus proportional differential leukocyte counts. Clin Lab. Haem. 1995:17,
115-123
5) Ross DW, Bentley SA. Evaluation of an automated hematology system (Technicon H1). Arch Pathol Lab Med. 1986;110:803-808
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6) Clinical and Laboratory Standards Institute (CLSI). Reference Leukocyte (WBC) Differential Count (Proportional) and Evaluation of
Instrumental Methods; Approved Standard—Second Edition. CLSI document H20-A2 (ISBN 1-56238-628-X). Clinical and Laboratory
Standards Institute, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania 19087-1898 USA, 2007
7) Miers MK, et al. White blood cell differentials as performed by the Technicon H-1; evaluation and implementation in a tertiary care
hospital. Lab Med. 1991;22:99-106
8) Hallawell R, et al. An evaluation of the Sysmex NE8000 hematology analyzer. Am J Clin Pathol. 1991;96:594-601
9) Cornbleet PJ, et al. Evaluation of the CellDyn 3000 differential. Am J Clin Pathol. 1992;98:603-614
10) Krause JR. The automated white blood cell differential. A current perspective. Hematol Oncol Clin North Am. 1994;8:605-16
11) Goyzueta FG, et al. Automated differential white blood cell counts in the young pediatric population. Lab Med. 1996;27:48-52
12) Gulati GL, et al. Suspect flags and regional flags on the Coulter-STKS. An assessment. Lab Med. 1999;30:675-680
13) Grimaldi E, Scopacasa F. Evaluation of the Abbott CELL-DYN 4000 hematology analyzer. Am J Clin Pathol. 2000;113:497-505
HEM.34200 WBC Differential Verification Phase II

The laboratory uses defined criteria for review and evaluation of leukocyte differential
counter data, histograms, and/or blood films for clinically important results flagged by the
automated differential counter.
NOTE: Clinically important results include pathologic quantities of normal cell types and
abnormal cells. Flagging mechanisms include those within the particular instrument, inspection of
histographic/cytographic displays, laboratory criteria based on local experience, and awareness
of published evaluations.
✓ Records of verification of flagged values
REFERENCES
1) Rümke CL. The statistically expected variability in differential leukocyte counts. In: Differential leukocyte counting, CAP conference/
2) Payne BA, Pierre RV. Using the three-part differential: part II. Implementation of the system. Lab Med. 1986;17:517-522
3) Kalish RJ, Becker K. Evaluation of the Coulter S-Plus V three-part differential in a community hospital, including criteria for its use.
Am J Clin Pathol. 1986;86:751-755
4) Ross DW, Bentley SA. Evaluation of an automated hematology system (Technicon H-1). Arch Pathol Lab Med. 1986;110:803-808
5) Clinical and Laboratory Standards Institute (CLSI). Reference Leukocyte (WBC) Differential Count (Proportional) and Evaluation of
Instrumental Methods; Approved Standard—Second Edition. CLSI document H20-A2 (ISBN 1-56238-628-X). Clinical and Laboratory
Standards Institute, 940 West Valley Road, Suite 1400, Wayne, Pennsylvania 19087-1898 USA, 2007
6) Miers MK, et al. White blood cell differentials as performed by the Technicon H-1; evaluation and implementation in a tertiary care
hospital. Lab Med. 1991;22:99-106
7) Hallawell R, et al. An evaluation of the Sysmex NE-8000 hematology analyzer. Am J Clin Pathol. 1991;96:594-601
8) Cornbleet PJ, et al. Evaluation of the Cell-Dyn 3000 differential. Am J Clin Pathol. 1992;98:603-614
9) Krause JR. The automated white blood cell differential. A current perspective. Hematol Oncol Clin North Am. 1994;8:605-16
10) Goyzueta FG, et al. Automated differential white blood cell counts in the young pediatric population. Lab Med. 1996;27:48-52
11) Gulati GL, et al. Suspect flags and regional flags on the Coulter-STKS. An assessment. Lab Med. 1999;30:675-680
MANUAL DIFFERENTIALS
This section applies to all manually interpreted differentials, including those performed using automated image
analysis systems requiring manual verification or interpretation of cell classification or other morphologic
findings.
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● Manual differential policies and procedures
● Sampling of patient peripheral blood smears (uniquely identified, properly stained,

free of precipitate, good cell distribution)
● File of unusual slides
● How do you ensure consistency among personnel performing blood cell microscopy?
● What criteria are used for referring a blood film for review by a pathologist,
supervisor, or technologist with expertise in hematomorphology?
HEM.34300 Blood Film Quality Phase I

The quality of blood films is satisfactory (properly stained, free of precipitate, good cell
distribution).
REFERENCES
1) Wenk RE. Comparison of five methods for preparing blood smears. Am J Med Technol. 1976;42:71-78
2) College of American Pathologists. Differential leukocyte counting. CAP conference/aspen. Northfield, IL: CAP, 1977
3) Stiene-Martihn EA. Causes for poor leukocyte distribution in manual spreaderslide blood films. Am J Med Technol. 1980;46:624-632
4) Lewis SM. Blood film evaluations as a quality control activity. Clin Lab Haematol. 1990;12:119-127
5) Turgeon ML. Clinical hematology, theories and procedures, 2nd ed. Boston, MA: Little, Brown, 1993;16-25
6) Dacie JV, Lewis SM. Practical hematology, 8th ed. New York, NY: Churchill Livingstone, 1995;83-89
HEM.34320 Stain Reactivity Phase II

All stains are checked for intended reactivity each day of use.
✓ Records of stain QC at defined frequency
REFERENCES
amendments of 1988; final rule. Fed Register. 2003(Jan 24):7166 [42CFR493.1256(e)(2)]
**REVISED** 10/24/2022
HEM.34400 Morphologic Observation Evaluation - CBC Phase II
The laboratory evaluates consistency of morphologic observation among personnel
performing blood cell microscopy at least annually.
NOTE: The laboratory must ensure the identification and morphology of blood cells is reported
consistently amongst all personnel performing the microscopic analysis.
Suggested methods to accomplish this include:
1. Circulation of a pre-graded set of blood films with defined leukocyte differential
distributions, and RBC and platelet morphology.
2. Multi-headed microscopy
3. Use of blood or marrow photomicrographs with referee and consensus identifications
(eg, former CAP surveys photomicrographs)
4. Use of digital images
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5. Enrollment and participation of all personnel in an external assessment program for

morphologic observation for peripheral blood smear morphology.
In the case of comparative blood film WBC differentials, the method of Rümke is recommended
to define statistical agreement among observers.
The laboratory director or designee must determine acceptability criteria for agreement. The
laboratory must maintain records of performance and record corrective actions taken for
personnel demonstrating significant discrepancies from the group consensus.
✓ Records of evaluation AND/OR
✓ Records of enrollment/participation of staff in an external assessment program
REFERENCES
1) Rümke CL. The statistically expected variability in differential leukocyte counts, In: Differential leukocyte counting, CAP conference/
2) Wood B, et al. Teaching the clinical interpretation of peripheral blood smears to second-year medical school class using the
peripheral blood-tutor computer program. Am J Clin Pathol. 1998;109:514-520
3) College of American Pathologists. Surveys hematology glossary. Northfield, IL: CAP, 1999:1-26
4) Brigden ML, Dalal BI. Morphologic abnormalities, pseudosyndromes, and spurious test results. Lab Med. 1999;30:397-405
5) Haun DE, et al. A better way to assess WBC differential counting skills. Lab Med. 2000;31:329-333
6) College of American Pathologists Hematology and Clinical Microscopy Resource Committee. Hematology Benchtop Reference
Guide: An Illustrated Guide for Cell Morphology. Northfield, IL: College of American Pathologists, 2012.
7) Glassey E, ed. Color Atlas of Hematology: An Illustrated Field Guide Based on Proficiency Testing. 2nd Ed. College of American
Pathologists. Northfield, IL: CAP Press; 2018.
HEM.34450 Slide Retention - CBC Differential Phase I

Blood film slides (peripheral blood smears) are retained for at least one week for possible
review and/or reference.
NOTE: It may be desirable to retain outpatient films for a longer period and significantly abnormal
films indefinitely for teaching purposes.
**REVISED** 10/24/2022
HEM.34500 Morphology Assessment Phase II
Personnel follow defined criteria to fully assess and accurately report WBC, RBC and
platelet morphology as part of a manual WBC differential and/or blood film review.
NOTE: The laboratory must have a system to ensure that technical personnel have fully
assessed all morphologic findings in each patient film. Each laboratory director should, in
consultation with the medical staff, determine which morphologic findings are reportable.
For example, minor degrees of anisocytosis and poikilocytosis without specific types of RBC
abnormalities may be considered within the normal spectrum and not reportable to the chart. For
RBC abnormalities that are reported, the laboratory must define a qualitative or semiquantitative
grading system. When defined abnormalities (eg, spherocytes, target cells, fragments, etc.) are
present, non-specific listings of "anisocytosis" and/or "poikilocytosis" may not provide additional
clinically useful information.
✓ Patient reports that show assessment and reporting of morphologic findings
REFERENCES
1) Napoli V, et al. A semiquantitative estimate method for reporting abnormal RBC morphology. Lab Med. 1980;11:111-116
2) Krause JR. Redcell abnormalities in the blood smear: disease correlations. Lab Mgmt. 1985;23(10):29-35
3) Bell A, Lofsness KG. A photo essay on red cell morphology. J Med Tech. 1986;3:85-93
4) Lewis SM. Blood film evaluations as a quality control activity. Clin Lab Haematol. 1990;12:119-127
HEM.34600 Criteria for Blood Film Review Phase II

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The laboratory follows defined criteria for review of specified findings on blood films by
the pathologist, supervisor, or other technologist qualified in hematomorphology.
✓ Patient reports with reviewer comments OR electronic record OR review log
REFERENCES
1) Peterson P, et al. Physician review of the peripheral blood smear: when and why. An opinion. Lab Hematol. 2001;7:175-179
2) Gulati GL, et al. Criteria for blood smear review. Lab Med. 2002;33:374-377
BLOOD FILMS FOR MICROORGANISMS

● Sampling of blood parasite and microorganism policies and procedures
● Sampling of patient reports
● Buffer pH records
HEM.34655 Blood Film Microorganism Detection Phase II

Blood films submitted for microscopic examination allow for detection of microorganisms
that may be present.
NOTE: Microorganisms that should be recognized, if present, include parasites, such as

Plasmodium species, trypanosomes, and microfilaria. Occasionally, the morulae of Anaplasma
and Ehrlichia, which are bacteria, may be seen. Spirochetes of the Borellia genus may be seen
in patients with relapsing fever. Yeasts may sometimes be seen in patients with disseminated
histoplasmosis or with fungemia caused by other yeast species (eg, Candida species or
Malassezia species).
✓ Blood parasitology atlas or reference materials
REFERENCES
1) Clinical and Laboratory Standards Institute. Laboratory Diagnosis of Blood-borne Parasitic Diseases; Approved Guideline. CLSI
document M15-A. CLSI, Wayne, PA, 2000.
2) Pritt BS. Parasitology Benchtop Reference Guide: An Illustrated Guide for Commonly Encountered Parasites. Northfield, IL; College
of American Pathologists, 2014.
HEM.34687 Parasite Load Reporting Phase I

When blood films are positive for malaria parasites (Plasmodium spp.), the parasite
load (provided as percentage parasitemia or the number of parasites per µL of blood) is
reported along with the organism identification.
NOTE: It is important to determine the parasite load when blood films are reviewed and found
to be positive for malaria parasites because this information may be used to guide treatment
decisions and monitor the response to therapy. Due to the potential for drug resistance in some
of the Plasmodium species, particularly P. falciparum, it is important that every positive smear be
assessed and the parasite load reported exactly the same way on follow-up specimens as on the
initial specimen. This allows the parasite load to be monitored after therapy has been initiated.
The parasite load will usually drop very quickly within the first 24 hours; however, in cases of
drug resistance, the level may not decrease, but actually increase over time.
Although there are currently no requirements for reporting parasite load when blood films are
positive for Babesia species, physicians may ask for these data to guide treatment decisions and
monitor the response to therapy.
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✓ Patient reports for positive malaria cases
REFERENCES
2) Garcia LS, Diagnostic Medical Parasitology. Washington, DC, ASM Press, 2001
4) World Health Organization. Recording and Reporting Microscopy Results: Malaria Microscopy Standard Operating Procedure -
MM-SOP-6B. Version 1. http://www.wpro.who.int/mvp/lab_quality/2096_oms_gmp_sop_06b_rev.pdf. Effective January 1, 2016.
Accessed September 12, 2019.
5) World Health Organization. Malaria Parasite Counting. Malaria Microscopy Standard Operating Procedure - MM-SOP-9. Version
1.http://www.wpro.who.int/mvp/lab_quality/2096_oms_gmp_sop_09_rev1.pdf. Effective January 1, 2016. Accessed August 12, 2019.
HEM.34724 Thick and Thin Films Phase II

Both thick and thin films (routine blood films and/or buffy coat films), or methods of
equivalent sensitivity, are made to provide thorough examination for blood parasites.
REFERENCES
2) Thomson S, et al. External quality assessment in the examination of blood films for malHelvetica parasites within Ontario, Canada.
Arch Pathol Lab Med. 2000;124:57-60
**REVISED** 10/24/2022
HEM.34798 Malaria Stain Buffer pH Phase I
There are records that malaria stains are washed with a buffer of a pH appropriate for the
stain used.
NOTE: The ideal buffer pH for Plasmodium species identification is 7.0-7.2, as it allows for
optimal visualization of malarial cytoplasmic inclusions (eg, Schüffner's dots and Maurer's clefts).
REFERENCES
2) Garcia LS, Bruckner DA. Diagnostic medical parasitology. Washington, DC: American Society for Microbiology, 1997:702-703
4) Mathison BA, Pritt BS. Update on malaria diagnostics and test utilization. J Clin Microbiol. 2017;55(7): 2009-17.
HEM.34872 Slide Review Procedure Phase I

An adequate number of fields is examined under the 100 X oil-immersion objective (eg,
300 fields).
REFERENCES
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AUTOMATED RETICULOCYTES
● Automated reticulocyte procedure
HEM.35150 Spurious Reticulocyte Results Phase I

The laboratory has a process to detect spurious automated reticulocyte results prior to
reporting.
NOTE: Since all DNA- and RNA-containing cells will stain with DNA-RNA fluorescent dyes,
the process must identify when the instrument cannot discriminate such stained particles from
true reticulocytes. Potential interferences include Howell-Jolly bodies, nucleated erythrocytes,
Heinz bodies, basophilic stippling of red cells, macrothrombocytes, megakaryocyte fragments,
platelet clumps, and malaria or other intracellular organisms. Erythrocyte agglutination also
may give spuriously high results, as may very high leukocytosis or thrombocytosis. Interfering
particles may vary, depending on instrumentation, dye, and reaction conditions. Based upon
initial evaluation of the instrument by the laboratory, criteria must be developed to detect samples
with potentially erroneous results. This may be accomplished through flagging algorithms
incorporated in the instrument and by examination of a blood film from every sample to ensure
absence of relevant interferences.
✓ Records showing actions taken to verify reticulocyte count prior to reporting
REFERENCES
1) Jacobberger HW, et al. Flow cytometric analysis of blood cells stained with the cyanine dye Dioc1[3]: reticulocyte quantification.
Cytometry. 1984;5:589-600
2) Davis BH, et al. Utility of flow cytometric reticulocyte quantification as a predictor of engraftment in autologous bone marrow
transplantation. Am J Hematol. 1989;32:81-87
3) Davis BH, Bigelow NC. Flow cytometric quantification using thiazole orange provides clinically useful reticulocyte maturity index. Arch
Pathol Lab Med. 1989;113:684-689
4) Hackney JR, et al. Automated reticulocyte counting by image analysis and flow cytometry. Lab Med. 1989;20:551-555
5) Coulet M, Bezou MJ. Utilization of the automated reticulocyte counter Sysmex R-1000. Sysmex J. 1990;13:393-406
6) Wells DA, et al. Effect of iron status on reticulocyte mean channel fluorescence. Am J Clin Pathol. 1992;97:130-134
7) Riley RS, Ross W. Reticulocyte enumeration, In: Riley RS, Makin EJ, Ross W, eds. Clinical applications of flow cytometry. New York,
NY: Igaku-shoin, 1993:582-611
8) Batjer JD, et al. Predicting bone marrow transplant engraftment by automated flow cytometric reticulocyte analysis. Lab Med.
1994;25:22-26
9) Lofsness KG, et al. Evaluation of automated reticulocyte counts and their reliability in the presence of Howell-Jolly bodies. Am J Clin
Pathol. 1994;101:85-90
MANUAL RETICULOCYTES
● Manual reticulocyte procedure
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● Reticulocyte blood smear (uniquely identified, properly stained, free of precipitate,

good cell distribution)
HEM.35250 Reticulocyte Blood Film Quality Phase I

The quality of reticulocyte blood films is satisfactory (properly stained, free of precipitate,
good cell distribution).
REFERENCES
1) Fannon M, et al. Effect of staining and storage times on reticulocyte counts. Lab Med. 1982;13:431-433
**REVISED** 10/24/2022
HEM.35300 Reticulocyte Concentration Phase I
The reported reticulocyte concentration is based on a minimum sample size of 1,000 RBC.
NOTE: The written procedure must describe the method, number of cells counted, and
calculations used.
Commercial controls are not necessary for manual reticulocyte counts.
REFERENCES
1) Greenberg ER, Beck R. The effects of sample size on reticulocyte counting and stool examination. The binomial and Poisson
distributions in laboratory medicine. Arch Pathol Lab Med. 1984;108:396-398
2) Savage RA, et al. Analytic inaccuracy and imprecision in reticulocyte counting: a preliminary report from the College of American
Pathologists reticulocyte project. Blood Cells. 1985;11:97-112
3) Koepke JA. Update on reticulocyte counting. Lab Med. 1999;30:339-343
BODY FLUIDS
● Sampling of manual or automated body fluid policies and procedures
● Counting chamber condition

● Body fluid smear (uniquely identified, uniform cell distribution, appropriate dilution so
cells are not crowded, properly stained, adequate cell yield, ready recognition of cell
types that are reported)
● How do you ensure that morphologic observations are consistent among all
personnel who report body fluid cell differential results?
● What do you do if you suspect malignant or unusual cells on the body fluid smear?
MANUAL CELL COUNT - BODY FLUID

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HEM.35319 Diluting Equipment Phase II

Certified pipettes or commercial dilution systems are used when diluting body fluid
samples.
HEM.35338 Background Checks - Manual Counts Phase II

The diluting fluid is checked for non-specimen background particulates and changed
when indicated.
NOTE: Checking can be done by examining samples of these fluids under the microscope.
The check must be performed each day of use for manual diluting methods. If commercial
microdilution systems are used, daily checks are not required but each lot must be examined
visually for uniformity of filling and clarity. If diluting fluids are prepared by the laboratory, they
must be prepared aseptically; refrigeration is recommended to prevent contamination with
microorganisms.
✓ Records of background checks
HEM.35340 Manual Cell Count Controls Phase II

For manual body fluid cell counts, the laboratory analyzes at least one cell count control
specimen in duplicate or uses a procedural control each eight hours of patient testing.
NOTE: This requirement can be met with assayed liquid control material, a previously assayed
patient sample, or a procedural control. An example of a procedural control is correlation of the
cell count with the cellularity of a stained slide prepared by a standard, validated method. Liquid
control materials must be tested in duplicate.
✓ Records of cell count or procedural controls at defined frequency
REFERENCES
amendments of 1988; final rule. Fed Register. 2004(Oct 1):1041 [42CFR493.1269(a)
2) Galagan KA, Blomberg D, Cornbleet PJ, Glassy EF, Color Atlas of Body Fluids, CAP, 2006.
HEM.35347 Counting Chamber and Optical Grid Quality Phase I

The lines in all counting or motility chambers, ocular micrometers, and optical grids are
bright and free from scratches, dirt, or debris.
HEM.35357 Body Fluid Analysis Procedure Phase II

For manual body fluid cell counts, each sample is counted in duplicate.
NOTE: Testing records must reflect the performance of the counts in duplicate for all counting
chambers. Limits of agreement between replicate counts must be defined.
✓ Records or worksheets reflecting duplicate counts and corrective action when limits of
agreement are exceeded
REFERENCES
HEM.35376 Cell Clumps/Debris - Manual Methods Phase II

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The laboratory indicates (as part of the report) that results may be inaccurate if the fluid
specimen is partially clotted or has cell clumps or debris on the counting chamber.
HEM.35395 Red Cell Confirmation Techniques Phase I

There is an additional procedure beyond unstained bright-field microscopic visualization
of cells on the hemocytometer used when necessary to ensure the accurate distinction of
erythrocytes from other cell types.
NOTE: Suggested techniques include acid rinsing of the fluid sample to lyse erythrocytes after
initially counting all cells, the addition of a stain such as methylene blue to improve recognition of
non-erythrocytes, correlation with the number and proportion of cells on the cytospin preparation
or phase microscopy.
✓ Records of confirmation testing
AUTOMATED CELL COUNT - BODY FLUID
HEM.35414 Background Checks - Automated Counts Phase II

Instrument background counts are performed each day of testing on the diluent fluid and
lysing agent to check for contamination that might affect cell counts.
NOTE: This can be done by processing these fluids on the instrument used for cell counting and
checking for the presence of significant background in the diluting fluids and lysing agents.
✓ Records of background checks
HEM.35452 Acceptable Limits Phase II

The laboratory defines the upper and lower limits for counting body fluid cells
(erythrocytes, nucleated cells) outside of which the use of automated or semi-automated
cell counters is not reliable.
NOTE: The laboratory must have an appropriate protocol that limits the use of automated or
semi-automated instruments for cell counting in the very low concentration ranges often seen
with body fluids. The lower limit selected must reflect the particular instrument's background
count and sensitivity.
✓ Records of study to validate reportable range
REFERENCES
1) International Committee for Standardization in Haematology (ICSH). Protocol for evaluation of automated blood cell counters. Clin
Lab Haemat. 1984;6:69-84
2) Subira D, et al. Flow cytometric analysis of cerebrospinal fluid samples and its usefulness in routine clinical practice. Am J Clin
Pathol. 2002;117:952-958
**REVISED** 10/24/2022
HEM.35471 Cell Clumps/Debris - Automated Counts Phase II
The laboratory has a process to detect clumps of cells or debris that may give spurious
cell counts.
34 of 79
NOTE: The process may include a combination of approaches including macroscopic

assessment, microscopic evaluation, and instrument evaluation of the body fluid specimen.
Instrument generated flags and findings on microscopic examination that suggest the presence
of debris are important observations and may require the performance of a wet mount. Marked
clumping or clots precludes reporting an automated count. The laboratory report must note the
limited accuracy of cell counts in these situations, and include a description of the specimen
problem.
**REVISED** 10/24/2022
HEM.35490 Stabilized Controls Phase II
The laboratory analyzes two different stabilized control specimens each day of testing.
NOTE: Manufacturers' control material recommendations should be followed. The selected

control must be compatible with the methodology used by the instrument.
NUCLEATED CELL DIFFERENTIALS - BODY FLUID
HEM.35528 Body Fluid Cell Differentials Phase I

The method for differentiating body fluid cells is appropriate for the intended clinical use.
NOTE: The laboratory should use stained cytocentrifuge preparations to facilitate quantitative
differentials and complete classification of nucleated cell types in body fluids, as opposed
to performing differentials of unstained hemocytometer preparations. Differentials based
on supravitally-stained hemocytometer preparations, wedge smears and drop preparations
are considered suboptimal; their use should be limited to clinical circumstances requiring
differentiation of polymorphonuclear from mononuclear cells (eg, bacterial meningitis). Further
sub-classification of nucleated cells, particularly the detection of malignant cells, should be
performed using slide preparation methods that provide optimal cell recovery and morphologic
detail, such as cytocentrifugation. Cytocentrifuge preparations provide excellent morphologic
detail, deliver a high yield of cells even when the concentration is low, and have a high rate of
detection for malignant cells. In cases of leukemia or lymphoma, Romanowsky-stained cytospin
slides show excellent morphologic correlation with blood and bone marrow smears. If the
laboratory uses an alternate slide preparation method or stain for sub-classification of body fluid
mononuclear cells and/or detection of malignant cells, it must demonstrate from literature or in-
house studies that this technique is equivalent in cell yield/recovery and morphologic detail to
Romanowsky-stained cytocentrifuge preparations.
✓ Records showing in-house or literature validation of techniques other than Romanowsky-
stained cytocentrifuge preparations
REFERENCES
1) Mengel M. The use of the cytocentrifuge in the diagnosis of meningitis. Am J Clin Pathol. 1985;84:212-216
2) Ricevuti G, et al. Meningeal leukemia diagnosed by cytocentrifuge study of cerebrospinal fluid. Arch Neurol. 1986;43:466-470
3) Davey DD, et al. Millipore filter vs cytocentrifuge for detection of childhood central nervous system leukemia. Arch Pathol Lab Med.
1986;110:705-708
4) Clare N, Rone R. Detection of malignancy in body fluids. Lab Med. 1986;17:147-150
5) Odom LF, et al. Significance of blasts in low-cell cerebrospinal specimens from children with acute lymphoblastic leukemia. Cancer.
1990;66:1748-1754
6) Craver RD, Carson TH. Hematopoietic elements in cerebrospinal fluid in children. Am J Clin Pathol. 1991;95:532-535
7) Rippin KP, et al. Clinical evaluation of the slide centrifuge (cytospin) gram's stained smear for the detection of bacteriuria and
comparison with the Filtracheck-UTI and UTIscreen. Am J Clin Pathol. 1995;103:316-319
8) Jones CD, Cornbleet PJ. Wright-Giemsa cytology of body fluids. Techniques for optimal cytocentrifuge slide preparation. Lab Med.
1997;28:713-716
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9) Kleine TO, Lehmitz R. Evaluation of cytodiagnosis of cerebrospinal fluid (CSF) cells. Clin Chem. 2000;46:A137
HEM.35547 Body Fluid Smear Quality Phase I

The quality of body fluid smears is satisfactory (uniform cell distribution, appropriate
dilution so cells are not crowded, properly stained, adequate cell yield, ready recognition
of cell types that are reported).
REFERENCES
1) Jones CD, Cornbleet PJ. Wright-Giemsa cytology of body fluids. Techniques for optimal cytocentrifuge slide preparation. Lab Med.
1997;28:713-716
**REVISED** 10/24/2022
HEM.35566 Morphologic Observation Evaluation - Body Fluid Phase II
performing body fluid cell differentials at least annually.
NOTE: The laboratory must ensure the identification of body fluid cells is reported consistently
amongst all personnel performing the microscopic analysis.
1. Circulation of a pre-graded set of body fluid smears with defined nucleated cell
differential distributions
3. Use of body fluid photomicrographs with referee and consensus identifications (eg,
former CAP Surveys photomicrographs)
4. Use of digital images
morphologic observation for body fluid differentials.
REFERENCES
1) Clinical and Laboratory Standards Institute (CLSI). Body Fluid Analysis for Cellular Composition; Approved Guideline. CLSI
document H56-A (ISBN 1-56238-614-X). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne,
Pennsylvania 19087-1898 USA, 2006.
HEM.35585 Slide Review Phase II

Slides with suspected malignant cells are reviewed by a pathologist or other qualified
physician before final results reporting.
✓ Records of slide review
HEM.35604 Microscopic Result Comparison Phase I

If a body fluid specimen has a microscopic examination in more than one area of the
laboratory, there is a mechanism to compare the data and interpretations from these
different areas when a diagnosis of malignancy is suspected.
✓ Records of comparison
REFERENCES
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1) Clare N, Rone R. Detection of malignancy in body fluids. Lab Med. 1986;17:147-150

2) Walts AE, Strigle S. Toward optimal use of the cytology laboratory: quality improvement and cerebrospinal fluid specimens. Diagn
Cytopathol. 1995;13:357-361
3) Clinical and Laboratory Standards Institute (CLSI). Body Fluid Analysis for Cellular Composition; Approved Guideline. CLSI
document H56-A (ISBN 1-56238-614-X). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne,
Pennsylvania 19087-1898 USA, 2006.
HEM.35623 Cytomorphology Reference Library Phase I

There is a file of unusual slides and/or an atlas of body fluid cytomorphology readily
available to the technologist evaluating the slides, to assist in the identification of cell
types.
REFERENCES
1) Etzell JE, Clarke MR, Girgis G, et al; College of American Pathologists Hematology and Clinical Microscopy Resource Committee.
Body Fluids Benchtop Reference Guide: An Illustrated Guide for Cell Morphology. Northfield, IL. College of American Pathologists;
2013.
2) Kolmer HW. Atlas of cerebrospinal fluid cells, 2nd ed. New York, NY: Springer-Verlag, 1977
3) Dieppe PA, et al. Synovial fluid crystals. Quart J Med. 1979;192:533-553
4) Glasser L. Body fluids II. Reading the signs in synovia. Diag Med. 1980;3(6):35-50
5) Glasser L. Body fluids III. Tapping the wealth of information in CSF. Diag Med. 1981;4:23-33
6) Greening SE, et al. Differential diagnosis in effusion cytology. J Med Tech. 1984;1:885-895
7) Strasinger SK. Urinalysis and body fluids. A self instructional text. Philadelphia: FA Davis, 1985:134-186
8) Hyun BH, Salazar GH. Cerebrospinal fluid cells in leukemias, lymphomas, and myeloma. Lab Med. 1985;16: 667-670
9) Kjeldsberg CR, Knight JA. Body fluids, 3rd ed. Chicago, IL: American Society of Clinical Pathology, 1993
10) Galagan KA, Blomberg D, Cornbleet PJ, Glassy EF, Color Atlas of Body Fluids, CAP, 2006.
HEM.35642 Slide Retention - Body Fluid Differential Phase I

Body fluid slides (eg, pleural fluid, seminal fluid) are retained for at least one week for
possible review and/or reference.
NOTE: The laboratory may choose to retain significantly abnormal smears (eg, those
demonstrating microorganisms, cytologically suspicious or overtly malignant cells, etc.) for longer
periods to allow for review as part of the laboratory's correlative or quality assurance programs or
delayed clinical queries, as defined in the laboratory's slide retention policy. If a longer retention
period is defined, it must be followed.
RESULT REPORTING - BODY FLUID
HEM.35650 Body Fluid Result Reporting of Nucleated Cells Phase I

When absolute total cell counting methods cannot reliably distinguish white blood cells
from other nucleated cells, body fluid cell counts and differential results are reported with
the total nucleated cell count and a differential with all nucleated cell types observed.
NOTE: If the absolute total cell counting method in the laboratory cannot reliably distinguish
white blood cells from other nucleated cells (eg, unstained bright-field visualization of cells
in a hemocytometer chamber and certain automated counting technologies), the laboratory
must report the absolute total cell count (cells/µL) as TNC (total nucleated cells) not WBC (total
white blood cells). The relative differential (% of total cells counted) performed on a stained
cytocentrifuge slide, which can reliably distinguish white blood cells from other nucleated cells,
must include the percentage of all nucleated cell types (eg, lymphocyte, neutrophil, monocyte/
macrophage, basophils, eosinophil, plasma cell, mesothelial cell, bronchial lining cell, synovial
lining cell, ventricular lining cell, endothelial cell, squamous epithelial, and other) when TNC is
reported for the absolute total cell count.
✓ Patient report with body fluid cell count and differential results
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REFERENCES
1) Clinical and Laboratory Standards Institute. Body Fluid Analysis for Cellular Composition; Approved Guideline. CLSI document H56-
A. Clinical and Laboratory Standards Institute, Wayne, PA; 2006.
SEMEN ANALYSIS
The preceding items in the Body Fluid Cell Counting and Body Fluid Nucleated Cell Differentials are generally
applicable to semen analysis. Additional items of importance to this specialized area are identified in this
section.
● Sampling of manual and automated semen analysis policies and procedures
● Sampling of specimen collection and handling policies and procedures
● Sampling of patient records for all necessary collection information
● Patient instructions
● Sampling of stain QC records
● Sampling of calibration/calibration verification records
● Stained smear (properly stained, free of precipitate, uniform cell distribution,

recognition of reportable cell types)
● What do you do if there is difficulty distinguishing leukocytes from other round cells
when performing sperm counts using bright-field microscopy?
● How are the sperm motility methods in use verified?
● How do you ensure that morphologic observations are consistent among all
personnel who report sperm differential results?
● What is your course of action when the concentration of the specimen is outside of
the instrument measurement range?
● Follow a semen analysis from requisition, collection information, testing, reporting and
recording of results. Determine if practice follows laboratory procedure.
REQUISITIONS, SPECIMEN RECEIPT AND RESULTS REPORTING
HEM.35661 Azoospermic Specimen Result Reporting Phase I

For azoospermic and post-vasectomy seminal fluid specimens, the laboratory clearly
communicates the findings of the assay and either employs a concentrating technique on
seminal fluid or includes a comment in the patient report indicating that a concentrating
technique was not performed.
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NOTE: Without a concentration technique, the presence of both motile and non-motile sperm
may not be detected. The method for detection of motile and non-motile sperm and the
laboratory findings must be clearly communicated on the patient report so that the clinician can
interpret the results in context to the method performed. The decision on the method used and
extent of testing to be performed should be made in consultation with the medical staff served.
The American Urological Association (AUA) Vasectomy Guideline recommends a careful
evaluation of an uncentrifuged specimen, and does not recommend centrifugation of the
specimen for further assessment. The AUA Guideline also recommends reporting both the
presence and absence of sperm and presence or absence of sperm motility on the patient report.
If no sperm are seen in the uncentrifuged specimen, the guideline recommends reporting that the
presence of sperm is below the limit of detection.
✓ Patient report with concentration findings or appropriate comment indicating that
concentration was not performed
REFERENCES
1) Schlegel PN, Sigman M, Collura B, et al. Diagnosis and treatment of infertility in men: AUA/ASRM Guideline Part I. J Urol.
2021;205(1):36-43.
2) Vasectomy Update 2010. Can Urol Assoc J. 2010 October; 4(5):306-309
NOTE: If the laboratory only performs post-vasectomy checks, the remaining semen analysis requirements are
not applicable.
HEM.35680 Specimen Collection/Handling Phase I

There are written patient instructions for collection and prompt delivery of a semen
sample to the laboratory.
NOTE: This should be written in simple terms in a language readily understood by the patient.
Elements should include the need to abstain from ejaculation for 2-7 days before collection of the
specimen, avoidance of lubricants and other contamination, completeness of collection, use of
the supplied container, maintenance of sample temperature, and prompt delivery. Instructions
must be readily available and distributed to patients and to off-site physician offices that refer
specimens.
REFERENCES
1) WHO laboratory manual for the examination and processing of human semen, most recent editions (ie, fifth edition and sixth edition),
World Health Organization; 2010 and 2021.
HEM.35699 Specimen Collection/Handling Phase I

Semen specimens are accompanied by the following collection information, and records
are retained on the following.
1. Method of collection
2. Type of specimen container
3. Days of abstinence
4. Collection or transport problems (eg, incomplete specimen, exposure to
temperature extremes)
5. Time of specimen receipt and analysis
REFERENCES
HEM.35718 Liquefaction Phase I

All semen specimens are given sufficient time for liquefaction before testing.
REFERENCES
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HEM.35737 Specimen Handling - Pre-analytic Phase I

Semen specimens are mixed thoroughly before testing.
REFERENCES
HEM.35756 Specimen Characteristics - Analytic Phase I

All characteristics of the semen specimens are noted and reported (eg, gelatinous
clumps, viscosity, contaminants, erythrocytes, and abnormalities of liquefaction).
NOTE: Macroscopic and microscopic characteristics of the semen specimens must be noted and
reported, in accordance with the WHO laboratory manual for the examination of human semen
(ie, fifth or sixth edition).
✓ Patient reports
REFERENCES
1) Haugen TB, Grotmol T. pH of human semen. Int J. Androl. 1998;21:105-108
SPERM MOTILITY
**REVISED** 08/24/2023
HEM.35762 Motility Method Verification Phase I
The laboratory verifies the sperm motility method used (eg, video tapes/digital images
of specimens with known percent motility and/or specific motion quality) at least
semiannually.
NOTE: This requirement applies to both automated and manual sperm motility methods.
✓ Records of method verification
REFERENCES
1) Mortimer D. Practical laboratory andrology. New York, NY: Oxford University Press, 1994
2) Yeung CH, et al. A technique for standardization and quality control of subjective sperm motility assessments in semen analysis.
Fertil Steril. 1997;67:1156-1158
HEM.35765 Motility Quantification Phase II

Manual measures of percent sperm motility are quantified in a standardized manner.
NOTE: The laboratory must have a written method for determining and reporting sperm motility
that describes how sperm are assessed and counted (percent motility) and is based on a
reference method, such as the World Health Organization (WHO) Standards (ie, fifth or sixth
edition).
REFERENCES
Fertil Steril. 1997;67:1156-1158
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HEM.35768 Forward Progression Phase II

Forward progression of sperm is evaluated.
✓ Patient reports or worksheets with results of forward progression
REFERENCES
2) Vulcano GJ, et al. A lineal equation for the classification of progressive and hyperactive spermatozoa. Math Biosci. 1998;149:77-93
HEM.35775 Motility/Progression Evaluation Phase II

Sperm motility percent and progression are routinely evaluated within one hour of
collection.
✓ Records indicating time of collection and evaluation AND
✓ Patient reports noting exceptions, when appropriate
REFERENCES
HEM.35794 Standard Temperature Range Phase II

The laboratory has established a standard temperature range for semen analysis
assessment, and deviations from this temperature are noted on the report.
NOTE: Sperm motility is temperature-dependent. Temperature ranges must be defined.

✓ Records showing monitoring of temperatures
REFERENCES
HEM.35813 Motility Microscopic Examination Phase II

The laboratory has written instructions for evaluating a sufficient number of separate and
randomly chosen microscopic fields and sperm cells.
REFERENCES
HEM.35822 Viability Testing Criteria Phase I

The laboratory performs viability testing on specimens with low percent motility (eg, less
than 30%), or includes a comment that the decreased motility may be the result of non-
viable or non-motile sperm.
NOTE: Non-motile sperm may represent forms that were originally non-viable in the ejaculate,
or previously motile forms that have subsequently lost motility. Thus, viability assessment is
useful in making the distinction, and is commonly performed with a dye-exclusion method such
as eosin-nigrosin.
✓ Patient records or worksheet with results of viability testing OR patient report with cautionary
verbiage
REFERENCES
41 of 79
2) Gunalp S, et al. A study of semen parameters with emphasis on sperm morphology in a fertile population: an attempt to develop
clinical thresholds. Hum Repro. 2001;16:110-114
STAINED SMEAR - SPERM DIFFERENTIAL
HEM.35832 Sperm Morphology Classification Phase I

The sperm morphology classification method used is indicated on the report.
NOTE: Different classification systems have different reference intervals for normality. To
improve the consistency and usefulness of reporting, CAP recommends the use of the
WHO Standards (ie, fourth, fifth, or sixth edition), and the Kruger classification system, and
discontinuing the use of older classification systems.
REFERENCES
1) Kruger, T.F., et al. Sperm morphology features as a prognostic factor in vitro fertilization. Fertility and Sterility 46:1118-1123, 1986
2) WHO laboratory manual for the examination and processing of human semen, most recent editions (ie, fourth edition, fifth edition and
sixth edition) World Health Organization; 1999, 2010 and 2021.
3) Gunalp S, et al. A study of semen parameters with emphasis on sperm morphology in a fertile population: an attempt to develop
clinical thresholds. Hum Repro. 2001;16:110-114
4) Behnke EJ, Mayer JF, Ball GD, et al. Semen Analysis Benchtop Reference Guide: An Illustrated Guide with Emphasis on Sperm
Morphology. CAP Press; 2018.
**REVISED** 10/24/2022
HEM.35851 Morphologic Observation Evaluation - Sperm Phase II
performing microscopic morphologic classification of sperm and other cells at least
annually.
NOTE: The laboratory must ensure the identification of sperm and other cells is reported
consistently amongst all personnel performing the microscopic analysis.
1. Circulation of a pre-graded set of stained semen smears with defined specific
qualitative abnormalities of sperm
3. Use of current published references
4. Digital images
morphologic observation of semen smears.
REFERENCES
1) Souter VL, et al. Laboratory techniques for semen analysis; a Scottish survey. Health Bull (Edinb). 1997;55:140-149
2) Baker DJ, Witmyer J. Semen analysis training tool. Chicago, IL: American Society of Clinical Pathology, 1998
4) Kruger T, Frenken D. Atlas of Human Sperm Morphology Evaluation; Taylor & Frances, 2004
5) Glassy E. CAP Color Atlas of Hematology, 1998
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HEM.35870 Consultation Phase II

An individual with expertise in sperm morphology (the pathologist, laboratory director,
supervisor, or other technologist) is available for consultation, when needed.
REFERENCES
1) Revised guidelines for human embryology and andrology laboratories. Fertil Steril. 2008;90 (suppl 3):S45-S59
HEM.35889 Sperm Morphology Reference Phase I

There is a file of unusual slides or current atlas of sperm morphology, available for
training and reference.
REFERENCES
2) Kruger T, Frenken, D. Atlas of Human Sperm Morphology Evaluation, Taylor & Frances, 2004
HEM.35892 Stain Usage Phase I

Stains are used to facilitate morphologic classification of cell types in semen (as opposed
to performing differentials of unstained preparations).
REFERENCES
1) Coetzee K, et al. Predictive value of normal sperm morphology: a structured literature review. Hum Reprod Update. 1998;4:73-82
HEM.35893 Leukocyte Confirmation Techniques Phase I

There is an additional procedure beyond unstained bright-field microscopy to ensure the
accurate distinction of leukocytes from other round cells (eg, Wright's, leukocyte alkaline
phosphatase, or myeloperoxidase stains).
NOTE: This requirement only applies to laboratories that differentiate leukocytes from other
round cells on the patient report.
✓ Patient records or worksheets indicating use of additional procedure
REFERENCES
2) Fishel TJ, et al. Increased polymorphonuclear granulocytes in seminal plasma in relation to sperm morphology. Hum Reprod.
1997;12:2418-2421
3) Zimmermann BS, et al. Relationship of bacteriological characteristics to semen indices and its influence on fertilization and
pregnancy rates after IVF. Acta Obstet Gynecol Scand. 1997;76:964-968
4) Trum JW, et al. Value of detecting leukocytospermia in the diagnosis of genital tract infection in subfertile men. Fertil Steril.
1998;70:315-319
5) Schlegel PN, Sigman M, Collura B, et al. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part 1. J Urol.
2021;205(1):36-43.
HEM.35895 Stain QC Phase II

Quality control of all stains is performed and recorded to check for contamination and
intended reactivity each day of use.
✓ Records of stain QC
REFERENCES
HEM.35902 Stain Quality Phase II

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The stains used (Wright's, Papanicolaou, eosin-nigrosin, peroxidase, etc.) and slide
preparations are of sufficient quality to demonstrate the cellular characteristics for which
they are designed.
✓ Examples of each type of stained slide available for microscopic review by inspector, as
applicable
BIOCHEMICAL TESTS
HEM.35909 Biochemical Tests - Daily QC Phase II

For biochemical tests such as fructose, the laboratory performs positive and negative
controls with each assay.
REFERENCES
ANTI-SPERM ANTIBODY (ASA) TESTS
HEM.35910 Heat Inactivation Phase II

Serum and follicular fluid specimens used for indirect ASA testing are heat-inactivated
before use.
NOTE: Serum and follicular fluid specimens used for indirect ASA testing must be treated to
inactivate complement.
REFERENCES
1) Keel BA, Webster BW. CRC handbook of the laboratory diagnosis and treatment of infertility. Boca Raton, FL: CRC Press, 1990.
HEM.35911 Motility Testing Phase I

If the testing for ASA requires motile sperm, specimens are assayed with minimal delay
and the motility is assessed and recorded.
✓ Patient records and worksheets showing time of collection and evaluation of motility
REFERENCES
HEM.35912 ASA Controls Phase II

For indirect antibody testing, the laboratory performs positive and negative controls with
each assay.
✓ QC records
REFERENCES
1) Keel BA, Webster BW. CRC handbook of the laboratory diagnosis and treatment of infertility. Boca Raton, FL: CRC Press, 1990.
amendments of 1988; final rule. Fed Register. 2003(Jan 24):7166 [42CFR493. 1256(d)(iii)]
44 of 79
3) Evans ML, et al. A convenient mixed immunobeads screen for antisperm antibodies during routine semen analysis. Fertil Steril.
1998;70:344-349
AUTOMATED SEMEN ANALYSIS INSTRUMENTS
Various systems are in use and some requirements may not apply to every system. The requirements are
intended to check factors common to automated systems. Inspectors should use individual judgment in applying
the requirements to the particular type of system being used.
CALIBRATION AND QUALITY CONTROL
Several different methods may be used for calibration and quality control in the automated analysis of semen
characteristics. "Calibration" techniques include use of:
1. Multiple analyzed sperm specimens
2. Stabilized preparations of sperm cells (eg, fixed or preserved)
3. Sperm surrogates (eg, latex particles)
4. Digital images/videotaped sperm specimens
NOTE: If stabilized control materials are used, they must represent different analytic levels (eg, normal and
high). Similarly, retained patient specimens must be of differing counts and/or motility, as applicable.
HEM.35914 Calibration Materials Phase II

Calibration is verified with materials appropriate to the reportable range of the instrument,
and verification is recorded.
NOTE: The quality control procedure for the automated instrument must include calibration and
evaluation using defined limits of agreement with manually counted semen smears or stored
digital images, as appropriate for the particular system. Laboratories must verify at least every six
months that instruments are functioning correctly and are in control.
✓ Records of calibration verification
REFERENCES
HEM.35915 Daily QC Phase II

The laboratory performs quality control for the automated instrument during each day
of use, following the manufacturer instructions or using at least two levels of control at
different concentrations.
REFERENCES
amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1256(d)]

The test system is recalibrated when calibration verification fails to meet the established
criteria of the laboratory.
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✓ Records of recalibration, if calibration or calibration verification has failed
REFERENCES
HEM.35918 Calibration Material Validation Phase II

The material used for calibration is validated using primary reference procedures (eg,
manual counts).
✓ Records showing accuracy of calibration materials used, to include manufacturer's
certification/validation of commercial products OR in-house validation data
REFERENCES
2) Krause W. [Value of computer-assisted sperm analysis (CASA). reproducibility--online documentation--prognostic value]. [Article in
German]. Fortschr Med. 1996;114:470-473
3) Tsuji T, et al. Automated sperm concentration analysis with a new flow cytometry-based device, S_FCM. Am J Clin Pathol.
2002;117:401-408
HEM.35919 System Control Phase II

If a manual method is used as the system control for automated sperm counts, its
accuracy is verified and recorded at intervals appropriate for laboratory volume.
REFERENCES
1) Mortimer D. Practical laboratory andrology. New York, NY: Oxford University Press. 1994
2) Lenzi A. Computer-aided semen analysis (CASA) 10 years later: a test-bed for the European scientific andrological community. Int J
Androl. 1997;20:1-2
3) Mahmoud AM, et al. Performance of the sperm quality analyser in predicting the outcome of assisted reproduction. Int J Androl.
1998;21:41-46
2002;117:401-408
HEM.35920 Acceptable Limits - Controls Phase II

Acceptable limits are established for each quality control sample.
✓ Records of defined acceptable limits for control range of each lot
HEM.35921 Sperm Concentration Range Phase II

For automated sperm counts and motility, the laboratory confirms that the concentration
of the specimen is within the range appropriate for automated analysis.
REFERENCES
1) Vantman DD, et al. Computer assisted semen analysis: evaluation of method and assessment of the influence of sperm
concentration on linear velocity determination. Fertil Steril. 1988;49:510-515
Fertil Steril. 1997;67:1156-1158
3) Sidhu RS, et al. accuracy of computer-assisted semen analysis in prefreeze and post-thaw specimens with high and low sperm
counts and motility. Urology. 1998;51:306-312
2002;117:401-408
HEM.35923 Reportable Range Phase II

Upper and lower limits of all reportable parameters on instruments are defined, and
results that fall outside these limits are reported properly.
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NOTE: Results that fall outside of these limits may be verified by repeating the test, using an
alternative method or diluting/concentrating the specimen, as appropriate.
✓ Patient test verification records
REFERENCES
1) Mortimer D. Practical laboratory andrology. New York, NY: Oxford University Press. 1994
**REVISED** 10/24/2022
HEM.35924 Calibration Verification Criteria Phase II
Criteria for the frequency and acceptability of calibration verification are defined and
followed.
NOTE: Laboratories must either recalibrate or perform calibration verification at least every six
months and if any of the following occur:
1. At complete changes of reagents, unless the laboratory can demonstrate that
changing reagent lots does not affect either the range used to report patient test
results or the control values
2. If QC shows an unusual trend or shift or is outside acceptable limits, and the system
cannot be corrected to bring control values into the acceptable range
3. After major preventive maintenance or change of a critical instrument component
For automated semen analysis instruments, requirements for calibration verification may be
considered met if the laboratory follows the manufacturer's instructions for instrument operation
and tests two levels of control materials each day of testing. The control results must meet the
laboratory's criteria for acceptability.
✓ Records of calibration verification documented at defined frequency
REFERENCES
amendments of 1988; final rule. Fed Register. 2003(Jan 24):7165 [42 CFR 493.1255]
ABNORMAL HEMOGLOBIN DETECTION
For purposes of diagnosing hemoglobinopathies, more than one test may be necessary. As an example,
hemoglobin solubility testing alone is not sufficient for detecting or confirming the presence of sickling
hemoglobins in all situations.
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● Sampling of abnormal hemoglobin policies and procedures
● Sampling of patient reports (confirmatory testing, comments)
● Hemoglobin separation patterns (appropriate separations and controls)

● Examine a sampling of medium (media) used to identify hemoglobin variants
including alkaline/acid electrophoresis, isoelectric focusing, HPLC, or other methods
● What is your course of action when the primary screening method appears to show
Hb S?
● What is your course of action when the primary Hb electrophoresis method shows Hb
variants migrating in non-A/non-S positions?
HEM.35925 Hb S Primary Screen Phase II

For patient samples that appear to have Hb S in the primary screening by electrophoresis
or other separation methods, the laboratory either: 1) performs a second procedure
(solubility testing, or other acceptable method) to confirm the presence of Hb S, or 2)
includes a comment in the patient report recommending that confirmatory testing be
performed.
NOTE: For primary definitive diagnosis screening by electrophoresis or other separation

methods, all samples with hemoglobins migrating in the "S" positions or peak must be tested for
solubility or by other acceptable confirmatory testing for sickling hemoglobin(s). Known sickling
and non-sickling controls both must be included with each run of patient specimens tested.
HEM.35927 Daily QC - Hgb Separation Phase II

Controls containing at least three known major hemoglobins, including both a sickling
and a non-sickling hemoglobin (eg, A, F, and S) are performed with the patient
specimen(s) and separations are satisfactory.
NOTE: There are written procedures for instruments with multiple electrophoretic chambers or
capillaries to ensure that QC is performed on each individual chamber or capillary.
✓ QC records reflecting the use of appropriate controls AND
✓ Electrophoresis media/separation tracings demonstrating appropriate controls and separation
REFERENCES
1) Fairbanks VF. Hemoglobinopathies and thalassemias. Laboratory methods and case studies. New York, NY: BC Decker, 1980
2) Beuzard Y, et al. Isoelectric focusing of human hemoglobins, In Hanash, Brewer, eds. Advances in hemoglobin analysis. New York,
NY: Alan R. Liss, 1981:177-195
3) Cossu G, et al. Neonatal screening of beta-thalassemias by thin layer isoelectric focusing. Am J Hematol. 1982;13:149
4) Bunn HF, Forget BG. Hemoglobin: molecular, genetic and clinical aspects. Philadelphia, PA: WB Saunders, 1986
5) Honig GR, Adams JG III. Human hemoglobin genetics. Vienna, Austria: Springer-Verlag, 1986
6) Jacobs S, et al. Newborn screening for hemoglobin abnormalities. A comparison of methods. Am J Clin Pathol. 1986;85:713-715
7) Fishleder AJ, Hoffman GC. A practical approach to the detection of hemoglobinopathies: part I. The introduction and thalassemia
syndromes. Lab Med. 1987;18:368-372
8) Fishleder AJ, Hoffman GC. A practical approach to the detection of hemoglobinopathies: part II. The sickle cell disorders. Lab Med.
1987;18:441-443
9) Fishleder AJ, Hoffman GC. A practical approach to the detection of hemoglobinopathies: part III. Nonsickling disorders and cord
blood screening. Lab Med. 1987;18:513-518
10) Armbruster DA. Neonatal hemoglobinopathy screening. Lab Med. 1990;21:815-822
48 of 79
11) Adams JG III, Steinberg MH. Analysis of hemoglobins, In Hoffman R, et al, eds. Hematology: basic principles and practice. New
York, NY: ChurchillLivingstone, 1991:1815-1827
12) Mallory PA, et al. Comparison of isoelectric focusing and cellulose acetate electrophoresis for hemoglobin separation. Clin Lab Sci.
1994;7:348-352
13) Awalt E, et al. Tandem mass spectrometry (MS) – A screening tool for hemoglobinopathies. Clin Chem. 2001;47(suppl):A165
14) Bradley CA, Kelly A. Comparison of high performance liquid chromatography with electrophoresis for measurement of hemoglobins
A, A2, S, F, and C. Clin Chem. 2001;47(suppl):A172
15) Bradley CA, Kelly A. Calibration verification of hemoglobins A, A2, S, and F with an automated chromatography system. Clin Chem.
2001;47(suppl):A17315)
16) Hoyer JD, et al. Flow cytometric measurement of hemoglobin F in RBCs: diagnostic usefulness in the distinction of hereditary
persistence of fetal hemoglobin (HPFH) and hemoglobin S-HPFH from other conditions with elevated levels of hemoglobin F. Am J
Clin Pathol. 2002;117:857-863
HEM.35946 Hemoglobin Variants Phase II

All samples with hemoglobin variants migrating in "non-A, non-S" positions on alkaline
electrophoresis or other low resolution procedure are further defined with other
acceptable methods where clinically and technically appropriate.
NOTE: If all clinically significant variants are not clearly separated by the primary method,
additional testing must be performed to further characterize these hemoglobin variants.
Examples include:
● Performance by a complementary, separate methodology
● Increasing the duration of the assay (for HPLC) where the hemoglobins migrate/elute at
different configurations.
Further workup of such variants, including referral to another laboratory, is dependent upon the
patient's overall clinical situation, such as findings of erythrocytosis or a hemolytic anemia.
✓ Patient reports and records reflecting further work-up, when appropriate
REFERENCES
1) Giordina PC. Strategies for basic laboratory diagnostics of the hemoglobinopathies in multi-ethnic societies: interpretation of results
and pitfalls. Int J Hematol. 2013;35:465-79.
2) Sabath DE. Molecular diagnosis of thalassemias and hemoglobinopathies: an ACLPS critical review. Am J Clin Pathol.
2017;148:6-15.
3) Greene DN, Vaughn CP, Crews BO, Agarwal AM. Advances in detection of hemoglobinopathies. Clinica Chimica Acta.
2015;15:439-50.
4) Troxler H, Kleinert P, Schmugge M, Speer O. Advances in hemoglobinopathy detection and identification. Adv Clin Chem.
2012;57:1-28.
5) Bain BJ. Haemaglobinopathy diagnosis: algorithms, lessons and pitfalls. Blood Rev. 2011;25(5):205-13.
6) Awalt E, et al. Tandem mass spectrometry (MS) - A screening toll for hemoglobinopathies. Clin Chem. 2001;47(suppl):A165.
7) Bradley CA, Kelly A. Comparison of high performance liquid chromatography with electrophoresis for measurement of hemoglobins
A, A2, S, F, and C. Clin Chem. 2001;47(suppl):A172.
8) Bradley CA, Kelly A. Calibration verification of hemoglobins A, A2, S, and F with an automated chromatography system. Clin Chem.
2001;47(suppl):A173.
9) Hoyer JD, et al. Flow cytometric measurement of hemoglobin F in RBCs: diagnostic usefulness in the distinction of hereditary
persistence of fetal hemoglobin (HPFH) and hemoglobin S-HPFH from other conditions with elevated levels of hemoglobin F. Am J
Clin Pathol. 2002;117:857-863.
HEM.35984 Hb S Predominant Band Phase II

All samples that appear to have Hb S as the predominant band by the primary screening
and confirmed as sickling by appropriate methods are further examined to ascertain
whether the "Hb S" band or peak contains solely Hb S or both Hb S and Hb D, Hb G or
other variant hemoglobins.
NOTE: When the predominant hemoglobin component appears to be Hb S, it is necessary to

determine whether this represents homozygous Hb S or a heterozygote for Hb S and another
variant such as Hb D, Hb G, Hb Lepore, or other hemoglobin variant(s). Given the clinical
implications of homozygous Hb S (or Hb S/ß-zero thalassemia) it is imperative to exclude other
hemoglobin variants, however rare. Referral of these specimens to another laboratory for further
workup is acceptable.
49 of 79
✓ Patient records or worksheets showing exclusion of hemoglobin variants OR documentation
of referral for further work-up
REFERENCES
1) Black J. Isoelectric focusing in agarose gel for detection and identification of hemoglobin variants. Hemoglobin. 1984;8:117
2) Bunn HF, Forget BG. Hemoglobin: molecular, genetic and clinical aspects. Philadelphia, PA: WB Saunders, 1986
3) Fishleder AJ, Hoffman GC. A practical approach to the detection of hemoglobinopathies: part I. The introduction and thalassemia
syndromes. Lab Med. 1987;18:368-372
4) Fishleder AJ, Hoffman GC. A practical approach to the detection of hemoglobinopathies: part II. The sickle cell disorders. Lab Med.
1987;18:441-443
5) Fishleder AJ, Hoffman GC. A practical approach to the detection of hemoglobinopathies: part III. Nonsickling disorders and cord
blood screening. Lab Med. 1987;18:513-518
6) Adams JG III, Steinberg MH. Analysis of hemoglobins, In Hoffman R, et al, eds. Hematology: basic principles and practice. New
York, NY: Churchill-Livingstone, 1991:1815-1827
7) Mallory PA, et al. Comparison of isoelectric focusing and cellulose acetate electrophoresis for hemoglobin separation. Clin Lab Sci.
1994;7:348-352
HIGH PERFORMANCE LIQUID CHROMATOGRAPHY (HPLC)
HEM.35986 Calibration and Calibration Verification Phase II

Appropriate calibration or calibration verification is performed on each day of patient
testing or more frequently if required by the manufacturer's instructions.
NOTE: For qualitative assays, an appropriate calibrator should be run at normal and abnormal
levels. For quantitative assays, a multipoint calibration may be required if the measurement has
a non-linear response. For some assays, a level near the assay's limit of detection (LOD) or
at critical decision point(s) is needed. For measurement systems that have a linear response
verified by periodic multipoint calibration verification and AMR verification protocols, a calibration
procedure that uses a single calibrator at an appropriate concentration is acceptable. Analyses
based on a single point calibration must be controlled by appropriate quality control samples. In
addition, inclusion of a negative control (reagent blank) is good laboratory practice.
✓ Records of calibration/calibration verification
HEM.35987 Quality Control - HPLC Phase II

Appropriate controls are extracted and run through the entire procedure on each day of
patient testing.
NOTE: Controls used in chromatographic procedures must evaluate as much of the complete
testing process as is technically feasible. The control process includes any pre-treatment,
pre-purification or extraction steps, unless non-pretreated control material is inappropriate.
For qualitative assays, the negative and positive controls should be at concentrations that
meaningfully confirm performance below and above the decision threshold for the analyte. For
quantitative assays, appropriate controls must include at least one normal sample, and at least
one sample reflecting a disease range. For some assays, an additional control concentration may
be useful to confirm performance near the assay's LOD*, LOQ** or cut-off, if appropriate, or at a
concentration consistent with highly abnormal levels that test the AMR.
*LOD - limit of detection
**LOQ - limit of quantitation
If a hydrolysis step is required in the assay, the laboratory includes a control (when available)
with each batch to evaluate the effectiveness of hydrolysis.
✓ QC records at defined frequency
50 of 79
REFERENCES
1) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare, Medicaid and CLIA programs;
CLIA fee collection; correction and final rule. Fed Register. 2003(Jan 24):5232 [42CFR493.1256(d)(3)(ii)]
HEM.35988 Sample Run Order Phase II

A record of sample run order is maintained for review.
NOTE: The run list must include blanks, standards, controls, and patients included in each run
and be stored with the results of each batch run.
HEM.35990 Chromatographic Characteristics/Column Performance Phase II

Chromatographic characteristics and column performance are reviewed and approved for
each run before results are released.
NOTE: Checks should record testing variables such as the amount of sample injected and
indications of error, including split peaks, doublets, and tailing.
HEM.35992 Column Verification Phase II

New columns are verified for performance before use.
✓ Records of column verification
HEM.35998 Reagent Grade Phase II

Reagents, solvents and gases are of appropriate grade.
HEM.36001 Limit of Detection/AMR Phase II

The limit of detection (sensitivity) and the AMR for quantitative methods have been
determined for each procedure.
✓ Records of limit of detection and AMR determination
HEM.36005 Column/Detector Monitoring Phase II

The performance of the column and detector is monitored on each day of use.
NOTE: Unextracted standards and extracted calibrators or controls typically containing the target
compound(s), may be analyzed each day to monitor critical aspects of column performance.
Appropriate criteria for evaluating such parameters as retention time, relative retention time,
separation of closely eluting compounds of interest, chromatography quality, and detector
response should be established and monitored.
✓ Records for column and detector monitoring at defined frequency
HEM.36010 Carryover Detection Phase II

The laboratory has a process to detect and evaluate potential carryover.
NOTE: No matter what type of injection is used, the process must address criteria for the
evaluation of potential carryover from a preceding elevated (high concentration) sample to the
following sample in each analytical batch analysis.
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✓ Records of reassessment of samples with potential carryover
BONE MARROW PREPARATIONS

● Bone marrow policy and procedure
● Sampling of stain QC records
● Bone Marrow aspirate and/or biopsy slides (uniquely identified, with satisfactory
staining and cell distribution)
● Sample report (with integration of ancillary testing, as indicated)
● How do you reconcile clinically significant discrepancies between the bone marrow
morphologic diagnosis and the results of ancillary studies?
HEM.36030 Bone Marrow Procedures Phase II

Bone marrow aspiration and/or biopsy procedures include a process to verify patient
identification using at least two patient identifiers, the procedure site, and the procedure
to be performed.
REFERENCES
1) Clinical and Laboratory Standards Institute. Accuracy in Patient and Sample Identification. 2nd ed. CLSI standard GP33. Clinical and
Laboratory Standards Institute, Wayne, PA; 2019.
HEM.36100 Bone Marrow Slide Quality Phase I

The quality of bone marrow aspirate and touch slide preparations are satisfactory
(properly stained, free of precipitate).
NOTE: The aspirate smears must be properly stained and free of artifacts (eg, excessive stain
precipitate, cellular crushing, excessive blood) to allow for reliable differentiation of bone marrow
elements and their stages of maturation.
HEM.36150 Fixed Sections Phase I

Fixed sections (marrow biopsy or particle sections) are used as a diagnostic aid to the
smear aspirate, as appropriate for the clinical situation.
✓ Patient reports with records of aspirate and fixed section review, as applicable
REFERENCES
1) Krause JR, ed. Bone marrow biopsy. New York, NY: Churchill Livingstone, 1981:1-9
2) Bartl R, et al. Bone marrow biopsies revisited. Basel, Switzerland: Karger, 1982
3) Brunning RD. Bone marrow, In Rosai J, ed. Ackerman's surgical pathology. St Louis, MO: CV Mosby, 1989:1379-1454
4) Brunning RD. Bone marrow specimen processing, In Knowles DM, ed. Neoplastic hematopathology. Baltimore, MD: Williams &
Wilkins, 1992:1081-1095
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5) Dacie JV, Lewis SM. Practical hematology, 8th ed. New York, NY: Churchill Livingstone, 1995:178-184
6) Foucar K. Bone marrow pathology. Chicago, IL: American Society of Clinical Pathology, 1995
HEM.36200 Fixed Tissue Quality Phase II

The quality of fixed tissue sections of bone marrow is conducive to a reliable diagnosis
(eg, properly stained, no distortion).
NOTE: The sections must be properly stained and free of distortions (eg, thick or wrinkled
sections) to allow for reliable differentiation of bone marrow elements such as myeloid, erythroid,
and lymphoid populations.
HEM.36250 Fixed Tissue Correlation Phase I

If fixed tissue sections and bone marrow aspirate smears are evaluated in different
sections of the laboratory, or if separate reports are released at different times, there is a
mechanism to compare the data and interpretations from these different sections.
NOTE: Unified reporting of bone marrow aspirates and biopsies is strongly recommended.
If aspirate smears and biopsy reports are released by different sections of the laboratory,
or at different times, a mechanism must be in place to comment upon the existing report
and interpretation when the subsequent report is released. Any conflicting data should be
commented upon. Such data correlation is essential for diagnostic consistency and effective
patient management.
✓ Records of review/correlation with follow-up reporting if a discrepancy is identified
HEM.36270 Slide and Report Retention - Bone Marrow Evaluation Phase II

Bone marrow slides and reports are retained for at least 10 years.
HEM.36300 Bone Marrow Evaluation Phase II

Bone marrow specimens are evaluated by a pathologist or qualified hematologist and
formal reports prepared.
REFERENCES
1) Peterson LC, et al. Protocol for the examination of specimens from patients with hematopoietic neoplasms of the bone marrow: a
basis for checklists. Arch Pathol Lab Med. 2002;126:1050-1056
HEM.36325 Correlation of Results Phase I

There is a mechanism to correlate the results of ancillary studies (immunohistochemistry,
cytogenetics, molecular pathology, flow cytometry, etc.) with the morphologic diagnosis.
NOTE: The pathologist or qualified hematologist should correlate all of the special studies,
reconcile conflicting data, and render a final interpretation of all correlated studies where
appropriate. A mechanism should exist in the laboratory that records review of such studies not
available at the time of initial request. Clinically significant discrepancies must be reconciled and
recorded.
✓ Records of correlation of specialized studies with morphologic diagnoses
REFERENCES
1) Peterson LC, et al. Protocol for the examination of specimens from patients with hematopoietic neoplasms of the bone marrow: a
basis for checklists. Arch Pathol Lab Med. 2002;126:1050-1056
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HEM.36350 Iron Stain Phase I

An iron stain is prepared for bone marrow evaluations where indicated.
NOTE: The preferred specimen for the iron stain is an aspirate smear and/or clot section, not a
decalcified core biopsy.
HEM.36800 Stain Reactivity Phase II

All stains are checked for intended reactivity each day of use.
NOTE: Stains should be assessed using both a normal blood film and an evaluation of the
staining of residual apparently normal blood cells on the smears being tested. Rarely, the normal
control may react, but the expected staining of normal cells on the test smear may be absent
for technical reasons. Failure to evaluate the expected reactions of normal cells may cause
diagnostic errors.
✓ Records of stain QC at defined frequency
REFERENCES
RESULTS REPORTING - HEMATOLOGY

● Sampling of reporting policies and procedures
● Sampling of patient reports (reference intervals)
● How have you established or verified reference intervals?
HEM.36820 Reference Intervals Phase II

Patient results are reported with accompanying reference intervals or interpretive ranges.
NOTE: For WBC differential counts, the CAP recommends that laboratories report absolute cell
counts, along with their corresponding reference intervals. The CAP discourages the reporting
of percent cell counts without absolute counts on WBC differentials. Laboratories reporting only
percent cell counts must provide laboratory established reference intervals.
Under some circumstances it may be appropriate to distribute lists or tables of reference intervals
to all users and sites where reports are received. This system is usually fraught with difficulties,
but if in place and rigidly controlled, it is acceptable.
Reference interval citations from the manufacturer's insert or published literature citations may be
used to determine the reference interval. However, reference intervals have not been published
for many body fluid analytes and obtaining normal fluids to establish reference intervals may
not be feasible. If reference intervals are not available, results must be accompanied by an
appropriate comment such as, "The reference interval(s) and other method performance
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specifications are unavailable for this body fluid. Comparison of the result with concentration in
the blood, serum, or plasma is recommended."
✓ Patient reports
REFERENCES
1) Trost DC, et al. Probability-based construction of reference ranges for ratios of log-Gaussian analytes: an example from automated
leukocyte counts. Am J Clin Pathol. 2002;117:851-856
2) Clinical and Laboratory Standards Institute (CLSI). Defining, Establishing, and Verifying Reference Intervals in the Clinical Laboratory
- Approved Guideline-Third Edition. CLSI Document EP28-A3c. Clinical and Laboratory Standards Institute, Wayne, PA; 2010.
3) Etzell, JE. For WBC differentials reporting absolute numbers. CAP Today. 2010; 3:12
4) Richardson-Jones A, Twedt D, Hellman R. Absolute versus proportional differential leukocyte counts. Clin Lab. Haem. 1995:17(2),
115-123
COAGULATION
SPECIMEN COLLECTION AND HANDLING - COAGULATION
● Sampling of coagulation specimen collection and handling policies and procedures
● Sampling of specimen rejection records/log
● Sampling of patient coagulation specimens (anticoagulant, labeling, fill volume)
● How do you know if the specimen is clotted?

● What further actions are necessary if the specimen has a hematocrit of 60%?
● What is your course of action when you receive unacceptable coagulation
specimens?
● How do you ensure that platelet-poor plasma is used for testing?
HEM.36840 Specimen Collection - Intravenous Lines Phase I

Instructions for the clearing (flushing) of intravenous lines before drawing specimens for
hemostasis testing are defined and followed.
NOTE: Collection of blood for coagulation testing through intravenous lines that have been
previously flushed with heparin should be avoided, if possible. If the blood must be drawn
through an indwelling catheter, possible heparin contamination and specimen dilution must be
considered. When obtaining specimens from indwelling lines that may contain heparin, the line
should be flushed with 5 mL of saline, and the first 5 mL of blood or 6-times the line volume
(dead space volume of the catheter) be drawn off and not used for coagulation testing. For those
specimens collected from a normal saline lock (capped off venous port) twice the dead space
volume of the catheter and extension set should be discarded.
REFERENCES
1) Lew JKL, et al. Intra-arterial blood sampling for clotting studies. Effects of heparin contamination. Anesthesia. 1991;46:719-721
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2) Konopad E, et al. Comparison of PT and aPTT values drawn by venipuncture and arterial line using three discard volumes. Am J Crit
Care. 1992;3:94-101
3) Laxson CJ, Titler MG. Drawing coagulation studies from arterial lines; an integrative literature review. Am J Critical Care. 1994;
1:16-24
4) Adcock DM, et al. Are discard tubes necessary in coagulation studies? Lab Med. 1997;28:530-533
5) Brigden ML, et al. Prothrombin time determination. The lack of need for a discard tube and 24-hour stability. Lab Med.
1997;108:422-426
6) Clinical and Laboratory Standards Institute (CLSI). Collection, Transport, and Processing of Blood Specimens for Testing Plasma-
Based Coagulation Assays and Molecular Hemostasis Assays; Approved Guideline—Fifth Edition. CLSI Document H21-A5 (ISBN
1-56238-657-3). Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, PA 19087-1898 USA, 2008.
HEM.36860 Anticoagulant - Coagulation Phase I

Routine coagulation specimens are collected into 3.2% buffered sodium citrate.
NOTE: Sodium citrate is effective as an anticoagulant due to its mild calcium-chelating

properties. Of the 2 commercially available forms of citrate, 3.2% buffered sodium citrate
(105-109 mmol/L of the dihydrate form of trisodium citrate Na3C6H5O7·2H2O) is the
recommended anticoagulant for coagulation testing. Reference intervals for clot-based assays
must be determined using the same concentration of sodium citrate that the laboratory uses
for patient testing. The higher citrate concentration in 3.8% sodium citrate, may result in
falsely lengthened clotting times (more so than 3.2% sodium citrate) for calcium-dependent
coagulation tests (ie, PT and aPTT) performed on slightly underfilled samples and samples
with high hematocrits. The prolonged results are also more pronounced when the clotting time
is abnormal, such as in samples from patients on warfarin therapy. Both the World Health
Organization and CLSI recommend utilizing 3.2% sodium citrate (105-109 nm/L), as the
thromboplastin International Sensitivity Index (ISI) values applied in the INR calculations are
based on specimens collected in 3.2% sodium citrate. Coagulation testing cannot be performed
in samples collected in EDTA due to the more potent calcium chelation. While certain assay
systems, such as platelet mapping via thromboelastography require heparin, heparinized
tubes are not appropriate for clot-based plasma assays due to the inhibitory effect of heparin
on multiple coagulation proteins. Other testing for platelet function, such as light transmission
platelet aggregation assay can be performed on 3.2% or 3.8% sodium citrate.
REFERENCES
1) Adcock DM, et al. Effect of 3.2% vs 3.8% sodium citrate concentration on routine coagulation testing. Am J Clin Pathol.
1997;107:105-110
2) Reneke, J et al. Prolonged prothrombin time and activated partial thromboplastin time due to underfilled specimen tubes with 109
mmol/L (3.2%) citrate anticoagulant. Am J Clin Pathol. 1998;109:754-757
**REVISED** 08/24/2023
HEM.36880 Fill Volume and Specimen Mixing - Coagulation Phase I
Instructions for the acceptable fill volume and mixing of specimen collection tubes for
coagulation testing are defined and followed.
NOTE: The recommended proportion of blood to the sodium citrate anticoagulant volume is 9:1.
Inadequate filling of the collection device will decrease this ratio, and may lead to inaccurate
results for calcium-dependent clotting tests, such as the PT and aPTT. The effect on clotting time
from under-filled tubes is more pronounced when samples are collected in 3.8% rather than 3.2%
sodium citrate. The effect of fill volume on coagulation results also depends on the reagent used
for testing, size of the evacuated collection tube, and citrate concentration. A minimum of 90% fill
is recommended; testing on samples with less than 90% fill should be validated by the laboratory.
It is unacceptable to combine the contents from separate, underfilled sodium citrate collection
tubes.
Manufacturer's instructions for specimen mixing must be followed.
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✓ Records of rejected specimens
REFERENCES
1) Peterson P, Gottfried EL. The effects of inaccurate blood sample volume on prothrombin time (PT) and activated partial
thromboplastin time. Thromb Haemost. 1982;47:101-103
2) Adcock DM, Kressin D, Mariar PA. Minimum specimen volume requirements for routine coagulation testing. Dependence on citrate
concentration. Am J Clin Pathol. 1998;109:595-599
3) Reneke J, et al. Prolonged prothrombin time and activated partial thromboplastin time due to underfilled specimen tubes with 109
mmol/L (3.2%) citrate anticoagulant. Am J Clin Pathol. 1998;109:754-757
HEM.36900 Elevated Hematocrits - Coagulation Phase I

Instructions for the detection and special handling of specimens with elevated
hematocrits are defined and followed.
NOTE: A hematocrit value >55% may lead to spurious coagulation results. The citrate
anticoagulant distributes only in the plasma and not into the blood cells. For this reason, plasma
citrate concentration will be increased if the patient's hematocrit is greater than 55%, potentially
leading to spuriously prolonged PT and aPTT results, as well as erroneous results for other
calcium-dependent clotting tests such as clottable protein C/protein S and factor assays.
If possible, a new phlebotomy should be performed, using a reduced volume of sodium
citrate, adjusted for the elevated hematocrit. Conversely, there are no current data to support
a recommendation for adjusting the citrate concentration in the presence of severe anemia
(hematocrit <20%).
REFERENCES
2) Siegel JE, et al. Effect (or lack of it) of severe anemia on PT and APTT results. Am J Clin Pathol. 1998; 110:106-110
3) Siegel JE, et al. Monitoring heparin therapy. APTT results from partial- vs full-draw tubes. Am J Clin Pathol. 1998;110:184-187
4) Mariar RA, et al. Effect on routine and special coagulation testing values of citrate anticoagulant adjustment in patients with high
hematocrit values. Am J Clin Pathol. 2006: 126:400-405
5) Goodwin AJ. Q & A: Should a patient with a hematocrit greater than 55 percent be redrawn for correction always or only when
prothrombin time and partial prothrombin time are elevated? CAP Today. August 2016.
**REVISED** 08/24/2023
HEM.36920 Specimen Quality Assessment - Coagulation Phase II
Coagulation specimens are checked for clots before reporting results.
NOTE: Specimens with grossly visible clots may have extremely low levels of fibrinogen and
variably decreased levels of other coagulation proteins, causing PT, aPTT, fibrinogen and other
coagulation assays results to be inaccurate or unobtainable. Checking for clots may be done
before or after testing:
● With applicator sticks, where appropriate (should not be used with viscoelastic testing)
● By visual inspection of whole blood samples for large clots or centrifuged plasma for
small clots
● By analysis of results including waveform analysis or delta checks as applicable
Laboratories receiving centrifuged specimens (eg, frozen plasma) cannot rely on visual
inspection alone to detect specimen quality issues. For example, if a clot is not detected during
PT and aPTT testing and the fibrinogen level is <25 mg/dL, the sample may actually be serum
instead of plasma.
The laboratory must have a mechanism to identify these specimens appropriately and/or
to reject specimens, as applicable. Laboratories must work with their clients that perform
specimen processing to ensure that they practice appropriate specimen handling for coagulation
specimens.
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✓ Records of rejection for clotted specimens
REFERENCES
2) Arkin CF. Collection, handling, storage of coagulation specimens. Advance/Lab. 2002;11(1);33-38
HEM.36940 Specimen Handling for Plasma-based Testing - Coagulation Phase II

Coagulation tests are promptly performed on fresh plasma, or the platelet-poor plasma is
frozen until testing can be performed.
NOTE: After blood collection, there is progressive degradation of the labile coagulation factors
V and VIII, leading to increasing prolongation of the aPTT and PT. The allowable time interval
between specimen collection and sample testing depends on the temperature encountered
during transport and storage of the specimen. Allowable time intervals are as follows:
1. PT specimens, uncentrifuged or centrifuged with plasma remaining in the capped
tube above the packed cells, or as centrifuged plasma separated from the cells,
should be kept at room temperature (18 to 24°C) and tested no longer than 24
hours from the time of specimen collection. PT specimens should not be refrigerated
(during storage).
2. aPTT specimens that are uncentrifuged with plasma remaining in the capped tube
above the packed cells should be kept at room temperature (18 to 24°C) and tested
no longer than 4 hours after the time of specimen collection.
3. aPTT specimens that are centrifuged and plasma separated from cells can be kept
for 4 hours refrigerated (2 to 8°C) or at room temperature (18 to 24°C). Samples for
unfractionated heparin testing should be centrifuged within one hour from the time of
specimen collection
4. Samples for other coagulation factors (eg, thrombin time, protein C, factor V, factor
VIII) have variable stability and should be kept in the same manner as aPTT samples
If PT or aPTT testing cannot be performed within these times, platelet-poor plasma should be
removed from the cells and frozen at –20°C for up to 2 weeks or at –70°C for up to 12 months.
If a laboratory has established an allowable time interval different than that detailed above, data
must be available to verify that coagulation testing is valid in the time interval established.
REFERENCES
2) Adcock DM, et al. The effect of time and temperature variables on routine coagulation tests. Blood Coag Fibrinolysis. 1998;9:463-470
3) Neofotistos D, et al. Stability of plasma for add-on PT and aPTT tests. Am J Clin Pathol. 1998;109:758-763
4) Davis KD, et al. Use of different thromboplastin reagents causes greater variability in international normalized ratio results than
prolonged room temperature storage of specimens. Arch Pathol Lab Med. 1998;122:972-977
HEM.37150 DIC -Test Availability Phase II

Tests for defining or monitoring disseminated intravascular coagulation (DIC) are
available, if applicable to the patient population served.
NOTE: At a minimum, the platelet count, aPTT, PT/INR, fibrinogen assay and D-dimer (or FDP)
must be available.
Laboratories may wish to refer to criteria published by the International Society on Thrombosis
and Haemostasis (ISTH) and the Japanese Ministry of Health and Welfare for further information.
REFERENCES
1) Wada H, Gabazza EC, Asakura H, et al. Comparison of Diagnostic Criteria for Disseminated Intravascular Coagulation (DIC):
Diagnostic Criteria of the International Society of Thrombosis and Haemostasis (ISTH) and of the Japanese Ministry of Health and
Welfare for Overt DIC. Am J Hematol. 74:17-22, 2003.
2) Kotke-Marchant K (ed). An Algorithmic Approach to Hemostasis Testing. 2nd edition. CAP Press: 2016.
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**REVISED** 08/24/2023
HEM.37165 Coagulation Testing and Therapeutic Anticoagulant Recommendations Phase I
Recommendations are available to clinicians on the following:
● Laboratory tests used for monitoring heparin, low molecular weight heparin,
direct thrombin inhibitors (eg, lepirudin, bivalirudin, argatroban) and/or oral
anticoagulant therapy
● Utility and limitations of viscoelastic testing
● The therapeutic range for the tests, if available
● Information about potential interferences of anticoagulant medications on
coagulation testing.
NOTE: The coagulation tests available to clinicians should be applicable to the anticoagulant
drugs in use, and information is available on the test values that indicate that the anticoagulant is
present and/or is in a therapeutic range, when available.
For vitamin K antagonists (eg, warfarin), the prothrombin time (PT/INR) is recommended. Direct
oral anticoagulant medications (non-vitamin K) should not be monitored with PT/INR or aPTT
because the effect of these tests is not predictable. For unfractionated heparin the activated
partial thromboplastin time (aPTT) and/or activated clotting time are commonly used, but the
heparin assay (factor Xa inhibition) may also be employed. For low molecular weight heparin
or danaparoid, monitoring is often not necessary, but the heparin assay (Xa inhibition assay)
may be used in certain circumstances, as the aPTT is generally insensitive to the effect of these
agents. Direct parenteral thrombin inhibitors are often monitored using the aPTT. The thrombin
time may be useful to qualitatively verify the presence of direct thrombin inhibitors.
For viscoelastic testing, recommendations on the utility of testing in clinically meaningful
situations must be available, including the following as applicable:
● Proper test selection
● Instrument comparability and/or
● Recommendations for viscoelastic testing-based monitoring of antiplatelet or
anticoagulant medications.
✓ Memoranda to physicians, test reference guide, interpretive comments in patient reports, or
other mechanism for providing recommendations to physicians for ordering and interpreting
coagulation tests used for diagnostic purposes and anticoagulant therapy monitoring
REFERENCES
1) Leech BF, Carter CJ. Falsely elevated INR results due to the sensitivity of a thromboplastin reagent to heparin. Am J Clin Pathol.
1998;109:764-768
2) Fairweather RB, et al. College of American Pathologists conference XXXI on laboratory monitoring of oral anticoagulant therapy.
3) Olson JD, et al. College of American Pathologists conference XXXI on laboratory monitoring of oral anticoagulant therapy. Laboratory
monitoring of unfractionated heparin therapy. Arch Pathol Lab Med. 1998;122:782-798
4) Davis KD, et al. Use of different thromboplastin reagents causes greater variability in international normalized ratio results than
prolonged room temperature storage of specimens. Arch Pathol Lab Med. 1998;122:972-977
5) Laposata M, et al. College of American Pathologists conference XXXI on laboratory monitoring of low-molecular-weight heparin,
danaparoid, hirudin and related compounds, and argatroban. Arch Pathol Lab Med. 1998;122:799-807
6) Smythe MA, et al. Use of the activated partial thromboplastin time for heparin monitoring. Am J Clin Pathol. 2001;115:148-155
7) Smythe MA, et al. Different heparin lots. Does it matter? Arch Pathol Lab Med. 2001;125:1458-1462
8) Hirsh J, et al. Heparin and low-molecular-weight heparin: Mechanisms of action, pharmacokinetics, dosing, monitoring, efficacy and
safety. Chest. 2001; 119:64s-94s
9) Hirsh J, et al. Guide to anticoagulant therapy. Heparin: a statement for healthcare officials from the American Heart Association.
Circulation. 2001 19:2994-3018
10) Lippi G and Favaloro EJ. Recent guidelines and recommendations for laboratory assessment of the direct oral anticoagulants
(DOACs): is there consensus? Clin Chem Lab Med. 2015; 53(2):185-197.
11) Tomaselli GF, Mahaffey KW, Cuker A, et al. 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients
on Oral Anticoagulants: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am
Coll Cardiol. 2017; 70(24):3042-67.
12) Cuker A, Siegal D. Monitoring and reversal of direct oral anticoagulants. Hematology Am Soc Hematol Educ Program.
2015(1):117-124.
13) Adcock DM, Gosselin R. Direct Oral Anticoagulants (DOACs) in the Laboratory: 2015 Review. Thromb Res. 2015; 136(1):7-12.
14) College of American Pathologists. Coagulation Limited Proficiency Testing - Participant Summary Report (CGL-B 2016: Therapeutic
Anticoagulants) Continuing Education: 46-58. Published July 2016.
15) Funk DM. Coagulation assays and anticoagulant monitoring. Hematology Am Soc Hematol Educ Program. 2012(1):460-5.
16) Kottke-Marchant K, ed. An Algorithmic Approach to Hemostasis Testing. 2nd ed. Northfield, IL: CAP Press; 2016:379-402.
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17) Favaloro EJ, Lippi G. Interference of direct oral anticoagulants in haemostasis assays: high potential for diagnostic false positives
and false negatives. Blood Transfus. 2017; Oct; 15(6):491-494.
HEM.37175 Platelet-poor Plasma Phase I

At least annually and after major centrifuge maintenance or service, the laboratory
measures the actual platelet count of the "platelet-poor" plasma used for many
coagulation tests.
NOTE: Platelet-poor plasma is particularly important when testing for the presence of a lupus
anticoagulant, when measuring the level of unfractionated heparin, and in plasma samples to
be frozen for later testing. Platelet-poor plasma should have a residual platelet concentration
9
of less than 10 X 10 /L. This is important because platelet membranes form a procoagulant
surface that can accelerate coagulation and spuriously shorten clotting times. It is particularly
important when testing for the presence of a lupus anticoagulant; due to the high content of lipid
in the platelet plasma membrane, increased platelets in samples with the lupus anticoagulant can
cause the antiphospholipid antibody to bind to the platelet membrane, thus effectively removing
it from plasma. In this circumstance, the presence of lupus anticoagulant may not be detected
during diagnostic testing. Use of a 0.2-µm filter to achieve platelet-poor plasma samples is not
appropriate for all plasma-based coagulation studies. Filtration of plasma can result in selective
removal of factors V, VIII, IX, XII, and vWF; thus filtration of plasma to achieve a platelet-poor
specimen is discouraged. aPTT, prothrombin time/international normalized ratio (PT/NR) and
thrombin clotting time (TT) performed on fresh plasma samples are not affected by platelet
9
counts of at least up to 200 x 10 /L (200,000/µL).
Samples to be frozen should be "platelet-poor” because plasma contaminated with significant
numbers of platelets may yield different analytic results after thawing, due to lysis of platelets.
✓ Records of platelet concentration checks on all centrifuges used to prepare platelet-poor
plasma
REFERENCES
1) Lupus Anticoagulant Working Party. Guidelines on testing for the lupus anticoagulant. J Clin Pathol. 1991;44:885-889
2) Middleton AL, Oakley E. Activated partial thromboplastin time (aPTT): Review of Methods. Chicago, IL: American Society of Clinical
Pathology Check Sample PTS 91-8, 1991
3) Brien W, et al. Lupus anticoagulant testing: effect of the platelet count on the activated partial thromboplastin time. Brit J Biomed Sci
1993;50:114-116
5) Barnes PW, Eby CS, Lukoszyk M. Residual platelet counts in plasma prepared for routine coagulation testing with the Beckman
Coulter power processor. Lab Hematol. 2002;8:205-209
6) Favaloro EJ, Lippi B, Adcock DM. Preanalytical and postanalytical variables: The leading causes of diagnostic error in hemostasis?
Sem in Thromb Haem, 2008; 34:612-634
7) van den Besselaar AMHP, et al. Monitoring heparin therapy by the activated partial thromboplastin time--the effect of pre-analytical
conditions. Thromb Haemost, 1990; 57(2):226-231
QUALITY CONTROL - COAGULATION

● Sampling of quality control policies and procedures
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● How do you determine when QC is unacceptable and when corrective actions are
needed?
HEM.37300 Coagulation Quality Control Phase II

The laboratory performs controls using two different levels of control material each eight
hours of patient testing and each time there is a change in reagents, or more frequently if
specified in manufacturer's instructions, laboratory procedure, or the CAP Checklist.
NOTE: This includes photo-optical, electromechanical and manual methods.

For manual methods (ie, tilt tube method), controls must be performed by each individual who
performs the tilt tube test in the same eight hour period.
If an internal quality control process (eg, electronic/procedural/built-in) is used instead of an
external control material to meet daily quality control requirements, the laboratory must have
an individualized quality control plan (IQCP) approved by the laboratory director defining the
control process, including the frequency and use of external and internal controls. At a minimum,
external control materials must be analyzed with new lots and shipments of reagents or more
frequently if indicated in the manufacturer's instructions. Please refer to the IQCP section of the
All Common Checklist for the eligibility of tests for IQCP and requirements for implementation
and ongoing monitoring of an IQCP.
✓ Records of QC results including external and internal control processes AND
✓ Manufacturer product insert or manual
REFERENCES
1) Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare, Medicaid and CLIA programs;
CLIA fee collection; correction and final rule. Fed Register. 2003(Jan 24):5232 [42CFR493.1269(b)].
2) Steindel SJ, Tetrault G. Quality control practices for calcium, cholesterol, digoxin, and hemoglobin. A College of American
Pathologists Q-Probes study in 505 hospital laboratories. Arch Pathol Lab Med 1998;122:401-408
3) Voss EM, et al. Determining acceptability of blood glucose meters. Statistical methods of determining error. Lab Med.
1996;27:601-606
4) Clinical and Laboratory Standards Institute (CLSI). Statistical Quality Control for Quantitative Measurement Procedures: Principles
and Definitions. 4th ed. CLSI guideline C24. Clinical and Laboratory Standards Institute, Wayne, PA, 2016.
5) Ye JJ, et al. Performance evaluation and planning for patient/client-based quality control procedures. Am J Clin
Pathol.2000;113:240-248
6) LaBeau KM, et al. Quality control of test systems waived by the clinical laboratory improvement amendments of 1988. Perceptions
and practices. Arch Pathol Lab Med. 2000;124:1122-1127
amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1269(b) & 42CFR.493.1269(c)(2)]
8) Department of Health and Human Services, Centers for Medicare and Medicaid Services. S & C: 16-20-CLIA: Policy Clarification on
Acceptable Control Materials Used when Quality Control (QC) is Performed in Laboratories. April 8, 2016.
COAGULATION TESTS BASED ON

DIRECT MEASUREMENT OF ANALYTES
CAP accredited chemistry laboratories have been applying the concepts and procedures for calibration,
calibration verification, and analytic measurement range (AMR) verification to calibrated analytical methods for
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many years. Section directors and technologists with chemistry backgrounds will be helpful consultants to their
coagulation laboratory colleagues as calibration verification and AMR verification requirements evolve.
The checklist requirements apply to hemostasis test methods that are calibrated and directly measure the
concentration or activity of an analyte by employing enzyme immunoassay (EIA), including ELISA and
fluorescence immunoassay, immunoturbidity and chromogenic methods. Examples of commonly performed
hemostasis tests affected by these checklist requirements include: calibrated EIA or immunoturbidity methods
for coagulation factors, protein C antigen, free and total protein S antigens, von Willebrand factor antigen,
von Willebrand collagen binding activity, and quantitative D-dimer, and calibrated chromogenic assays for
antithrombin activity, protein C activity, and heparin or low molecular weight heparin. This list is not exhaustive,
and laboratory directors should review their laboratory's test menu to identify additional tests which fall into the
categories of methodologies described above.
Clot-based methods, (including PT, aPTT, thrombin time, factor assays and fibrinogen, lupus anticoagulant,
activated protein C resistance, qualitative and semi-quantitative assays) and all platelet function assays,
including ristocetin cofactor activity are exempt.
CALIBRATION: The process of adjusting an instrument or test system to establish a relationship between the
measurement response and the concentration or amount of the analyte that is being measured by the test
procedure.
CALIBRATION VERIFICATION: The process of confirming that the current calibration settings for each analyte
remain valid for a test system.
Each laboratory must define limits for accepting or rejecting results of the calibration verification process.
Calibration verification can be accomplished in several ways. If the manufacturer provides a calibration
validation or verification process, it must be followed. Other techniques include (1) assay of the current
calibration materials as unknown specimens and (2) assay of matrix-appropriate materials with target values
that are specific for the test system.
ANALYTICAL MEASUREMENT RANGE (AMR): The range of analyte values that a method can directly
measure on the specimen without any dilution, concentration, or other pretreatment that is not part of the usual
assay process.
LINEARITY AND THE AMR

Linearity is a fundamental characteristic of many analytic measurement methods, whereby there is a straight-
line relationship between "true" analyte concentrations and measured concentrations. In this context, linearity
refers to the relationship between the predicted and observed measurement results and not to the relationship
between instrument signal output and analyte concentration. For most assays, this relationship is linear within
the AMR.
AMR VERIFICATION
Laboratories are required to verify that the appropriate relationship is maintained over the AMR. Laboratories
may verify and use an AMR that is narrower than the range defined by the manufacturer. This may be
appropriate when materials available for method validation and/or AMR verification are not available to
verify the full range claimed by the manufacturer, or reporting values across the full range defined by the
manufacturer is not clinically relevant. For many assays, results beyond the AMR can be reported through
dilution or concentration studies (see HEM.37380 & HEM.37385). AMR verification is not required for calculated
test results (refer to the Definition of Terms in the All Common Checklist) as long as the individual results
contributing to the calculation have AMR verification.
Minimum requirements for AMR verification can be met by using matrix appropriate materials, which include
low, mid and high concentration or activity range of the AMR with recovery of results that fall within a defined
range of the target value. Records of the AMR verification process must be available.
CLOSENESS OF SAMPLE CONCENTRATIONS OR ACTIVITIES TO THE UPPER AND LOWER LIMITS OF

THE AMR
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When verifying the AMR, it is required that samples tested are near the upper and lower limits of the AMR.
Factors to consider in verifying the AMR are the expected analytic imprecision near the limits, the clinical
impact of errors near the limits, and the availability of test specimens near the limits. It may be difficult to obtain
specimens with values near the limits for some analytes. In such cases, reasonable procedures should be
adopted based on available specimen materials. The closeness of sample concentrations or activities to the
upper and lower limits of the AMR are defined at the laboratory director's discretion. The method manufacturer's
instructions for verifying the AMR must be followed, when available. The laboratory director must define limits
for accepting or rejecting tests of the AMR.
● Sampling of calibration and AMR policies and procedures
● Sampling of calibration/calibration verification records
● Sampling of AMR verification records
● What is your course of action if results fall outside the AMR?

● When was the last time you performed a calibration procedure for directly measured
coagulation analytes? How did you verify the calibration?
**REVISED** 10/24/2022
HEM.37360 Calibration Procedure Phase II
The laboratory calibrates each test system as defined and reviews the calibration records
for acceptability.
NOTE: Calibration of FDA-cleared/approved methods must be performed following the

manufacturer's instructions, at minimum, including the number, type, and concentration
of calibration materials, frequency of calibration, and criteria for acceptable performance.
Calibration procedures are typically specified in the manufacturer's instructions but may also be
established by the laboratory.
REFERENCES
1) Department of Health and Human Services, Centers for Medicare & Medicaid Services. Clinical laboratory improvement amendments
of 1988; final rule. Fed Register. 1992(Feb 28):7165 [42CFR493.1217]
2) Department of Health and Human Services, Centers for Medicare & Medicaid Services. Medicare, Medicaid and CLIA Programs;
Laboratory Requirements Relating to Quality Systems and Certain Personnel Qualifications; final rule. Fed Register. 2003(Jan
24):3707 [42CFR493.1255]
3) Clinical and Laboratory Standards Institute (CLSI). Evaluation of Matrix Effects. 4th ed. CLSI document EP14. Clinical and
Laboratory Standards Institute, Wayne, PA; 2022.
4) Miller WG. Quality control. In: Henry's Clinical Diagnostic and Management by Laboratory Methods, 21st Edition, ed McPherson RA,
Pincus MR. Saunders Elsevier, 2007 :99-111.
HEM.37363 Calibration and Calibration Verification Materials Phase II

High quality materials with test system and matrix-appropriate target values are used for
calibration and calibration verification whenever possible.
NOTE: Calibration and calibration verification must have defined analyte target values and
appropriate matrix characteristics for the clinical specimens and specific assay method. Many
instrument systems require calibration materials with system-specific target values to produce
accurate results for clinical specimens.
Suitable materials for calibration verification include, but are not limited to:
1. Calibrators used to calibrate the analytical system
2. Materials provided by the manufacturer for the purpose of calibration verification
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3. Previously tested unaltered patient/client specimens

4. Primary or secondary standards or reference materials with matrix characteristics
and target values appropriate for the method
5. Third party general purpose reference materials that are suitable for verification
In general, routine control materials and proficiency testing materials are not suitable for
calibration verification, except in situations where the material has been shown to be suitable (eg,
specifically designated by the method manufacturer) or no other materials are available.
Evidence of Compliance
✓ Records of calibration and calibration verification
REFERENCES
1) ISO 17511:2003 In vitro diagnostic medical devices--Measurement of quantities in biological samples--Metrological traceability of
values assigned to calibrators and control materials.
HEM.37365 Recalibration/Calibration Verification Criteria Phase II

Criteria for the frequency and acceptability of recalibration or calibration verification are
defined and followed.
NOTE: Laboratories must either recalibrate or perform calibration verification at least every six
months and if any of the following occur:
1. At changes of reagent lots unless the laboratory can demonstrate that the use of
different lots does not affect the accuracy of patient/client results
3. After major preventive maintenance or change of critical instrument component
Single use devices, and other test devices that do not allow user calibration, do not require
calibration verification.
✓ Records of calibration verification at defined frequency
REFERENCES
amendments of 1988; final rule. Fed Register. 2003(Jan 24):3707[42CFR493.1255(b)(3)]
2) Miller WG. Quality control. In: Henry's Clinical Diagnostic and Management by Laboratory Methods, 21st Edition, ed McPherson RA,
Pincus MR. Saunders Elsevier, 2007: 99-111.

The test system is recalibrated when calibration verification fails to meet the established
criteria of the laboratory.
✓ Records of recalibration, if calibration or calibration verification has failed
REFERENCES
**REVISED** 08/24/2023
HEM.37373 AMR Verification Materials Phase II
Verification of the analytical measurement range (AMR) is performed with matrix-
appropriate materials, which, at a minimum, include the low, mid and high range of the
AMR, and appropriate acceptance criteria are defined.
NOTE: The matrix of the sample (ie, the environment in which the sample is suspended
or dissolved) may influence the measurement of the analyte. In many cases, the method
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manufacturer will recommend suitable materials. Other suitable materials for AMR verification
include the following:
1. Linearity material of appropriate matrix, eg, CAP CVL Survey-based or other suitable
linearity verification material
2. Previously tested patient/client specimens, that may be altered by admixture
with other specimens, dilution, spiking in known amounts of an analyte, or other
technique
3. Primary or secondary standards or reference materials with matrix characteristics
and target values appropriate for the method
4. Patient samples that have reference method assigned target values
5. Control materials, if they adequately span the AMR and have method specific target
values
Factors to consider in verifying the AMR are the expected analytic imprecision near the limits,
the clinical impact of errors near the limits, and the availability of test specimens near the limits.
It may be difficult to obtain specimens with values near the limits for some analytes. In such
cases, reasonable procedures should be adopted based on available specimen materials. The
closeness of sample concentrations and activities to the upper and lower limits of the AMR are
defined at the laboratory director's discretion.
✓ Records of AMR verification
REFERENCES
2) Anne Ford. As coag tests evolve, so do checklist requirements. Northfield, IL; College of American Pathologists. CAP Today
November 2012
3) Shah VP, Midha KK, Dighe S, et al. Bioanalytical Method Validation - Pharm Res. 1992;9(4):588-92.
4) Hartmann C, Smeyers-Verbeke J, Massart DL, McDowall RD. Validation of bioanalytical chromatographic methods. J Pharm Biomed
Anal. 1998;17(2):193-218.
5) Findlay JW et al. Analytical Methods Validation - Bioavailability, Bioequivalence and Pharmacokinetic Studies. Pharm Res.
2000;17(12):1551-7.
6) Killeen AA, Long T, Souers R, Styler P, Ventura CB, Klee GG. Verifying Performance Characteristics of Quantitative Analytical
Systems: Calibration Verification, Linearity, and Analytical Measurement Range. Arch Pathol Lab Med. 2014:138(9): 1773-81.
**REVISED** 08/24/2023
HEM.37375 AMR Verification Phase II
Verification of the analytical measurement range (AMR) is performed at least every six
months and following the defined criteria. Records are retained.
NOTE: The AMR must be verified at least every six months after a method is placed in service
and if any of the following occur:
1. A change of reagent lots unless the laboratory can demonstrate that the use of
different lots does not affect the accuracy of patient/client results, and the range used
to report patient/client test data.
3. After major preventive maintenance or change of a critical instrument component
It is not necessary to independently verify the AMR if the calibration of an assay includes
calibrators that span the full range of the AMR, with low, midpoint and high values represented
(ie, three points) and if the system is calibrated at least every six months. A one-point or two-
point calibration does not include all of the necessary points to verify the AMR.
AMR verification is not required for clot-based coagulation tests, platelet function tests, and
other tests where output is a unit of time or arbitrary reporting unit (rather than measured
analyte concentration). AMR verification is not required for calculated test results as long as the
individual results contributing to the calculation have AMR verification.
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✓ Records of AMR verification, as required, at least every six months
REFERENCES
2) Anne Ford. As coag tests evolve, so do checklist requirements. Northfield, IL; College of American Pathologists. CAP Today
November 2012
HEM.37380 Diluted or Concentrated Samples Phase II

If a result is greater than or less than the AMR, a numeric result is not reported unless
the sample is processed by dilution, a mixing procedure or concentration so that the
processed result falls within the AMR.
NOTE:
1. A measured value that is outside the AMR may be unreliable and should not be
reported in routine practice. Dilution, a mixing procedure* or concentration of a
sample may be required to achieve a measured analyte activity or concentration
that falls within the AMR. The processed result must be within the AMR before it is
mathematically corrected by the concentration or dilution factor to obtain a reportable
numeric result.
2. For each analyte, the composition of the diluent solution and the appropriate
volumes of sample and diluent must be specified in the procedure manual.
Specifying acceptable volumes is intended to ensure that the volumes pipetted are
large enough to be accurate without introducing errors in the dilution ratio.
3. All dilutions, whether automatic or manual, should be performed in a way that
ensures that the diluted specimen reacts similarly to the original specimen in the
assay system. For some analytes, demonstrating that more than one dilution ratio
similarly recovers the elevated concentration may be helpful.
4. This checklist requirement does not apply if the concentration or activity of the
analyte that is outside the AMR is reported as "greater than" or " less than" the limits
of the AMR.
*This procedure is termed the "method of standard additions." In this procedure, a known
quantity (such as a control) is mixed with the unknown, and the concentration of the mixture is
measured. If equal volumes of the two samples are used, then the result is multiplied by two, the
concentration of the known subtracted, and the concentration of the unknown is the difference.
✓ Patient reports or worksheets
HEM.37385 Maximum Dilution Phase II

For analytes that may have results falling outside the limits of the AMR, the laboratory
defines the maximum dilution that may be performed to obtain a reportable numeric
result.
NOTE:
1. For each analyte, the laboratory protocol should define the maximum dilution that
falls within the AMR and that can be subsequently corrected by the dilution factor
to obtain a reportable numeric result. Note that for some analytes, an acceptable
dilution protocol may not exist because dilution would alter the analyte or the matrix
causing erroneous results. Also note that, for some analytes, there may be no clinical
relevance to reporting a numeric result greater than a stated value.
2. Analytes for which a dilution protocol is unable to bring the activity or concentration
into the AMR should be reported as "greater than" the highest estimated values.
3. Establishment of allowable dilutions is performed when a method is first placed into
service and is reviewed biennially thereafter as part of the procedure manual review
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by the Laboratory Director or designee. The laboratory director is responsible for

establishing the maximum allowable dilution of samples that will yield a credible
laboratory result for clinical use.
✓ Patient reports or worksheets
HEM.37390 Cut-Off Values for Qualitative Tests Phase II

For qualitative tests that use a quantitative cut-off value to distinguish positive from
negative results, the analytic performance around the cut-off value is verified or
established initially, and reverified at least every six months thereafter.
NOTE: This requirement applies to tests that report qualitative results based on a quantitative
measurement using a threshold (cut-off value) to discriminate between positive and negative
results for clinical interpretation. It does not apply to methods where the laboratory is not able to
access the actual numerical value from the instrument.
Appropriate materials for establishment and verification of the cut-off are identical to those
recommended for calibration verification. The requirement can be satisfied by the process of
calibration or calibration verification using calibrators or calibration verification materials with
values near the cut-off. It may also be satisfied by the use of QC materials that are near the cut-
off value if those materials are claimed by the method manufacturer to be suitable for verification
of the method's calibration process.
Verification of the cut-off should also be performed at changes of lots of analytically critical
reagents (unless the laboratory director has determined that such changes do not affect the cut-
off); after replacement of major instrument components; after major service to the instrument;
and when QC materials reflect an unusual trend or shift or are outside of the laboratory's
acceptable limits, and other means of assessing and correcting unacceptable control values fail
to identify and correct the problem.
For FDA-cleared or approved tests, the clinical appropriateness of the cut-off value is evaluated
as part of the clinical validation performed by the manufacturer. For laboratory-developed tests
and modified FDA-cleared or approved tests, refer to COM.40640 for validation of clinical claims.
✓ Records of initial establishment and verification of the cut-off value at defined frequency
COAGULATION STUDIES
PT/INR AND APTT

● Sampling of reporting policies and procedures
● Sampling of patient PT/INR and aPTT reports
● How have you established or validated your PT and aPTT reference intervals using
the current lot numbers of PT and aPTT reagents?
● How have you established and validated your aPTT-based heparin therapeutic
range?
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● How do you establish the geometric mean used to calculate the INR?
● Examine the current PT reagent lot package insert for the ISI value. Verify that the
correct ISI value was used for the INR calculation based on the reagent lot number
and instrument model used.
● Review the data used to establish the geometric mean for the INR calculation, and
confirm that the correct geometric mean is being used in the INR calculation.
● Review records of INR calculations to confirm use of the appropriate ISI value
following changes in reagents, reagent lots, or instrumentation.
● Check patient reports for PT and aPTT testing and assess use of the correct
reference intervals, INR calculations, and associated parameters.
● Track a PT and aPTT specimen from testing in the laboratory to results reporting.
Assess the reference intervals on patient reports, and correct INR calculations and
associated parameters.
**REVISED** 10/24/2022
HEM.37400 Alternative Method Criteria Phase I
For photo-optical coagulation systems, the laboratory defines and follows criteria for
determining when alternative procedures are performed (eg, lipemia, hyperbilirubinemia,
turbidity, etc.).
NOTE: Very long clotting times may not be reproducible on an automated coagulation
instrument. Criteria must be established by each laboratory for performance of the PT or aPTT
by an alternate technique (eg, manual method) when the readable range of the instrument is
exceeded. In addition, criteria must be provided for performance of alternate procedures in
the presence of significant hyperbilirubinemia or lipemia, paradoxically short aPTTs and non-
duplicating aPTTs.
✓ Records showing results from alternative procedures, as applicable
REFERENCES
1) Favaloro EJ, Lippi B, Adcock DM. Preanalytical and postanalytical variables: The leading causes of diagnostic error in hemostasis?
Sem in Thromb Haem, 2008; 34:612-634
HEM.37600 Clot Detection Phase II

For electromechanical coagulation systems with reusable probes to detect a clot,
instructions for cleaning the probes are available.
HEM.37800 Duplicate Testing - Manual Testing Phase II

Manual coagulation testing (eg, PT, aPTT, fibrinogen) determinations are performed in
duplicate and criteria for agreement are defined.
✓ Records or worksheets reflecting duplicate testing of each sample including corrective action
when limits of agreement are exceeded
REFERENCES
amendments of 1988; final rule. Fed Register. 2003(Jan 24):7168 [42CFR493.1269(c)(2)]
HEM.37820 ISI Phase II

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The ISI is appropriate to the particular PT reagent and instrumentation used.
NOTE: The laboratory must demonstrate appropriateness of its ISI, a measurement of the
sensitivity with which thromboplastin reagents detect decreased levels of vitamin K-dependent
coagulation factors. The ISI used must be appropriate for the particular reagent-instrument
combination and method of clot detection. Acceptable records include information from the
instrument/reagent manufacturer or local calibration using an FDA-approved product. This is
especially true for photo-optical vs. electromechanical instruments, but may also vary among
different instruments within the same classification.
✓ Record showing information from the instrument/reagent manufacturer OR use of an ISI
calculated from laboratory specimens
REFERENCES
1) Clinical and Laboratory Standards Institute (CLSI). One-Stage Prothrombin Time (PT) Test and Activated Partial Thromboplastin
Time (aPTT) Test; 3rd ed. CLSI document H47. Clinical and Laboratory Standards Institute, Wayne, PA, 2023.
2) Fairweather RB, et al. College of American Pathologists Conference XXXI on laboratory monitoring of oral anticoagulant therapy.
3) Clinical and Laboratory Standards Institute (CLSI). Procedures for Validation of INR and Local Calibration of PT/INR Systems;
Approved Guideline. CLSI document H54-A. Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne,
PA 19087-1898, USA, 2005.
amendments of 1988; final rule. Fed Register. 2003(Jan 24): [42CFR493.1252(a)]
HEM.37830 INR Calculation Adjustment for ISI Phase II

The calculation of the INR is adjusted using the appropriate ISI value for every new lot of
PT reagent, changes in types of reagent, or change in instrumentation.
NOTE: The ISI value usually changes with each new lot of PT reagent. The ISI reflects the
sensitivity of the PT reagent to decreased levels of the vitamin K-dependent coagulation factors.
This change in sensitivity will affect the calculation of the INR value.
The laboratory must be able to provide records that calculation of the INR is correct and that the
ISI value is appropriate for the lot of thromboplastin reagent and for the method of clot detection.
Such records must be available whether the INR is calculated by the coagulation instrument,
laboratory information system, or manually.
It is critical to calculate and report appropriate INR values. Reporting erroneous INR values may
lead to use of excessive or insufficient vitamin K antagonist medication, which may result in
bleeding or thrombotic complications in patients.
✓ Records showing that the ISI values used in the INR calculation were appropriate for new
lots and types of PT reagent and for any other changes
REFERENCES
PA 19087-1898, USA, 2005.
HEM.37840 INR Geometric Mean Phase II

The appropriate geometric mean of the PT reference interval is used in the INR
calculation.
NOTE: The appropriate geometric mean of the PT reference interval must be used in the INR
calculation, given by the formula:
ISI
INR=(PT of patient / PT of geometric mean normal population)
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The mean normal population value may change when the specimen collection process,
instrument, reagent lot, or reagent changes.
When the distribution of values is distributed normally, the geometric mean, the arithmetic mean,
the median and the mode of the population being studied are identical theoretically. These values
diverge from each other, however, as the population distribution becomes more skewed. The
geometric mean is a more appropriate estimate of the average value than the arithmetic mean
when the population of interest is lognormally distributed because the geometric mean takes
skewing into account.
Calculation of the geometric mean is indicated below; this calculation is available in many
spreadsheet programs, such as Microsoft Excel.
GM = antilog [(log(X1) + log(X2) + log(X3) + . . . log(Xn))/n].
✓ Records for geometric mean determinations and INR calculations for each instrument and PT
reagent lots used
REFERENCES
3) Ansell J, et al. Managing oral anticoagulant therapy. Chest 2001;119:22s-38s
4) Critchfield GC, Bennett ST. The influence of the reference mean prothrombin time on the international normalized ratio. Am J Clin
Pathol. 1994 Dec;102(6):806-11
PA 19087-1898, USA, 2005.
**REVISED** 10/24/2022
HEM.37860 Report Verification Criteria Phase II
Patient reports are checked for correct INR calculations, patient values, and reference
intervals under the following circumstances.
1. Change in lot or type of PT reagent
2. Change in instrument
3. Establishment of new PT reference interval
4. Change in INR calculation
5. At defined intervals, in the absence of the above changes
NOTE: It is suggested that the calculations be checked at the following INR values: 2.0 and
3.0. Patient reports must be checked at least once per year even in the absence of changes to
the test system and calculations. This requirement applies whether the INR is calculated by the
coagulation analyzer or by the laboratory information system.
✓ Records of patient report checks at defined frequency
REFERENCES
3) Ansell J, et al. Managing oral anticoagulant therapy. Chest 2001;119:22s-38s
PA 19087-1898, USA, 2005.
HEM.37870 Reference Intervals Phase II

Reference intervals for PT and aPTT are current for the reagent or lot number, and are
appropriately determined.
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NOTE: Because of the variability between different types of PT and aPTT reagents, and even
different lots of PT and aPTT reagents, there may be significant changes in the reference interval
after a change of the type or lot of reagent. For this reason, the laboratory should establish and
then verify the reference interval with each change of lot or change in reagent.
✓ Reports showing verification of the reference interval with changes of lot or reagent AND
✓ Patient reports reflecting the use of the correct reference intervals
REFERENCES
1) Clinical and Laboratory Standards Institute (CLSI). Defining, Establishing, and Verifying Reference Intervals in the Clinical Laboratory
- Approved Guideline-Third Edition. CLSI Document EP28-A3c. Clinical and Laboratory Standards Institute, Wayne, PA; 2010.
**REVISED** 10/24/2022
HEM.37880 Unfractionated Heparin Therapeutic Interval Phase I
The aPTT-based unfractionated heparin (UFH) therapeutic interval is established and
subsequently verified using an appropriate method.
NOTE: The UFH-responsiveness of aPTT reagents may change from lot to lot and among
different reagents used on different instrument platforms. For this reason, it is necessary to
establish the UFH therapeutic interval for the aPTT assay with each change of coagulation
instrument and/or reagent type. The therapeutic interval must be verified with each new lot of a
given aPTT reagent.
The aPTT is commonly used to monitor the anticoagulant effects of UFH. The therapeutic interval
for UFH therapy should be initially validated for new reagents or instruments by using ex vivo
plasma samples anticoagulated with 3.2% sodium citrate obtained from patients receiving
therapeutic doses of UFH. This can be accomplished by measuring the aPTT and UFH activity
and then deriving the aPTT therapeutic interval by comparison to UFH activity. For subsequent
reagent lot changes, the therapeutic interval can be verified by comparing the aPTT of patient
samples using the new and the prior aPTT lots. It is not best practice to use plasma samples
spiked with UFH in vitro to calculate the therapeutic interval, as differences in UFH binding
proteins in vitro may lead to overestimation of the therapeutic interval.
Laboratories in a local care network or system using the same instrument and same lot of an
aPTT reagent, can share their nomogram of UFH. However, a verification study using one
laboratory as the reference laboratory to show that their results are comparable to each other
must be performed.
Guidance on determining the UFH therapeutic interval using the aPTT can be found on cap.org
at https://documents.cap.org/documents/heparin-sensitivity-new-aptt-reagents.pdf.
UFH assays using factor Xa inhibitory or lla inhibitory assays are preferred alternate methods to
monitor UFH therapy.
✓ Records of establishment and verification of the aPTT UFH therapeutic interval for each lot of
aPTT reagent used
REFERENCES
1) Rosborough TK. Comparison of anti-factor Xa heparin activity and activated partial thromboplastin time in 2,773 plasma samples
from unfractionated heparin-treated patients. Am J Clin Pathol. 1997;108:662-668
2) Olson JD, et al. College of American Pathologists conference XXXI on laboratory monitoring of anticoagulant therapy. Laboratory
monitoring of unfractionated heparin therapy. Arch Pathol Lab Med. 1998;122:782-798
3) Smythe MA, et al. Use of the activated partial thromboplastin time for heparin monitoring. Am J Clin Pathol. 2001;115:148-155
4) Smythe MA, et al. Different heparin lots. Does it matter? Arch Pathol Lab Med. 2001;125:1458-1462
5) Hirsh J, et al. Guide to anticoagulant therapy. Heparin: a statement for healthcare officials from the American Heart Association.
Circulation. 2001 19:2994-3018
6) Hirsh J, Raschke R. Heparin and low-molecular-weight heparin: the Seventh ACCP Conference on Antithrombotic and Thrombolytic
Therapy. Chest. 2004 Sep;126(3 Suppl):188S-203S
8) Brill-Edwards P, Ginsberg JS, Johnston M, Hirsh J. Establishing a therapeutic range for heparin therapy. Ann Intern Med.
1993;119:104-9.
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D-DIMER STUDIES
● Sampling of D-dimer policies and procedures
● Sampling of D-dimer patient reports
HEM.37924 D-dimer Unit Results Phase II

The unit type (eg, FEU or D-DU) and unit of magnitude (eg, ng/mL) reported with the
patient results are the same units as generated directly by the D-dimer method (following
manufacturer's product insert); or if different units are reported, the laboratory verifies the
correct conversion of the units on an annual basis.
NOTE: The CAP and Clinical Laboratory and Standards Institute (CLSI) recommend that units
not be converted from those stated in the package insert. If units are converted, the laboratory
must verify the conversion of the units in patient reports for patient values, cut-off values, and
reference intervals with changes in reagents, instrument and at least once per year in the
absence of a change, with records retained.
The units generated directly by the D-dimer method can be determined from the package insert.
If units are not stated in the package insert, consult with the manufacturer of the D-dimer method.
The following chart demonstrates the correct conversion factor for the different reporting units:
Manufacturer Final Units Correct Conversion Equivalency Equation

Units Factor
FEU ng/mL D-DU ng/mL 0.5 1 FEU ng/mL = 0.5 D-DU ng/mL
FEU ng/mL D-DU µg/mL 0.0005 1 FEU ng/mL = 0.0005 D-DU µg/mL
FEU µg/mL FEU ng/mL 1000 1 FEU µg/mL = 1000 FEU ng/mL
D-DU ng/mL FEU ng/mL 2 1 D-DU ng/mL = 2 FEU ng/mL
D-DU µg/mL FEU ng/mL 2000 1 D-DU µg/mL = 2000 FEU ng/mL
D-DU µg/mL D-DU ng/mL 1000 1 D-DU µg/mL = 1000 D-DU ng/mL
✓
Patient reports with unit type (FEU vs. DDU) and unit of magnitude (ng/mL vs. µg/mL)
that are the same as the units directly generated by the D-dimer method and in the
manufacturer's product insert OR
✓ Records of the annual verification to confirm correct conversion of the unit type (FEU vs.
DDU) and unit of magnitude (ng/mL vs. µg/mL) if units are reported that are different than
those directly generated by the D-dimer method
REFERENCES
1) Clinical and Laboratory Standards Institute (CLSI). Quantitative D-dimer for the Exclusion of Venous Thromboembolic Disease;
Approved Guideline. CLSI document H59-A . Clinical and Laboratory Standards Institute, Wayne, PA; 2011.
2) Olson JD, Cunninghan MT, Higgins RA, et. al. D-dimer: simple test, tough problems. 2013; 137:1030-1038
HEM.37925 D-dimer - Evaluation of VTE Phase II

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If a quantitative D-dimer method is used in the evaluation of venous thromboembolism

(VTE), the method is valid for this purpose.
NOTE: D-Dimer methods intended for evaluation of VTE may be used, along with pretest
probability, if a method specific cut-off value is available. Cut-off values are not universal, so
method specific data regarding the negative predictive value and the sensitivity should be
available. For cut-off data acquired from the literature, the CLSI (H59-A) recommends a negative
predictive value of ≥98% (lower limit of CI ≥95%) and a sensitivity of ≥97% (lower limit of CI
≥90%) for non-high pretest probability of VTE.
For D-dimer methods that are FDA-cleared/approved for exclusion of VTE, the package insert
includes the cut-off value and this value should be provided in the report. It is not feasible for
most laboratories to perform a sufficient clinical validation of a D-dimer cut-off for use in the
evaluation of VTE (ie, either exclusion or aid in diagnosis), including separate validation of the
cut-off for deep vein thrombosis and pulmonary embolism. Therefore using the cutoff supplied
from the manufacturer is strongly recommended.
If a laboratory or group of laboratories determine a cut-off (not published in literature or the
package insert), a summary of data including the NPV, sensitivity, and power of determination
must be available. The CLSI Guideline H59-A recommends correlation with imaging studies
and follow-up after three months on a minimum of 200 cases to establish the threshold for VTE
exclusion.
✓ Package insert stating an Intended Use for the exclusion of VTE or aid in the diagnosis of
VTE AND
✓ A method specific cut-off for the evaluation of VTE from the package insert, literature, or an
extensive clinical validation study
REFERENCES
1) Olson J, Cunningham M, Brandt J, et al. Use of the D-Dimer for Exclusion of VTE: Difficulties Uncovered through the Proficiency
Testing Program of the College of American Pathologists (CAP). J Thromb Hemostasis, Abstract, August 2005
2) Spannagl M, Haverkate F, Reinauer H, Meijer P. The performance of quantitative D-dimer assays in laboratory routine. Blood Coagul
Fibrinolysis. 2005 Sep;16(6):439-43
3) Goodacre S, Sampson FC, Sutton AJ, et al. Variation in the diagnostic performance of D-dimer for suspected deep vein thrombosis.
QJM. 2005 Jul;98(7):513-27. Epub 2005 Jun 13
4) Gardiner C, Pennaneac'h C, Walford C, et al. An evaluation of rapid D-dimer assays for the exclusion of deep vein thrombosis. Br J
Haematol. 2005 Mar;128(6):842-8
5) Diamond S, Goldweber R, Katz S. Use of D-dimer to aid in excluding deep venous thrombosis in ambulatory patients. Am J Surg.
2005 Jan;189(1):23-6
6) Wolf SJ, McCubbin TR, Feldhaus KM, et al. Prospective validation of Wells Criteria in the evaluation of patients with suspected
pulmonary embolism. Ann Emerg Med. 2004 Nov;44(5):503-10
7) Gould MK. Review: of the various D-dimer assays, negative ELISA results are most useful for excluding a diagnosis of deep venous
thrombosis or pulmonary embolism. ACP J Club. 2004 Nov-Dec;141(3):77
8) Stein PD, Hull RD, Patel KC, et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic
review. Ann Intern Med. 2004 Apr 20;140(8):589-602
Approved Guideline. CLSI document H59-A (ISBN 1-56238-747-2). Clinical and Laboratory Standards Institute, 940 West Valley
Road, Suite 1400, Wayne, Pennsylvania 19087 USA, 2011.
HEM.37930 D-dimer Reporting Phase II

If a D-dimer test is used for evaluation of venous thromboembolism (VTE), the laboratory
reports the VTE exclusion cut-off value as stated by the manufacturer. If the D-dimer test
is intended for other purposes (eg, DIC evaluation) a reference interval is required.
NOTE: This requirement only applies to quantitative D-dimer tests.

The cut-off value and upper limit of the reference interval are not always identical. The upper
limit of the reference interval may be used to evaluate disseminated intravascular coagulation
(DIC), while the cut-off value is used for evaluation of VTE (see COM.29950 regarding reference
interval reporting). The cut-off value and/or reference interval must be reported in units identical
to the patient results, including both unit type (FEU or D-DU) and unit of magnitude (eg, ng/mL).
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✓ Patient reports including both the reference interval and/or the cut-off value for VTE
evaluation
REFERENCES
HEM.37935 Sensitivity of D-dimer Test - Evaluation of VTE Phase I

If a D-dimer test is insufficiently sensitive to exclude venous thromboembolism, the
laboratory informs clinicians that the test must not be used for this purpose.
NOTE: Manual agglutination D-dimer and FDP (fibrin degradation products) assays are not
adequately sensitive for evaluation of deep vein thrombosis and/or pulmonary embolism.
REFERENCES
MIXING STUDIES
● Sampling of mixing studies policies and procedures
● Sampling of mixing study testing records
Plasma-mixing studies (ie, mixing patient plasma with normal plasma) may be performed to distinguish whether
an abnormal screening coagulation test result (PT or aPTT) is caused by a factor deficiency or an inhibitor.
HEM.37937 Mixing Studies Procedure Phase II

When plasma-mixing studies are performed, an appropriate pooled plasma is utilized.
NOTE: It is not appropriate to use single patient plasma samples with normal PT/aPTT values as
the “normal” plasma reagent, as factor levels may vary over a wide range without affecting PT/
aPTT results. Pooled plasma prepared in the laboratory or commercial products comprised of at
least 20 apparently healthy donors are acceptable.
REFERENCES
1) Kaczor DA, et al. Evaluation of different mixing study reagents and dilution effect in lupus anticoagulant testing. Am J Clin Pathol.
1991;95:408-411
HEM.37938 Mixing Studies Procedure Phase II

For samples with positive mixing study results (suggestive of an inhibitor), there is either
a procedure to detect heparin or other antithrombotic drugs that inhibit coagulation,
or the result is reported with a comment that the effect of inhibitor drugs cannot be
excluded.
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NOTE: Anticoagulant drugs that act as coagulation inhibitors (eg, heparin, factor Xa inhibitors or
direct thrombin inhibitors) may give positive results in mixing study assays. Laboratories must
screen mixing study samples with elevated PT and/or aPTT results for these anticoagulant drugs.
● For heparin, performing a thrombin time assay, heparin Xa inhibition assay, repeating the
aPTT with polybrene, or treating the sample with heparinase may be acceptable.
● For direct thrombin inhibitors, performing a thrombin time should detect the presence
of the inhibitor. A thrombin time should be greatly prolonged (or even give a "clot
undetected" result) in the presence of a direct thrombin inhibitor. A thrombin time has
the advantage of detecting not only heparin, but also the presence of direct thrombin
inhibitors such as lepirudin, bivalirudin and argatroban.
Alternately, the test result from a positive mixing study must include a comment that “the
presence of anticoagulant inhibitor drugs such as heparin or direct thrombin inhibitors cannot be
excluded.”
REFERENCES
1) Jim RTS. A study of the plasma thrombin time. J Lab Clin Med. 1957; 50:45-60
2) Harsfalvi J, et al. The use of polybrene for heparin neutralization in protein C activity assay. Blood Coag Fibrinolysis. 1990;1:357-361
3) Haynes SR, et al. Accuracy of coagulation studies performed on blood samples obtained from arterial cannulae. Brit J Anaesth.
1992;69:599-601
4) Carlsson SC, Mattsson C, Eriksson UG, et al. A review of the effects of the oral direct thrombin inhibitor ximelagatran on coagulation
assays. Thromb Res. 2005;115(1-2):9-18
5) Chang SH, Tillema V, Scherr D.A "percent correction" formula for evaluation of mixing studies. Am J Clin Pathol. 2002
Jan;117(1):62-73
6) Kaczor DA, Bickford NN, Triplett DA. Evaluation of different mixing study reagents and dilution effect in lupus anticoagulant testing.
Am J Clin Pathol. 1991 Mar;95(3):408-11
COAGULATION FACTOR ASSAYS (EXCLUDING

FIBRINOGEN BY IMMUNOLOGIC METHODS)
The factor activity of a plasma sample is measured by its ability to correct the prolonged clotting time of factor-
deficient plasma. The aPTT or PT of mixtures of diluted test plasma and factor-deficient plasma are inversely
proportional to the concentration of the factor in the test plasma mixtures. Mixtures of diluted reference plasma
of known factor activity and factor-deficient plasma are used to construct a reference curve that can be used to
convert aPTT or PT values of the test plasma mixtures to units of activity.
Fibrinogen can be measured using different methodologies. The following testing methods for fibrinogen are
applicable to the requirements in this section:
1 The Clauss method (a functional assay based on the time to fibrin clot formation when excess
thrombin is added to patient plasma).
2 The PT-derived fibrinogen assay (an assay which reports a fibrinogen level based on the
prothrombin time).
The requirements in this section are not applicable to immunologic methods, which measure fibrinogen
antigens. Relevant requirements for immunologic methods are covered in the "Coagulation Tests Based on
Direct Measurement of Analytes" section.
● Sampling of factor assay policies and procedures
● Sampling of records for standard curves and standard curve verification
● Sampling of calibration/calibration verification/recalibration records
75 of 79
● How do you evaluate results for inhibitor effects?
HEM.37940 Standard Curve Phase II

For coagulation end point-based factor assays, three or more points are plotted for the
standard curve.
NOTE: Plotting less than three points may generate an erroneous line.
✓ Records of standard curves for factor assays
REFERENCES
1) Kitchen S, Preston FE. Assay of Factor VIII and Other Clotting Factors. In: Kitchen S, Olson JD, Preston FE, eds. Quality in
Laboratory Hemostasis and Thrombosis. 2nd ed. Hoboken, NJ: Wiley-Blackwell: 2013; chap 10.
2) Clinical and Laboratory Standards Institute. Determination of Coagulant Factor Activities Using the One-State Clotting Assay;
Approved Guideline. 2nd ed. CLSI document H48-ED2. Clinical and Laboratory Standards Institute, Wayne, PA, 2016.
**REVISED** 08/24/2023
HEM.37960 Standard Curve Verification Phase II
The standard curves are verified with at least two reference points for each factor assay
determination each eight hours of patient testing and each time there is a change in
reagents.
NOTE: The Y intercept of the standard curve varies according to the reagent and environmental
or instrument conditions. Verifying the curve (eg, two or more points with assayed reference
plasma) each time ensures accuracy of the result. If more than two standard curves exist (ie,
normal concentration and low concentration curves), the CAP recommends using at least one
reference point on each curve.
✓ Records of QC at defined frequency
REFERENCES
HEM.37980 Factor Assay Criteria Phase II

Three or more dilutions are plotted for each functional factor activity assay to detect non-
parallelism and report non-parallelism if detected.
NOTE: This requirement does not apply to chromogenic factor assays or fibrinogen assays.
When performing factor assays, at least three dilutions of patient plasma in buffer are prepared
either by the instrument or off the instrument. Multiple dilutions of test plasma are required to
evaluate the extent of parallelism between test results and those of the reference plasma. This is
necessary to be able to detect whether a factor inhibitor is present.
Criteria for demonstration of non-parallelism (or non-specific inhibitor effect) may vary between
laboratories and instrument types. For example, in some laboratories, individual results of each
dilution are reviewed and should agree within 20% of each other to be considered linear or
parallel. In this instance, the average of all three results may be reported. Some coagulation
instruments perform this determination automatically based on criteria programmed into the
instrument.
76 of 79
Non-specific inhibitors often demonstrate a "dilution effect" characterized by non-parallelism of

results with increasing dilutions. An example of non-parallel results is as follows: the 1:10 dilution
yields 30% activity, the 1:20 dilution 50%, and the 1:40 dilution 75% activity. Further dilutions
should be performed as needed and in accordance with the laboratory's practice and instrument
capability, at least until the factor activity falls within the reference interval. In situations of non-
parallelism, the highest value obtained with dilution should be recorded with a comment about
dilution effect made in the laboratory report. In this instance, the mean result should not be
reported nor should the value of the least dilute result.
Use of at least three patient dilutions enhances accuracy by minimizing dilutor error, and allows
for detection of inhibitors or anticoagulants. To be valid, at least one value must fall within the
upper and lower limits of the standard curve used for the calculation of the result.
The goal is to provide clinically useful data when a non-specific inhibitor activity is detected, (eg,
a lupus anticoagulant or an anticoagulant drug like heparin). A comment like "inhibitor pattern
detected" along with reporting the activity obtained at the highest dilution or over serial dilutions
clarifies the result.
Functional fibrinogen assays may be subject to interference by certain anticoagulants; for
guidelines on fibrinogen assays refer to COM.40500 and HEM.37165.
✓ Records or worksheets showing patient data analyzed at three or more dilutions
REFERENCES
2) Clinical and Laboratory Standards Institute. Procedure for the Determination of Fibrinogen in Plasma; Approved Guideline; 2nd ed.
CLSI document H30-A2. CLSI, Wayne, PA, 2001.
HEM.37984 Inhibitor Interference Phase I

If non-specific inhibitor interference is apparent in a factor activity assay, the laboratory
reports the highest factor activity apparent with dilution.
NOTE: This requirement is not applicable to fibrinogen assays.

REFERENCES
1) Mackie I, Cooper P, Lawrie A, Kitchen S, Gray E, Laffan M; British Committee for Standards in Haematology. Guidelines on the
laboratory aspects of assays used in haemostasis and thrombosis. Int J Lab Hematol. 2013;35(1):1-13.
PLATELET FUNCTION STUDIES

● Sampling of platelet function study policies and procedures
● How are specimens for platelet function studies handled prior to analysis?
**REVISED** 10/24/2022
77 of 79
HEM.38300 Platelet Function Studies Phase II

Platelet functional studies (platelet aggregation or initial platelet function test) are
performed within an appropriate period after venipuncture.
NOTE: Following venipuncture, platelets continue to activate in vitro, so that platelet functionality
becomes abnormal after a period of several hours. The laboratory must ensure that platelet
functional studies (platelet aggregation or initial platelet function test) are completed between
30 minutes and four hours from the time of phlebotomy, or erroneous results could be obtained.
Manufacturer's instructions for specimen stability must be followed for FDA-cleared/approved
platelet function study assays.
PRP (platelet rich plasma) should be used within three to four hours of platelet donation. The
effects of time are related to changes in pH, which are directly related to the escape of CO2
from the PRP sample tube. Platelets may be refractory to epinephrine when using PRP samples
tested within 30 minutes of venipuncture; this is cited as the rationale for not testing PRP until
at least 30 minutes after phlebotomy. There is evidence to suggest that this initial platelet
refractoriness and subsequent gain of function occurs because centrifugation releases ADP
from red blood cells and platelets. Specimens collected for whole blood aggregometry should be
stored capped at room temperature and tested within four hours.
✓ Records of testing completed within the defined time period
REFERENCES
1) Clinical and Laboratory Standards Institute (CLSI). Platelet Function Testing by Aggregometry; Approved Guideline. CLSI document
H58-A. Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, PA 19087-1898 USA, 2008.
2) Winokur R, Hartwig JH. Mechanism of shape change in chilled human platelets. Blood. 1995; 85:1796-1804.
3) Mani H, Kitchmayr K, Klaffling C, et al. Influence of blood collection techniques on platelet function. Platelets. 2004;15(5):315-318.
4) Kattlove HE, Alexander B. The effect of cold on platelets. I. Cold-induced platelet aggregation. Blood. 1971;38(1):39-48.
5) Kattlove HE, Alexander B, White F. The effect of cold on Platelets. II. Platelet function after short-term storage at cold temperatures.
Blood. 1972;40(5):688-695.
HEM.38350 Specimen Handling - Platelets Phase II

Blood specimens for platelet aggregation and platelet function studies are handled at
room temperature before testing.
NOTE: Platelets develop a cold-induced conformational change and dysfunction when handled at
temperatures <20°C. Even when re-warmed, platelets may not regain normal function. Therefore,
platelet specimens must always be handled at "room temperature," which is generally defined as
20 to 25°C (68 to 77°F) before testing and must never be refrigerated, chilled on ice or frozen.
REFERENCES
1) Winokur R, Hartwig JH. Mechanism of shape change in chilled human platelets. Blood. 1995; 85:1796-1804
2) Clinical and Laboratory Standards Institute (CLSI). Platelet Function Testing by Aggregometry; Approved Guideline. CLSI document
H58-A. Clinical and Laboratory Standards Institute, 940 West Valley Road, Suite 1400, Wayne, PA 19087-1898 USA, 2008.
3) Mani H, Kitchmayr K, Klaffling C, et al. Influence of blood collection techniques on platelet function. Platelets. 2004;15(5):315-318
4) Kattlove HE, Alexander B. The effect of cold on platelets. I. Cold-induced platelet aggregation. Blood. 1971;38(1):39-48
5) Kattlove HE, Alexander B, White F. The effect of cold on Platelets. II. Platelet function after short-term storage at cold temperatures.
Blood. 1972;40(5):688-695
HEM.38400 Platelet Aggregation Studies Phase II

Platelet aggregation studies are performed at the temperature recommended by the
manufacturer.
✓ Records of temperature checks OR automated internal instrument temperature monitoring
**REVISED** 10/24/2022
HEM.38500 Optical Turbometric Method Phase I
78 of 79
If platelet aggregation studies are performed by an optical turbometric methodology using

platelet rich plasma, the optimal platelet concentration range and special handling for
specimens outside of the optimal range are defined.
NOTE: Optical platelet turbometric studies measure the change in percent of light transmittance
as platelets aggregate. These techniques typically use platelet rich plasma (PRP). If the platelet
count in the PRP is too high or too low, erroneous results may occur. The laboratory must have
a procedure for ensuring that the platelet count in the PRP is optimal for study. The optimal
platelet concentration may vary from laboratory to laboratory but a commonly defined range
9
is 200-300 X 10 /L. Samples with platelet concentrations greater than optimal can be diluted
9
into the optimal range with platelet-poor plasma (PPP) (<10 X 10 /L). There is evidence that
PPP can inhibit platelet aggregation, but also evidence that adjustment of PRP with PPP does
not adversely affect interpretation of aggregation responses to platelet agonists in patients with
abnormal bleeding histories. Therefore, the decision to adjust or not adjust PRP with PPP is at
the discretion of the laboratory. Platelet agonist reference intervals derived from control subjects
should be established with the same method used to evaluate patients. Samples with less than
or greater than the defined optimal platelet concentration can be analyzed, but a disclaimer
should be added when abnormal results are obtained, as the decreased platelet concentration
alone may adversely affect the results.
✓ Patient reports with disclaimer if concentration is less than or greater than the optimal
concentration
REFERENCES
1) Cattaneo M, et al. Platelet aggregation studies: autologous platelet-poor plasma inhibits aggregation when added to platelet-rich
plasma to normalize platelet count. Haematologica. 2007;92:694-7
2) Linnemann B, et al. Standardization of light transmittance aggregometry for monitoring antiplatelet therapy: and adjustment for
platelet count is not necessary. J Thromb Haemost. 2008;6:677-83
3) Favaloro EF, et al. Platelet function testing: auditing local practice and broader implications. Clinical Laboratory Science.
2010;23:21-31
4) Hayward CPM, et al. Development of North American Consensus Guidelines for medical laboratories that perform and interpret
platelet function testing using light transmission aggregometry. Am J Clin Pathol. 2010;134:955-63
5) Castiloux JF, et al. A prospective cohort study of light transmission platelet aggregometry for bleeding disorders: Is testing native
platelet-rich plasma non-inferior to testing platelet count adjusted samples? Thromb Haemost. 2011;106:675-82
ELECTROPHORESIS - COAGULATION
● Sampling of electrophoretic coagulation study policies and procedures
● Electrophoretic patterns (appropriate separations)
NOTE: These requirements apply to electrophoresis procedures performed for studies for von Willebrand
multimers and Protein C antigen, or other factor antigens by Laurel Rocket technique.
HEM.38550 Daily QC - Electrophoresis Phase II

79 of 79
Suitable control samples are run and reviewed with each batch of patient samples for all
electrophoresis procedures for which controls are available.
✓ Records of electrophoresis QC
HEM.38600 Electrophoresis Separation Phase II

Electrophoresis separations are satisfactory.
NOTE: The laboratory must be able to provide instrument printouts, sample electrophoresis
results and patient reports.
RESULTS REPORTING - VISCOELASTIC TESTING

● Sampling of viscoelastic testing policies and procedures
**NEW** 08/24/2023
HEM.38700 Viscoelastic Testing - Error Communication Phase II
If viscoelastic testing for hemostasis analysis is performed in the laboratory and the
results are viewable remotely by clinical personnel in real-time, the laboratory promptly
communicates analytic errors to the responsible clinical personnel.
NOTE: Because real-time laboratory data is viewable by clinical personnel prior to reporting the
final test results, the laboratory must ensure that there is training of staff for prompt notification
to the responsible clinical personnel when analytic errors are detected. Communication must be
recorded.
✓ Records of communication to responsible clinical personnel when analytic errors are
detected

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COAGULATION FACTOR ASSAYS (EXCLUDING FIBRINOGEN BY IMMUNOLOGIC METHODS)........................74

ON-LINE CHECKLIST DOWNLOAD OPTIONS

CHECKLIST ACCREDITATION RESOURCES

SUMMARY OF CHECKLIST EDITION CHANGES

Previously Cited Checklist Requirements

NEW Checklist Requirements

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REVISED Checklist Requirements

Requirement Effective Date

DELETED/MOVED/MERGED Checklist Requirements

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● What do you do if controls are out of range?

WAIVED TESTS - GENERAL

HEM.18038 QC - Waived Tests Phase II

NOTE: Quality control must be performed according to manufacturer's instructions. To detect

HEM.18691 QC Corrective Action - Waived Tests Phase II

HEM.18705 Calibration, Calibration/Verification - Waived Tests Phase II

NONWAIVED TESTS - GENERAL

HEM.19360 Daily QC - Nonwaived Tests Phase II

● Quantitative tests - two controls at different concentrations at least daily, except

HEM.19380 Control Range Establishment or Verification Phase II

HEM.20050 Numeric QC Data Phase II

HEM.20070 Precision Statistics Phase I

NOTE: As an example, if the laboratory's normal-level commercial control usually yields a

HEM.20090 Alternative Control Procedures Phase II

NOTE: "Performance" includes elements of accuracy, precision, and clinical discriminating

HEM.20120 QC Handling Phase II

HEM.20140 QC Confirmation of Acceptability Phase II

HEM.20146 Monthly QC Review Phase II

SPECIMEN COLLECTION AND HANDLING

● Sampling of patient CBC specimens (anticoagulant, labeling, storage)

● How do you know if the CBC specimen is clotted, lipemic, or hemolyzed?

HEM.22000 Collection in Anticoagulant Phase II

HEM.22050 CBC Anticoagulant Phase II

HEM.22100 Capillary Tube Collection Criteria Phase II

HEM.22150 Specimen Quality Assessment - CBC Phase II

HEM.22200 Hemolyzed or Lipemic Specimens - CBC Phase II

COMPLETE BLOOD COUNT (CBC) INSTRUMENTS

HEM.25400 Precalibrated Instrument Verification Phase II

HEM.25700 Calibration Phase II

NOTE: Criteria for calibration verification include:

HEM.25780 Recalibration Phase II

CBC INSTRUMENT QUALITY CONTROL

HEM.25850 Stabilized Controls Phase II

HEM.25990 QC Procedure Phase II

RETAINED PATIENT SPECIMENS

HEM.26660 QC - Retained Patient Specimens Phase I

HEM.27330 QC - CBC Defined Range Phase I

ERROR DETECTION AND VERIFICATION

HEM.30070 Sampling Mode Comparison Phase I

HEM.30100 Detection/Correction Procedure - WBC Phase II

HEM.30150 Spurious CBC Results Phase II

HEM.30200 Red Cell Indices Phase I

HEM.30250 Reportable Range Phase II

HEM.30300 Platelet Abnormalities Phase II