Description
About the ISO 15189 Toolkit
Medical laboratories are accredited, not certified. An accreditation body assesses your laboratory against ISO 15189:2022 and grants accreditation for a defined scope: named examinations, on named sample types, by named methods, at named locations. An examination outside that schedule is not accredited work, however well it is performed.
The other thing the standard makes explicit is who the work is for. ISO 15189’s stated objective is the welfare of the patient, and clause 4.3 places obligations on the laboratory that run to the patient rather than to the clinician who requested the examination. That clause has no equivalent in ISO/IEC 17025, and it is where a medical laboratory toolkit either does the work or quietly skips it.
The ISO 15189 Toolkit contains 82 templates: 63 Word documents and 19 Excel registers, matrices, logs and checklists. Every document cites the clauses it implements, and every one is editable in Microsoft Office.
What is included in the ISO 15189 Toolkit?
- 82 documentation templates covering every clause of ISO 15189:2022 — clause 4 impartiality, confidentiality and patients through to clause 8 management system, plus the point-of-care requirements in Annex A
- All files in Microsoft Office format (.docx, .xlsx) — fully editable, with every laboratory-specific value marked as a placeholder
- Instant download immediately after purchase
Clinical laboratories run on registers — examination schedules, competence authorisations, calibration status, reagent lots, sample rejections, critical value notifications, POCT devices and operators — which is why 19 of the 82 documents are working Excel tools rather than prose.
The ISO 15189 Toolkit covers the fourth edition, and what changed in it
ISO 15189:2022 is the fourth edition, published in December 2022. It withdrew both ISO 15189:2012 and ISO 22870:2016, the separate point-of-care testing standard, whose requirements were absorbed into it. ISO’s own summary of the changes names three things: alignment with ISO/IEC 17025:2017, which moved the management requirements to the end of the document; the incorporation of point-of-care testing; and increased emphasis on risk management.
All three are reflected in how the ISO 15189 Toolkit is built. Risk management sits among the governance documents rather than inside the management system, because that is where clause 5.6 puts it. Point-of-care testing gets its own section rather than a paragraph. And the clause order follows the 2022 structure, so the folder list reads as an implementation sequence rather than a translation exercise.
Where the ISO 15189 Toolkit puts its weight
Most medical laboratory template packs are thin exactly where accreditation is won or lost, and where patients are actually harmed. The ISO 15189 Toolkit is not:
- Pre-examination gets seven documents, not one. The published error literature has put the majority of laboratory errors in this phase for decades. Request content, patient identification, collection technique, transport limits, and acceptance criteria each get their own procedure — and rejection monitoring is reported by requesting location, because a laboratory-wide rejection rate is a statistic and a ward-level rate is a conversation with the person who can fix it.
- Critical results, including what happens when nobody answers. Clause 7.4.1.6 requires notification to someone who can act. The toolkit provides the critical value list, the read-back requirement, a four-step escalation route for when the ward telephone rings out, and the out-of-hours route for community patients — the part most procedures leave blank and the part where harm actually occurs.
- Patients as a party in their own right. Information, consent proportionate to the examination, capacity, refusal and withdrawal, reasonable adjustments, dignity at collection, and the right to complain without it affecting care. Clause 4.3, treated as a requirement rather than a courtesy.
- Point-of-care testing as governance, not a footnote. ISO 22870 is withdrawn and its requirements are now yours. The toolkit covers deployment approval, the agreement with each clinical service, operator training at ward scale, device lockout, expired-consumable checks, and the authority to withdraw a device — because oversight that cannot stop anything is a reporting function.
- Measurement uncertainty the way medical laboratories actually evaluate it. A top-down procedure using your own internal quality control, calibrator and bias data, with a worked serum creatinine budget showing why an IQC-only figure understates the result.
ISO 15189 Toolkit structure
- Programme and Scope — 4 documents
- Impartiality and Patients — 5 documents
- Structure and Governance — 6 documents
- Personnel and Competence — 6 documents
- Facilities and Environment — 4 documents
- Equipment and Traceability — 6 documents
- Reagents and Consumables — 3 documents
- Agreements and Providers — 4 documents
- Pre-examination — 7 documents
- Examination — 8 documents
- Post-examination — 5 documents
- Nonconformity and Data — 5 documents
- Continuity and POCT — 4 documents
- Management System — 6 documents
- Mapping and Traceability — 4 documents
- Audit and Assessment — 5 documents
The clause 8 decision comes first
Clause 8 can be met two ways, and choosing late means writing documents twice. Option A implements the management system requirements set out in ISO 15189 itself. The alternative lets a laboratory already operating a system in accordance with ISO 9001 satisfy clause 8 through it.
The ISO 15189 Toolkit ships a determination procedure that records the decision and its evidence before any clause 8 document is drafted, a full Option A management system, and a gap assessment identifying which clause 8 requirements an existing system already meets.
One consequence is routinely missed: clause 8.9.2 requires management review inputs that an ISO 9001 review does not have — external quality assessment performance, turnaround time monitoring, continuing education, feedback from patients as well as users, risk to patients, and impartiality outcomes. The toolkit’s management review pack lists all twenty-six inputs so an existing-system laboratory can see exactly what it has to add.
List of Documentation Toolkit:
- ISO 15189 Scope of Accreditation Statement.docx
- Accreditation Programme Charter.docx
- Toolkit Index and Deployment Guide.docx
- Examination Schedule and Scope Register.xlsx
- Impartiality Policy.docx
- Confidentiality and Patient Information Policy.docx
- Requirements Regarding Patients Procedure.docx
- Patient Consent and Information Provision Procedure.docx
- Impartiality Risk Register.xlsx
- Legal Entity and Laboratory Structure Statement.docx
- Laboratory Director Appointment and Responsibilities.docx
- Laboratory Activities Definition.docx
- Quality Objectives and Policy Statement.docx
- Risk Management Procedure.docx
- Risk and Opportunity Register.xlsx
- Personnel Competence Policy.docx
- Competence Assessment and Authorisation Procedure.docx
- Training and Continuing Education Procedure.docx
- Personnel Records and Job Descriptions Standard.docx
- Competence Matrix and Authorisation Register.xlsx
- Training and Competence Record Template.docx
- Facilities and Environmental Conditions Standard.docx
- Environmental Monitoring Procedure.docx
- Biosafety Containment and Waste Procedure.docx
- Environmental Monitoring Log.xlsx
- Equipment Management Policy.docx
- Calibration and Metrological Traceability Procedure.docx
- Equipment Verification and Intermediate Checks Procedure.docx
- Equipment Adverse Incident and Failure Procedure.docx
- Equipment Register.xlsx
- Calibration and Maintenance Schedule.xlsx
- Reagents and Consumables Management Procedure.docx
- Reagent Lot Verification and Acceptance Procedure.docx
- Reagent and Consumable Inventory Register.xlsx
- Service Agreements Procedure.docx
- Externally Provided Products and Services Procedure.docx
- Referral Laboratory Selection and Monitoring Procedure.docx
- Approved Supplier and Referral Laboratory Register.xlsx
- Pre-examination Process Standard.docx
- Examination Request and Requisition Procedure.docx
- Patient Identification and Preparation Procedure.docx
- Primary Sample Collection Procedure.docx
- Sample Transport and Handling Procedure.docx
- Sample Receipt Acceptance and Rejection Procedure.docx
- Sample Acceptance and Rejection Log.xlsx
- Method Verification and Validation Procedure.docx
- Measurement Uncertainty Evaluation Procedure.docx
- Biological Reference Intervals Procedure.docx
- Examination Procedure Documentation Standard.docx
- Internal Quality Control Procedure.docx
- External Quality Assessment Procedure.docx
- Comparability of Examination Results Procedure.docx
- Method Register and Validation Status.xlsx
- Results Review and Authorisation Procedure.docx
- Reporting of Results Standard.docx
- Critical and Alert Value Notification Procedure.docx
- Amended Reports Procedure.docx
- Sample Storage Retention and Disposal Procedure.docx
- Nonconforming Work Procedure.docx
- Complaints Procedure.docx
- Control of Data and Information Management Standard.docx
- Laboratory Information System Validation Procedure.docx
- Nonconformity and Complaints Register.xlsx
- Continuity and Emergency Preparedness Plan.docx
- Point-of-Care Testing Governance Policy.docx
- POCT Operator Training and Authorisation Procedure.docx
- POCT Device and Operator Register.xlsx
- Quality Manual.docx
- Management System Option Determination Procedure.docx
- Control of Documents Procedure.docx
- Control of Records Procedure.docx
- Improvement and Corrective Action Procedure.docx
- Corrective Action and Improvement Register.xlsx
- Accreditation Body Requirements Supplement.docx
- ISO 15189 Clause Compliance Matrix.xlsx
- ISO 15189 to ISO 17025 Crosswalk.xlsx
- Document Control Master List.xlsx
- Internal Audit Procedure.docx
- Management Review Procedure and Input Pack.docx
- Assessment Evidence Pack Index.docx
- ISO 15189 Internal Audit Checklist.xlsx
- Audit Programme and Findings Register.xlsx
ISO 15189 Toolkit and accreditation
Because ISO 15189:2022 is assessed by an accreditation body rather than a certification body, the ISO 15189 Toolkit includes what an assessor asks for: a clause compliance matrix, an internal audit checklist covering every clause, an audit programme and findings register, a management review pack, and an assessment evidence pack index organised around the patient journey an assessor will trace — because assessors do not read a system from the top, they pick a patient and follow the sample.
For laboratories holding or seeking ISO/IEC 17025 as well, the toolkit includes a crosswalk between the two standards showing where evidence transfers and — more usefully — where it does not. Our guide to ISO 15189 explains what the 2022 edition changed and where medical laboratories most often lose findings; the guide to ISO 17025 covers the testing and calibration side of that comparison.
Simply add your laboratory’s name, replace the bracketed placeholder values with your own detail, and implement the documented policies and procedures within your operational framework.
Frequently Asked Questions (FAQ)
What is the ISO 15189 Toolkit?
It is a set of 82 ready-to-edit documentation templates covering every clause of ISO 15189:2022, the international standard for quality and competence in medical laboratories. It includes policies, procedures, registers, matrices and checklists across sixteen sections, from scope of accreditation through to assessment evidence.
Can a medical laboratory be certified to ISO 15189?
No. Medical laboratories are accredited, not certified, and accreditation is granted for a defined scope of examinations rather than for the standard as a whole. There is no ISO 15189 certificate in the sense that ISO 9001 has one.
Which edition does the ISO 15189 Toolkit follow?
ISO 15189:2022, the fourth edition and the current one. It replaced ISO 15189:2012 and also withdrew ISO 22870:2016, the point-of-care testing standard, whose requirements it absorbed.
Does the ISO 15189 Toolkit cover point-of-care testing?
Yes, and this is one of the reasons to prefer a toolkit built after 2022. ISO 22870 no longer exists as a separate standard, so POCT performed under your laboratory’s oversight is inside ISO 15189’s scope. The toolkit covers governance, deployment approval, agreements with clinical services, operator training and authorisation at ward scale, and a device and operator register.
What is the difference between ISO 15189 and ISO 17025?
ISO 15189 applies to medical laboratories and ISO/IEC 17025 to testing and calibration laboratories generally. Clause 8 and most of the resource requirements are close cousins. The differences are substantial: ISO 15189 adds obligations to patients, a named laboratory director with evidenced competence, risk management among the governance clauses, biological reference intervals, critical result notification, and a pre-examination, examination and post-examination structure that ISO/IEC 17025 does not use. The toolkit includes a crosswalk quantifying exactly that.
Do I need ISO 9001 to use this toolkit?
No. If you hold an ISO 9001 system, the toolkit’s determination procedure and gap assessment let you carry clause 8 through it. If you do not, the full clause 8 documentation is included.
What formats are the documents in?
63 Microsoft Word documents and 19 Microsoft Excel workbooks. The Word documents carry a table of contents, document control fields and a consistent structure; the workbooks include instruction sheets, controlled dropdown lists, worked example rows, conditional formatting and validation checks. Nothing is locked and no password is required.
How long does ISO 15189 accreditation take?
Typically twelve to twenty-four months from a standing start. The documents are rarely the constraint. The long poles are external quality assessment, which runs to the scheme provider’s distribution calendar; metrological traceability, which has to be established; competence, which has to be demonstrated over time; and point-of-care sites, which are consistently the largest underestimate in the programme.
Does the ISO 15189 Toolkit cover my accreditation body’s own requirements?
It provides the framework for them. Accreditation bodies add requirements on top of ISO 15189 — participation frequency, symbol use, notification obligations, director qualifications, sector schemes — and these differ by body and change without notice. The toolkit includes a supplement structured around the areas where bodies commonly add requirements, together with a notification obligations table, for you to complete from your body’s current publications.
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