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Comprehensive ISO 15189 Toolkit – 82 Medical Laboratory Templates

ISO 15189 Toolkit delivers 82 ready-to-use Microsoft Office templates covering every clause of ISO 15189:2022 — obligations to patients, the laboratory director, risk management, the full pre-examination, examination and post-examination pathway, critical result notification, point-of-care testing, and the management system. Built for medical laboratories preparing for accreditation.

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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:

  1. ISO 15189 Scope of Accreditation Statement.docx
  2. Accreditation Programme Charter.docx
  3. Toolkit Index and Deployment Guide.docx
  4. Examination Schedule and Scope Register.xlsx
  5. Impartiality Policy.docx
  6. Confidentiality and Patient Information Policy.docx
  7. Requirements Regarding Patients Procedure.docx
  8. Patient Consent and Information Provision Procedure.docx
  9. Impartiality Risk Register.xlsx
  10. Legal Entity and Laboratory Structure Statement.docx
  11. Laboratory Director Appointment and Responsibilities.docx
  12. Laboratory Activities Definition.docx
  13. Quality Objectives and Policy Statement.docx
  14. Risk Management Procedure.docx
  15. Risk and Opportunity Register.xlsx
  16. Personnel Competence Policy.docx
  17. Competence Assessment and Authorisation Procedure.docx
  18. Training and Continuing Education Procedure.docx
  19. Personnel Records and Job Descriptions Standard.docx
  20. Competence Matrix and Authorisation Register.xlsx
  21. Training and Competence Record Template.docx
  22. Facilities and Environmental Conditions Standard.docx
  23. Environmental Monitoring Procedure.docx
  24. Biosafety Containment and Waste Procedure.docx
  25. Environmental Monitoring Log.xlsx
  26. Equipment Management Policy.docx
  27. Calibration and Metrological Traceability Procedure.docx
  28. Equipment Verification and Intermediate Checks Procedure.docx
  29. Equipment Adverse Incident and Failure Procedure.docx
  30. Equipment Register.xlsx
  31. Calibration and Maintenance Schedule.xlsx
  32. Reagents and Consumables Management Procedure.docx
  33. Reagent Lot Verification and Acceptance Procedure.docx
  34. Reagent and Consumable Inventory Register.xlsx
  35. Service Agreements Procedure.docx
  36. Externally Provided Products and Services Procedure.docx
  37. Referral Laboratory Selection and Monitoring Procedure.docx
  38. Approved Supplier and Referral Laboratory Register.xlsx
  39. Pre-examination Process Standard.docx
  40. Examination Request and Requisition Procedure.docx
  41. Patient Identification and Preparation Procedure.docx
  42. Primary Sample Collection Procedure.docx
  43. Sample Transport and Handling Procedure.docx
  44. Sample Receipt Acceptance and Rejection Procedure.docx
  45. Sample Acceptance and Rejection Log.xlsx
  46. Method Verification and Validation Procedure.docx
  47. Measurement Uncertainty Evaluation Procedure.docx
  48. Biological Reference Intervals Procedure.docx
  49. Examination Procedure Documentation Standard.docx
  50. Internal Quality Control Procedure.docx
  51. External Quality Assessment Procedure.docx
  52. Comparability of Examination Results Procedure.docx
  53. Method Register and Validation Status.xlsx
  54. Results Review and Authorisation Procedure.docx
  55. Reporting of Results Standard.docx
  56. Critical and Alert Value Notification Procedure.docx
  57. Amended Reports Procedure.docx
  58. Sample Storage Retention and Disposal Procedure.docx
  59. Nonconforming Work Procedure.docx
  60. Complaints Procedure.docx
  61. Control of Data and Information Management Standard.docx
  62. Laboratory Information System Validation Procedure.docx
  63. Nonconformity and Complaints Register.xlsx
  64. Continuity and Emergency Preparedness Plan.docx
  65. Point-of-Care Testing Governance Policy.docx
  66. POCT Operator Training and Authorisation Procedure.docx
  67. POCT Device and Operator Register.xlsx
  68. Quality Manual.docx
  69. Management System Option Determination Procedure.docx
  70. Control of Documents Procedure.docx
  71. Control of Records Procedure.docx
  72. Improvement and Corrective Action Procedure.docx
  73. Corrective Action and Improvement Register.xlsx
  74. Accreditation Body Requirements Supplement.docx
  75. ISO 15189 Clause Compliance Matrix.xlsx
  76. ISO 15189 to ISO 17025 Crosswalk.xlsx
  77. Document Control Master List.xlsx
  78. Internal Audit Procedure.docx
  79. Management Review Procedure and Input Pack.docx
  80. Assessment Evidence Pack Index.docx
  81. ISO 15189 Internal Audit Checklist.xlsx
  82. 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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