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Online procedure manual


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We are thinking about going to only an online procedure manual. If you have an online procedure manual can you tell me some of the JACHO or CAP standard that you must met? I know that CAP says you can have either an electronic or paper manual. I need to know what you do if you have new procedures that have never been signed by either the medical director or the lab director?:confused:

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I worked at two places that had on-line manuals. Both were large facilities that used PDF's in read-only diretories for security. They were easy to read, relatively easy to update, and had great complaince with tracking software.

The only thing I missed was a meta-search: being able to search all documents for the word "platelet" or "Anti-A", and the like.

It would be interesting to see what happens if the medical director changed ...

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We are in the process of converting. We are using Sharepoint. I have only seen a demo so far but it looks like it will be great. We haven't figured out a way to get rid of the large, bulky notebooks yet (in case of a network downtime). Any ideas?

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It was the procedural changes I was thinking about, that would be hard to keep up with / keep updated cd's. I guess if each area had its own cd that would easily managed. I just though of something, I wonder if Sharepoint could prompt the supervisor making the change to make a new cd. I bet it could, I'll check.

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This is great info! I have as one of my goals for 2009-2010 to get our procedure/policy manuals on line. Is Sharepoint a PDF style format? Would you be eliminating all hard copies? I am in favor of totally eliminating the paper binders. Thanks for initiating this feed. I too am anxious to hear what other facilities are implementing in regard to on line manuals.

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We are putting our Lab procedures on-line on our hospital's "Intranet" as they are reveiwed/revised (and as time permits.) It is our policy to keep ONE master paper copy in the Lab, and that is the copy we keep in our "discontinued" file when it is revised or removed from use (rather than keeping a bunch of discs.)

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I just finished writing a document control system for our facility using MS Access as the front end. I evaluated the up/time downtime and electronic copies scenarios and the solution I came up with has these aspects:

  1. The original documents are in paper with Ink signatures. This includes annual review documents. They are in a protected location (e.g. the managers office) and thus available for use during disasters where the electrical, network or computer systems are not accessible. This solves the 'electronic signature' issue in our mixed network environment and provides a backup/downtime copy.
  2. In normal use, the table of contents is linked to each users area of responsibility as defined in the user module. So a Blood Bank tech sees blood bank docs and a chemistry tech doesn't (but they do see chemistry docs). The TOC is available via any PC in the lab.
  3. The electronic table of contents is searchable by SOP number, title or keyword(s).
  4. The electronic copies are secured PDFs that cannot be printed or copy/pasted from. They can be displayed on the screen and that is it. The attachments can be in a variety of formats (as need dictates) and can be printed as we need many of them for use as forms.
  5. Only users with certain access levels can 'check out' and create new drafts of defined polices.

There is more to it than that, but all of these aspects (and more) are included in commercial systems. We are just having problems getting administration to cut loose a quarter-mil in the current fiscal crisis. I really liked Title21, which was one of the systems we would like to buy when someone can cough up some cash.

I have seen other facilities use 'read only' documents with a hyperlinked TOC very successfully. It all depends on how techno-saavy you are.

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If we have such a large electrical failure that none of my computers are working, then chances are really good that I am not doing any testing either. All of my computers are on the same emergency power as my equipment.

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