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Best Practices for CAP Personnel Records

  • 1.  Best Practices for CAP Personnel Records

    Posted 09-04-2018 12:50
    I am looking for best practices on organizing personnel records to the meet the associated CAP requirement and would like input:
    1. Where are your personnel records maintained?  Lab or HR or both?
    2. If you are a large healthcare system, do you allow records to be maintained at each individual site?  Or do you have a centralized repository?
    3. Paper vs. computer?  My experience is that many laboratories are still using file folder systems.  Has anyone developed some type of computer database? 
    Thanks, in advance, for any insight!

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    Karrie Hovis, MHS, CMP, CQIA, MLS(ASCP)CM
    Education Coordinator
    Ochsner Health System
    (318) 617-2336
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  • 2.  RE: Best Practices for CAP Personnel Records

    Posted 09-05-2018 07:58
    ​Karrie:

    • Where are your personnel records maintained?  Lab or HR or both?
      • There are two files for every employee.  Their official human resource file is maintained in human resources.  That is consistent across all departments for legal purposes, accreditation, etc.  This includes anything related to their hiring, annual evaluations, and disciplinary documentation and, of course, their salary changes over time.  In the lab, each manager/supervisor maintains a file on each of their employees which would include any competency documentation, training. etc.
    • If you are a large healthcare system, do you allow records to be maintained at each individual site?  Or do you have a centralized repository?
      • Employee records are maintain at the location where they work.  Each of our 7 hospitals and our Central Laboratory maintains these records in the lab/HR department at each site.
      • For our clinics, those records are maintained in the central HR department for that part of the organization.  Each of our regional supervisors maintains their competency/training records for the employees in the clinics they supervise.
    • Paper vs. computer?  My experience is that many laboratories are still using file folder systems.  Has anyone developed some type of computer database? 
      • Combination.  All hiring records, annual evaluations are in computer files.  Any disciplinary documents are paper, that is then scanned into a system.  The competency and training files in the lab are paper.

    Rick

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    Rick Panning
    Senior Administrative Director
    HealthPartners
    Bloomington MN
    6512805909
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  • 3.  RE: Best Practices for CAP Personnel Records

    Posted 09-05-2018 08:33
    Where I have worked, the lab held onto the files for current employees for 2 years beyond the end of their employment, then the files went to HR for purging and retention for the appropriate time in our area.  The only thing that was not included in the lab file was the colorblindness testing done by employee health.  All other documents were in the paper file.  The hospital was in the process of converting from paper to electronic records, and that process was handled by HR.

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    Tracy Frankowski
    Program Director, Cooperative Medical Technology Program and Laboratory Safety Officer
    Akron Children's Hospital
    Akron OH
    330-543-8720
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  • 4.  RE: Best Practices for CAP Personnel Records

    Posted 09-05-2018 15:57
    ​Karrie,

    We have official HR records in both the lab and HR.  The labs have a paper copy, however anything official is scanned into an electronic file that the Pathology Department maintains that is also sent to HR (scanned electronically).



     Best,
    Kristina

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    Kristina Martin
    Clinical Pathology Operations Manager
    Michigan Medicine
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  • 5.  RE: Best Practices for CAP Personnel Records

    Posted 09-05-2018 21:31
    Our records have always been kept in the lab manager's office in our individual folders.  There are some things in our folders that the originals are kept in HR if I'm not mistaken, but everything that is required by CAP is in those folders.

    Dawn Jones is a former lab manager for us and is currently a lab manager at one of Ochsner Health System facilities - she would be a good resource for you to reach out to as well.


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    Alesia Wallin
    Lead Chemistry/POC
    CHI Memorial Hospital Georgia

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  • 6.  RE: Best Practices for CAP Personnel Records

    Posted 09-06-2018 10:59
    Thank you all for your input!  I appreciate it.

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    Karrie Hovis, MHS, CMP, CQIA, MLS(ASCP)CM
    Education Coordinator
    Ochsner Health System
    (318) 617-2336
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