Summary of CAP Question

From:Victor Tobias <>

Thank you all for the quick responses. The answers are varied as I would
expect. It seems to depend upon who is doing the inspection. Below are
the replies that I received.

I just have a coversheet that is signed every year. If any
procedures are added or updated later, then the individual procedure is

Every policy needs to have the signature of the person who is
for it's review(technical director)  A cover sheet is fine which depicts
of the signatures from the staff who have reviewed the manuals
contents/revisions for the year.

Two separate inspectors have told us that a signature sheet at the front
the manual was acceptable as long as all procedures were listed on that
signature sheet.

I have a cover sheet with my signature and the pathologist that is
responsible for the AP section.  Then on each procedure I initial it.
have always passed our inspections with this.

The state of NJ requires individual procedure review pages.  I use a
separate page for revision approval and staff review signatures so that
record of the review process is not lost each time the procedure is
and reprinted.

Every policy or procedure needs a Supervisor's Initials yearly, proving
you have reviewed and approved the policy/procedure that is in use.
your employee's may sign a cover-sheet yearly proving that they have
and understand each policy and/or procedure that is pertinent to their

Every individual procedure is signed off by me (supervisor, every year)
we have a cover sheet the techs sign off on every year.

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