第一篇：太原市類風(fēng)濕病醫(yī)院二甲復(fù)審制度

前言

隨著醫(yī)藥衛(wèi)生體制改革，促進(jìn)我院管理理念更新，使我院推行標(biāo)準(zhǔn)化、規(guī)范化、精細(xì)化管理，提高我院管理水平，建立正常工作秩序，改善服務(wù)態(tài)度，提高醫(yī)療護(hù)理質(zhì)量，防止醫(yī)療差錯事故，使我院工作適應(yīng)社會主義建設(shè)的要求，在總結(jié)《醫(yī)院工作制度與人員崗位職責(zé)等規(guī)定匯編》的基礎(chǔ)上，結(jié)合我院的實際情況，重新修訂了《醫(yī)院工作制度及人員崗位職責(zé)》。

本書共收錄醫(yī)院工作制度

項，人員崗位職責(zé)

項，十五項核心制度是要求醫(yī)務(wù)人員必須熟練掌握，同時各部門根據(jù)本制度和職責(zé)的原則要求，認(rèn)真貫徹執(zhí)行。

太原市類風(fēng)濕病醫(yī)院 二O一一年九月

目錄

上篇

太原市類風(fēng)濕病醫(yī)院工作制度

行政管理工作制度········································································1

一、院領(lǐng)導(dǎo)干部深入科室制度·································································1

二、會議制度···············································································1

三、院長查房制度···········································································2

四、請示報告制度···········································································2

五、總值班制度·········································································2

六、衛(wèi)生工作制度···········································································3

七、病歷管理制度···········································································3

八、醫(yī)院統(tǒng)計制度···········································································4

九、醫(yī)院圖書館/室管理制度···································································4

十、進(jìn)修工作管理制度·······································································4

十一、患者入院、出院工作管理制度····························································5

十二、住院處工作制度.······································································5

十三、掛號工作度···········································································6

十四、職工上崗前教育制度…·································································6

十五、在崗職工規(guī)范化培訓(xùn)制度·······························································6

十六、請假考勤制度·········································································6

十七、社會監(jiān)督制度·········································································7

十八、醫(yī)德教育和醫(yī)德考核制度·······························································7

十九、檔案管理制度·········································································7

二十、信息部門管理制度·····································································8 二

十一、醫(yī)院應(yīng)急管理制度···································································8 二

十二、衛(wèi)生技術(shù)人力資源管理制度···························································9 二

十三、醫(yī)院標(biāo)識管理制度···································································9 二

十四、消防與安全管理制度································································10 二

十五、投訴處理管理制度··································································10 二

十六、信息公示制度······································································11 二

十七、員工意外傷害（含感染、化學(xué)、放射等）管理制度··········································11 二

十八、患者知情同意告知制度······························································11 二

十九、醫(yī)院院務(wù)公開制度··································································12 醫(yī)院各委員會工作制度·································································

一、院務(wù)委員會工作制度···································································

二、醫(yī)院醫(yī)療質(zhì)量管理委員會工作制度························································

三、醫(yī)院護(hù)理質(zhì)量委員會工作制度···························································

四、醫(yī)院學(xué)術(shù)委員會工作制度·······························································

五、醫(yī)療技術(shù)管理委員會工作制度···························································

六、醫(yī)院感染管理委員會工作制度···························································

七、藥物與治療學(xué)委員會工作制度···························································

八、臨床用血管理委員會工作制度···························································

九、醫(yī)院病案管理委員會工作制度···························································

十、醫(yī)學(xué)倫理委員會工作制度工作制度························································

十一、醫(yī)院醫(yī)療事故鑒定委員會工作制度·····················································

十二、醫(yī)院安全委員會工作制度···························································

十三、實驗室生物安全管理委員會工作制度····················································

十四、醫(yī)療器械臨床使用安全管理委員會工作制度················································

十五、醫(yī)院后勤管理委員會工作制度···························································

十六、信息安全管理委員會工作制度···························································

醫(yī)療管理制度············································································12

一、搶救室工作制度········································································12

二、門診工作制度··········································································12

三、處方制度··············································································13

四、病歷書寫制度··········································································14

五、查房制度··············································································16

六、醫(yī)囑制度··············································································16

七、醫(yī)療質(zhì)量管理制度······································································17

八、查對制度··············································································18

九、會診制度··············································································22

十、轉(zhuǎn)院轉(zhuǎn)科制度··········································································22

十一、雙向轉(zhuǎn)診制度········································································22

十二、病例討論制度········································································24

十三、值班與交接班制度····································································25

十四、手術(shù)室管理制度······································································26

十五、麻醉科工作制度······································································26

十六、重大醫(yī)療過失行為和醫(yī)療事故報告制度··················································27

十七、醫(yī)療技術(shù)管理制度····································································27

十八、臨床檢驗危急值報告與應(yīng)用制度························································28

十九、臨床實驗（檢驗、病理）標(biāo)本采集、儲存運送制度········································28

二十、患者評估管理制度····································································29 二

十一、手術(shù)（有創(chuàng)操作）分級管理制度························································30 二

十二、危重患者進(jìn)行高風(fēng)險診療操作的資格許可授權(quán)制度······································31 二

十三、首診負(fù)責(zé)制度······································································31 二

十四、約束器具使用制度··································································32 二

十五、急危重患者搶救及報告制度··························································32 二

十六、住院病歷環(huán)節(jié)質(zhì)量與時限基本要求····················································32 二

十七、病房小藥柜管理制度································································34 二

十八、中醫(yī)科工作制度····································································35 二

十九、針灸室工作制度····································································35 三

十、醫(yī)學(xué)工程/醫(yī)療器械科（組）工作制度······················································35 護(hù)理管理工作制度·······································································36

一、護(hù)理部工作制度········································································36

二、病房管理制度··········································································36

三、早會制度··············································································37

四、交接班制度············································································37

五、夜班督導(dǎo)工作制度······································································38

六、執(zhí)行醫(yī)囑制度··········································································38

七、分級護(hù)理制度··········································································39

八、護(hù)理會診制度··········································································41

九、病房藥品管理制度······································································41

十、病房消毒隔離制度······································································42

十一、皮膚壓力傷登記報告制度······························································43

十二、導(dǎo)管滑脫登記報告制度（中心靜脈插管、氣管插管等）·······································.43

十三、病房安全制度········································································43

十四、患者膳食管理制度····································································44

十五、健康教育制度········································································44

十六、探視、陪伴管理制度···································································45

十七、注射室工作制度······································································45

十八、治療室工作制度······································································46

十九、換藥室工作制度······································································46

二十、患者入院、出院、轉(zhuǎn)院、轉(zhuǎn)科護(hù)理工作制度·················································46 二

十一、物資、器材管理制度·································································47 二

十二、病人外出檢查制度··································································48 二

十三、護(hù)理查房制度······································································49 二

十四、護(hù)理查對制度······································································49 二

十五、護(hù)理人員技能定期評估制度··························································51 二

十六、護(hù)理新技術(shù)準(zhǔn)入制度································································51 二

十七、護(hù)理制度、操作常規(guī)變更批準(zhǔn)制度·····················································52 二

十八、護(hù)理人員繼續(xù)教育制度······························································52 二

十九、護(hù)理應(yīng)急管理預(yù)案··································································53 三

十、護(hù)理差錯、事故登記報告制度···························································58 三

十一、病房醫(yī)囑計算機(jī)錄入管理制度························································59 三

十二、護(hù)理文書書寫基本規(guī)范與質(zhì)量監(jiān)管制度················································59 三

十三、特殊科室管理制度··································································62 三

十四、手部衛(wèi)生規(guī)范與質(zhì)量監(jiān)管制度························································68 醫(yī)院感染管理制度·······································································69

一、醫(yī)院感染監(jiān)測管理制度·································································69

二、醫(yī)院感染消毒隔離制度·································································70

三、消毒藥械管理制度·····································································70 四、一次性使用無菌醫(yī)療用品管理制度·······················································71

五、醫(yī)療廢物管理制度·····································································71

六、醫(yī)院感染的分級防護(hù)管理制度···························································71

七、預(yù)防重點部位醫(yī)院感染制度·····························································72

八、醫(yī)院感染管理委員會工作制度···························································73 藥劑部門工作制度·······································································73

一、醫(yī)院藥事管理委員會工作制度···························································74

二、臨床用藥管理制度·····································································74

三、藥劑科工作制度·······································································75

四、調(diào)劑室工作制度·······································································75

五、制劑室工作制度·······································································76

六、靜脈用藥配置中心（室）工作制度·························································77

七、臨床藥師工作制度·····································································78

八、藥房值班工作制度·····································································79

九、藥庫工作制度·········································································80

十、藥品采購工作制度·····································································80

十一、藥品驗收和保管制度·······························································81

十二、藥品質(zhì)量監(jiān)控制度·································································81

十三、住院患者自備藥品制度·····························································83

十四、麻醉藥品、一類精神藥品管理制度····················································83

十五、第二類精神藥品管理制度···························································85 醫(yī)技科室工作制度·······································································85

一、檢驗科工作制度········································································85

二、輸血科/血庫工作制度····································································86

三、中心實驗室管理制度····································································87

四、臨床檢驗危急值報告制度································································89

五、醫(yī)學(xué)影像科（室）工作制度································································90

六、特殊檢查室工作制······································································90

七、理療科工作制度········································································91

八、針灸室工作制度········································································91 財務(wù)與物價工作制度·····································································92

一、財務(wù)部門工作制度······································································92

二、經(jīng)費審批及報銷制度····································································92

三、醫(yī)療收費制度··········································································93

四、財產(chǎn)物資管理制度······································································93

五、票據(jù)管理制度··········································································94

六、固定資產(chǎn)管理制度······································································94

七、門診收費處工作制度····································································94

八、住院處收費工作制度····································································95

九、住院患者退費管理制度··································································95

十、財務(wù)會計檔案管理制度··································································95

十一、儀器設(shè)備、耗材妥購制度·······························································96

十二、物價工作管理制度····································································96

十三、醫(yī)療服務(wù)價格公示制度································································97

十四、醫(yī)療服務(wù)項目的病例記錄和費用核查制度················································97

十五、住院患者“每日情”制度································································97

十六、績效工資分配管理制度································································97

十七、內(nèi)部審計工作制度····································································98

下 篇

太原市類風(fēng)濕病醫(yī)院人員崗位職責(zé)

管理工作人員職責(zé)······································································100

一、院長職責(zé)············································································100

二、行政副院長職責(zé)······································································100

三、辦公室主任職責(zé)······································································100

四、醫(yī)務(wù)科/處主任職責(zé)····································································101

五、醫(yī)用圖書管理員職責(zé)··································································101

六、病案管理員職責(zé)······································································101

七、醫(yī)療統(tǒng)計人員職責(zé)····································································102

八、人事（或人力資源管理）科科長職責(zé)······················································102

九、總務(wù)科科長職責(zé)······································································102

十、醫(yī)學(xué)裝備管理部門主任職責(zé)····························································103

十一、信息管理部門負(fù)責(zé)人職責(zé)··························································103

十一、醫(yī)療保險管理部門負(fù)責(zé)人職責(zé)·························································103 醫(yī)療工作人員職責(zé)······································································104

一、臨床科主任職責(zé)·······································································104

二、臨床主任醫(yī)師職責(zé)·····································································105

三、臨床主治醫(yī)師職責(zé)·····································································105

四、總住院醫(yī)師職責(zé)·······································································105

五、臨床住院醫(yī)師職責(zé)·····································································106

六、門診部主任職責(zé)·······································································106

七、麻醉科主任職責(zé)·······································································107

八、麻醉科主任醫(yī)師職責(zé)···································································107

九、麻醉科主治醫(yī)師職責(zé)···································································107

十、麻醉科醫(yī)師職責(zé)·······································································107 護(hù)理部工作人員職責(zé)····································································108

一、護(hù)理部主任職責(zé)·······································································108

二、護(hù)理部副主任職責(zé)·····································································108

三、護(hù)士長職責(zé)···········································································109

四、主任（副主任）護(hù)師職責(zé)·································································109

五、主管護(hù)師職責(zé)·········································································110

六、護(hù)師職責(zé)·············································································110

七、護(hù)士職責(zé)·············································································110

八、護(hù)理員職責(zé)···········································································111

九、門診護(hù)士長職責(zé)·······································································111 十、門診護(hù)士職責(zé)········································································111

十一、手術(shù)室護(hù)士長職責(zé)···································································112

十二、手術(shù)室護(hù)士職責(zé)·····································································112

十三、消毒供應(yīng)中心（室）護(hù)士長職責(zé)·························································112

十四、消毒供應(yīng)中心（室）護(hù)士職責(zé)···························································113 藥學(xué)工作人員職責(zé)······································································113

一、藥劑科主任職責(zé)······································································113

二、藥劑科各室、組負(fù)責(zé)人職責(zé)·····························································114

三、主任(中、西)藥師職責(zé)··································································114

四、主管（中、西）藥師職責(zé)·································································114

五、藥劑師（中藥師）職責(zé)··································································114

六、藥劑士（中藥藥劑士）職責(zé)······························································115

七、臨床藥師職責(zé) ·······································································115

八、調(diào)劑人員職責(zé)········································································115

九、制劑人員職責(zé)········································································116

十、藥品采購人員職責(zé)····································································116

十一、藥品驗收保管人員職責(zé)····························································116

十二、藥學(xué)信息咨詢服務(wù)人員職責(zé)························································116 醫(yī)技工作人員職責(zé)······································································117

一、醫(yī)學(xué)影像/放射科主任職責(zé)······························································117

二、醫(yī)學(xué)影像/放射科主任醫(yī)師職責(zé)··························································117

三、醫(yī)學(xué)影像/放射科主治醫(yī)師職責(zé)··························································117

四、醫(yī)學(xué)影像/放射科醫(yī)師職責(zé)······························································118

五、醫(yī)學(xué)影像/放射科技師職責(zé)······························································118

六、醫(yī)學(xué)影像/放射科技士、技術(shù)員職責(zé)·······················································118

七、物理治療科主任職責(zé)··································································118

八、理療科主治醫(yī)師職責(zé)··································································119

九、理療科醫(yī)師職責(zé)······································································119

十、理療科技師、技士、見習(xí)員職責(zé)··························································119

十一、醫(yī)院感染管理部門主任/負(fù)責(zé)人職責(zé)··················································119

十二、檢驗科主任職責(zé)··································································120

十三、主任（副主任）檢驗師職責(zé)··························································121

十四、主管檢驗師職責(zé)··································································122

十五、檢驗師職責(zé)······································································122

十六、檢驗士職責(zé)······································································122

十七、臨床檢驗醫(yī)師職責(zé)································································123

十八、檢驗科質(zhì)量主管職責(zé)······························································123

十九、檢驗科技術(shù)主管職責(zé)······························································123 財務(wù)工作人員職責(zé)······································································124

一、財務(wù)部門負(fù)責(zé)人職責(zé)··································································124

二、財務(wù)部門會計職責(zé)····································································125

三、財務(wù)部門出納職責(zé)····································································125

四、財務(wù)部門成本及獎金核算人員職責(zé)······················································125

五、住院處、門急診收費處收費員職責(zé)·······················································126

六、住院、門急診收費處審核人員職責(zé)·······················································126

七、價人員職責(zé)···········································································126

第二篇：醫(yī)院二甲復(fù)審核心制度

二甲復(fù)審核心制度1.1.2 主要承擔(dān)常見病、多發(fā)病、部分疑難病的診療工作，兼顧預(yù)防、保健、康復(fù)功能，可提供 24 小時急危重癥診療服務(wù)。1.1.2.1 【C】主要承擔(dān)常見病、多發(fā) 1.有承擔(dān)本轄區(qū)常見病、多發(fā)病、部分疑難疾病診療的設(shè)施設(shè)備、技術(shù)梯隊與病、部分疑難病的診療工 處置能力。作?？商峁?24 小時急診 a.有設(shè)施設(shè)備、技術(shù)梯隊及處置能力，詳詢醫(yī)務(wù)處診療服務(wù)。（★）2.急診部門獨立設(shè)置，承擔(dān)本區(qū)域急危重癥的診療。1Y a.急診部獨立設(shè)置 b.可以承擔(dān)本區(qū)域急危重癥的治療 3.預(yù)防、保健、康復(fù)獨立設(shè)置。a.沒有獨立設(shè)置

4.根據(jù)病源，與三級綜合醫(yī)院距離較遠(yuǎn)或危重病人轉(zhuǎn)診困難的二級醫(yī)院的重癥 醫(yī)學(xué)床位數(shù)可占醫(yī)院總床位的 2。a.成立的重癥醫(yī)學(xué)科病床數(shù)為10張 5.醫(yī)學(xué)影像可提供 24 小時急診診療服務(wù)。a.可以提供24小時急診診療服務(wù) 【B】符合“C”，并 1.重癥醫(yī)學(xué)床位占醫(yī)院總床位的＞3。a.沒有達(dá)到 2.且符合重癥評估標(biāo)準(zhǔn)的患者≥30。a.沒有達(dá)到 3.醫(yī)學(xué)影像（含 CT、超聲）可提供 24 小時急診診療服務(wù)。a.可以提供24小時急診診療服務(wù) 【A】符合“B”，并 1.重癥醫(yī)學(xué)科床位占醫(yī)院總床位的≥5。a.沒有達(dá)到 2.且符合重癥評估標(biāo)準(zhǔn)的患者≥40。a.沒有達(dá)到1.4.3.2 【C】編制各類應(yīng)急預(yù)案。（★）1.根據(jù)災(zāi)害易損性分析的結(jié)果制訂各種專項預(yù)案，明確應(yīng)對不同突發(fā)公共事件2 的標(biāo)準(zhǔn)操作程序。a.已成立了應(yīng)對不同突發(fā)公共事件的預(yù)案 b．對不同突發(fā)事件有相關(guān)標(biāo)準(zhǔn)操作程序 23.院發(fā)（2008）18號文件 2.制訂醫(yī)院應(yīng)對各類突發(fā)事件的總體預(yù)案和部門預(yù)案，明確在應(yīng)急狀態(tài)下各個 部門的責(zé)任和各級各類人員的職責(zé)以及應(yīng)急反應(yīng)行動的程序。a.制定了處理各類事件的總體預(yù)案 b.對各類突發(fā)事件有相關(guān)領(lǐng)導(dǎo)組及人員職責(zé)、應(yīng)急行動程序。3.有節(jié)假日及夜間應(yīng)急相關(guān)工作預(yù)案，配備充分的應(yīng)急處理資源，包括人員、應(yīng)急物資、應(yīng)急通訊工具等。a.有相關(guān)預(yù)案（已下載）b．具有人員、應(yīng)急物資、應(yīng)急通訊工具 【B】符合“C”，并 編制醫(yī)院應(yīng)急預(yù)案手冊，方便員工隨時查閱，各部門各級各類人員知曉本部門 和本崗位相關(guān)職責(zé)與流程。a.沒有醫(yī)院應(yīng)急預(yù)案手冊 ？？？ 【A】符合“B”，并 定期并及時修訂總體預(yù)案和專項預(yù)案，持續(xù)完善。a.沒有修訂預(yù)案1.6.4 根據(jù)政府指令，接受城市三級醫(yī)院對口支援的醫(yī)院，達(dá)到二級醫(yī)院標(biāo)準(zhǔn)，應(yīng)將“達(dá)標(biāo)工作”任務(wù)作為院長目標(biāo)責(zé)任制與醫(yī)院工作計劃，有實施方案，專人負(fù)責(zé)。

1.6.4.1 【C】政府指令的受援的二級醫(yī)

1、受援的二級醫(yī)院，應(yīng)將“達(dá)標(biāo)工作”任務(wù)作為院長目標(biāo)責(zé)任制與醫(yī)院院，應(yīng)將“達(dá)標(biāo)工作”任務(wù) 工作計劃，有實施具體的方案。作為院長目標(biāo)責(zé)任制與醫(yī) a.有實施的具體方案。（咨詢王園媛，省立醫(yī)院，對口支援）院工作計劃，有實施方

2、有專人負(fù)責(zé)，對口支援工作，保證達(dá)標(biāo)工作進(jìn)行。案，專人負(fù)責(zé)。（★）a.有專人負(fù)責(zé) 詳詢醫(yī)務(wù)處3 Y

3、相關(guān)人員熟悉實施方案的相關(guān)內(nèi)容。a.有相關(guān)內(nèi)容?！綛】符合“C”，并 用當(dāng)年案例證實在以下二方面能有提升：（1）承擔(dān)縣域內(nèi)居民的常見病、多發(fā)病、危急和部分疑難重癥的診治任務(wù)，解決影響群眾生產(chǎn)生活的重大疾病能力有一定提升。沒有（2）開展 24 小時連續(xù)性急診科院內(nèi)急救服務(wù)，組織建立本縣域內(nèi)醫(yī)療急救服 務(wù)網(wǎng)絡(luò)，承擔(dān)日常院前急救救治任務(wù)的能力有一定提升。沒有 【A】符合“B”，并 1.有數(shù)據(jù)及相關(guān)案例證實受援方案取得預(yù)定目標(biāo)。？？？？ 2.數(shù)據(jù)指標(biāo)顯示在嚴(yán)重外傷（顱腔、胸腔、腹腔內(nèi)大出血，與其它威脅生命需 要緊急手術(shù)搶救）、急性心肌梗死（僅 STEMI）、急性腦卒中等急危重癥病人診 治效率及處理結(jié)果取得顯著進(jìn)步，其能力在本區(qū)域具有明顯優(yōu)勢。？？？？2.3.4.2 【C】對急性創(chuàng)傷、急 農(nóng)藥中毒、1.醫(yī)院對急性創(chuàng)傷、農(nóng)藥中毒、急診分娩、急性心肌梗死、急性腦卒中、急性診分娩、急 急性心肌梗死、顱腦損傷、高危妊娠孕產(chǎn)婦與高危新生兒等重點病種的急診服務(wù)流程與服務(wù)時性腦卒中、急性顱腦損傷、限有明文規(guī)定，并且在技術(shù)、設(shè)施方面提供支持。高危妊娠孕產(chǎn)婦等重點病 a.有對上述急癥的急診服務(wù)流程，技術(shù)、設(shè)施提供支持（已下載）見補(bǔ)充材料種的急診服務(wù)流程與服務(wù) 2.急診服務(wù)體系中相關(guān)部門（包括急診科、各專業(yè)科室、各醫(yī)技檢查科室、藥時限有明文規(guī)定，能落實到 劑科以及掛號與收費等）責(zé)任明確，各司其職，確?；颊吣軌颢@得連貫、及時、位。（★）有效的救治。4 a.各相關(guān)部門責(zé)任明確，能夠確?；颊攉@得及時有效的救治 3.急診服務(wù)流程體系相關(guān)責(zé)任部門人員知曉履職要求。a.有具體急診服務(wù)流程體系（已下載）【B】符合“C”，并 1.用關(guān)鍵質(zhì)量指標(biāo)與服務(wù)時限來管理與協(xié)調(diào)各個相關(guān)科室的服務(wù)。a.沒有關(guān)鍵質(zhì)量指標(biāo)與服務(wù)時限 2.有培訓(xùn)與教育，措施落實到位。a.沒有培訓(xùn)與教育 3.職能部門知曉與履行監(jiān)管責(zé)任，對存在問題與缺陷有改進(jìn)措施。a.沒有改進(jìn)措施 【A】符合“B”，并 危重癥患者來源與救治能力在本區(qū)域具有優(yōu)勢明顯。a.有優(yōu)勢2.6.1.1 【C】患者及其近親屬、授權(quán)委托人 1.有保障患者合法權(quán)益的相關(guān)制度并得到落實。對病情、診斷、醫(yī)療措施和醫(yī) a.有相關(guān)制度。（有關(guān)尊重患者隱私權(quán)、民族習(xí)慣和宗教信仰的有關(guān)規(guī)定）療風(fēng)險等具有知情選擇的權(quán) b.落實。（病案中的知情同意書）利。醫(yī)院有相關(guān)制度保證醫(yī)務(wù) 2.醫(yī)務(wù)人員尊重患者的知情選擇權(quán)利，對患者進(jìn)行病情、診斷、醫(yī)療措施和醫(yī)人員履行告知義務(wù)。（★）療風(fēng)險告知的同時，能提供不同的診療方案。5 Y a.能夠提供不同的診療方案。病案中體現(xiàn)（不同病種各異通知各科要有不用的診療方案記 錄）3.醫(yī)務(wù)人員熟知并尊重患者的合法權(quán)益。a.完全了解。（07.六安市立醫(yī)院維護(hù)醫(yī)患雙方合法權(quán)益相關(guān)知識培訓(xùn)綱要）【B】符合“C”，并 1.患者或近親屬、授權(quán)委托人對醫(yī)務(wù)人員的告知情況能充分理解并在病歷中體 現(xiàn)。a.患者能充分理解。（在病案中充分體現(xiàn)）（知情同意書要有患者的意見不能僅有簽字。）

2.職能部門對上述工作進(jìn)行督導(dǎo)、檢查、總結(jié)、反饋，有改進(jìn)措施。a.有監(jiān)督改進(jìn)措施。（病案檢查中體現(xiàn)）【A】符合“B”，并 持續(xù)改進(jìn)有成效。（01）2.7.1 貫徹落實《醫(yī)院投訴管理辦法（試行）》，實行“首訴負(fù)責(zé)制”，設(shè)立或指定專門部門統(tǒng)一接受、處理患者和醫(yī)務(wù)人員投訴，及時處理并答復(fù)投訴人。2.7.1.1 【C】貫徹落實《醫(yī)院投訴管理辦法 1.設(shè)立院領(lǐng)導(dǎo)接待室并執(zhí)行院長接待入日制度、意見箱、投訴電話等。（試行）》，實行“首訴負(fù)責(zé) a.執(zhí)行院長接待日制度。（六安市立醫(yī)院行政管理制度——院長接待日制度）制”，設(shè)立或指定專門部門統(tǒng) b.意見箱。（電梯內(nèi)）一接受、處理患者和醫(yī)務(wù)人員 c.投訴電話。（24小時通暢2166）投訴，及時處理并答復(fù)投訴 2.設(shè)立專門科室、專職人員接待醫(yī)療糾紛投訴，并有登記記錄。人。（★）a.醫(yī)務(wù)處，吳忠鈺。6 Y 3.定期對員工進(jìn)行醫(yī)療糾紛案例分析、醫(yī)療安全教育培訓(xùn)及相關(guān)法律法規(guī)培訓(xùn) 和考試，有獎罰措施 a.案例分析。（1.4月份）b.教育培訓(xùn)考試。（院長培訓(xùn)班）c．獎罰措施。4.有投訴管理相關(guān)制度及明確的處理流程。a.有制度和流程。（見醫(yī)療糾紛投訴接待與處理程序）5.有明確的投訴處理時限并得到嚴(yán)格執(zhí)行。a.處理時限嚴(yán)格執(zhí)行。（見醫(yī)療糾紛投訴接待與處理程序）【B】符合“C”，并 1.實行“首訴負(fù)責(zé)制”，科室、職能部門處置投訴的職責(zé)明確，有完善的投訴 協(xié)調(diào)處置機(jī)制。a.科室、職能部門職責(zé)。b.處置機(jī)制。（見醫(yī)療糾紛投訴接待和處理程序）2.有配置完善的錄音錄像設(shè)施的投訴接待室。a.有。（醫(yī)務(wù)處對面會議室。）3.職能部門對上述工作進(jìn)行督導(dǎo)、檢查、總結(jié)、反饋，有改進(jìn)措施。a.有改進(jìn)措施。【A】符合“B”，并 1.每季召開一次專題醫(yī)療糾紛投訴事件的討論會，各科科主任均應(yīng)參加通報 會。a.有參加。（1月份，4月份，少7月份）2.職能部門對提出持續(xù)改進(jìn)措施有成效評價的記錄。a.沒有記錄3.1.2 在診療活動中，嚴(yán)格執(zhí)行“查對制度”，至少同時使用姓名、年齡、床號等兩項核對患者身份，確保對正確的患者實施正確的操作。3.1.2.1 【C】在診療活動中，嚴(yán)格執(zhí)行 1.有標(biāo)本采集、給藥、輸血或血制品、采集供臨床檢驗及病理標(biāo)本、發(fā)放特殊，“查對制度” 至少同時使 飲食、診療活動及操作前患者身份確認(rèn)的制度、方法和核對程序。核對時應(yīng)讓用姓名、年齡兩項等項目核 患者或其近親屬、授權(quán)委托人陳述患者姓名。對患者身份，確保對正確的 a.有患者身份確認(rèn)制度、方法及核對程序。已下載 見補(bǔ)充材料（患者實施正確的操作?！铮?.至少同時使用兩種患者身份識別方式，如姓名、年齡、出生年月、年齡、病7 歷號、床號等（禁止僅以房間或床號作為識別的唯一依據(jù)）。a.至少使用患者姓名、性別、床號3種方式識別。見以上制度。3.相關(guān)人員熟悉上述制度和流程并履行相應(yīng)職責(zé)。a.抽查各科室醫(yī)務(wù)人員

【B】符合“C”，并 有規(guī)章制度和或程序規(guī)范各科室在任何環(huán)境和任何地點下都必須持續(xù)地履行 查對制度，識別“患者身份”。a.患者身份識別制度及程序 見補(bǔ)充材料 【A】符合“B”，并 1.各科室對本科執(zhí)行查對制度有監(jiān)管。a.抽查各科室醫(yī)務(wù)人員 2.職能部門對上述工作進(jìn)行督導(dǎo)、檢查、總結(jié)、反饋，有改進(jìn)措施。a.護(hù)理部、醫(yī)務(wù)處進(jìn)行督導(dǎo)、檢查、總結(jié)、反饋。b．沒有改進(jìn)措施3.3.3 有手術(shù)安全核查與手術(shù)風(fēng)險評估制度與工作流程。3.3.3.1 【C】有手術(shù)安全核查與手術(shù)風(fēng) 1.有手術(shù)安全核查與手術(shù)風(fēng)險評估制度與流程。險評估制度與流程。（★）a.有 《手術(shù)安全核查制度及流程》 《手術(shù)風(fēng)險評估制度與流程》8 Y 2.實施“三步安全核查”，并正確記錄：《手術(shù)安全核查制度》（1）第一步：麻醉實施前：三方按《手術(shù)安全核查表》依次核對患者身份（姓 名、性別、年齡、病案號）、手術(shù)方式、知情同意情況、手術(shù)部位與標(biāo)識、麻 醉安全檢查、皮膚是否完整、術(shù)野皮膚準(zhǔn)備、靜脈通道建立情況、患者過敏史、抗菌藥物皮試結(jié)果、術(shù)前備血情況、假體、體內(nèi)植入物、影像學(xué)資料等內(nèi)容。

（2）第二步：手術(shù)開始前：三方共同核查患者身份（姓名、性別、年齡）、手 術(shù)方式、手術(shù)部位與標(biāo)識，并確認(rèn)風(fēng)險預(yù)警等內(nèi)容。手術(shù)物品準(zhǔn)備情況的核查 由手術(shù)室護(hù)士執(zhí)行并向手術(shù)醫(yī)師和麻醉醫(yī)師報告。（3）第三步：患者離開手術(shù)室前：三方共同核查患者身份（姓名、性別、年 齡）、實際手術(shù)方式，術(shù)中用藥、輸血的核查，清點手術(shù)用物，確認(rèn)手術(shù)標(biāo)本，檢查皮膚完整性、動靜脈通路、引流管，確認(rèn)患者去向等內(nèi)容。3.手術(shù)院感風(fēng)險評估表應(yīng)在手術(shù)結(jié)束后填寫。a.具體體現(xiàn)在病案中《手術(shù)風(fēng)險評估表》 4.手術(shù)安全核查項目填寫完整。a.查手術(shù)患者病案 【B】符合“C”，并 1.制定規(guī)章制度和工作步驟來統(tǒng)一程序，支持在手術(shù)室之外的內(nèi)科和牙科等部 門的操作，確保正確部位，正確操作和正確病人。a.有相應(yīng)實行措施（手術(shù)安全核查，風(fēng)險評估制度發(fā)文含內(nèi)科、門診）2.手術(shù)核查手術(shù)風(fēng)險評估執(zhí)行率≥95。a.查手術(shù)病案 已達(dá)標(biāo)（具體體現(xiàn)在病案中院感調(diào)查表）【A】符合“B”，并 職能部門對上述工作進(jìn)行督導(dǎo)、檢查、總結(jié)、反饋，有改進(jìn)措施。a.術(shù)前病案檢查及反饋（01.以及報送考評辦扣款材料）3.4.2 醫(yī)務(wù)人員在臨床診療活動中應(yīng)嚴(yán)格遵循手衛(wèi)生相關(guān)要求。

3.4.2.1 【C】醫(yī)護(hù)人員在臨床診療活動 1.對員工提供手衛(wèi)生培訓(xùn)。中應(yīng)嚴(yán)格遵循手衛(wèi)生相關(guān) a.有對洗手的規(guī)范程序的培訓(xùn)，各醫(yī)務(wù)人員熟悉該洗手程序。要求。（★）2.有手衛(wèi)生相關(guān)要求（手清潔、手消毒、外科洗手操作規(guī)程等）的宣教、圖示。9Y a.各科室洗手池有宣教、圖示。3.手術(shù)室等重點部門外科洗手操作正確率 100。a．手術(shù)室外科洗手操作正確率100，抽查相關(guān)醫(yī)務(wù)人員 【B】符合“C”，并 1.職能部門有對規(guī)范洗手進(jìn)行督導(dǎo)、檢查、總結(jié)、反饋，有改進(jìn)措施。a.護(hù)理部進(jìn)行督導(dǎo)、檢查、總結(jié)、反饋 b.有改進(jìn)措施 已下載 見補(bǔ)充材料 2.洗手正確率≥90。a.達(dá)到90抽查醫(yī)務(wù)人員 【A】符合“B”，并 不斷提高洗手正確率，洗手正確率≥95。a.不斷提高3.6.2 建立“危急值”評價制度。3.6.2.1 【C】嚴(yán)格執(zhí)行“危急值”報告制 1.醫(yī)技部門相關(guān)人員知曉本部門“危急值”項目及內(nèi)容，能夠有效識別和確認(rèn)度與流程。（★）“危急值”。a.抽查醫(yī)技科相關(guān)人員（通知各科）10 Y 2.接獲危急值報告的醫(yī)護(hù)人員應(yīng)完整、準(zhǔn)確記錄患者識別信息、危急值內(nèi)容、和報告者的信息，按流程復(fù)核確認(rèn)無誤后，及時向經(jīng)治或值班醫(yī)師報告，并做 好記錄。a.查各科記錄（通知各科）3.醫(yī)師接獲危急值報告后應(yīng)及時追蹤、處置并記錄。a.查科室病案（通知各科）【B】符合“C”，并 信息系統(tǒng)能自動識別、提示危急值，相關(guān)科室能夠通過網(wǎng)絡(luò)及時向臨床科室發(fā) 出危急值報告，并有語音或醒目的文字提示。a.與檢驗科聯(lián)系確定，可以自動識別 【A】符合“B”，并 有網(wǎng)絡(luò)監(jiān)控功能，保障危急值報告、處置及時、有效。a.各科有監(jiān)控、報告處理（詳見各科室報告流程）3.9.1 有主動報告醫(yī)療安全（不良）事件與隱患缺陷的制度與可執(zhí)行的工作流程，并讓醫(yī)務(wù)人員充分知曉。3.9.1.1 【C】有主動報告醫(yī)療安全（不 1.有醫(yī)療安全（不良）事件的報告制度與流程，多種途經(jīng)便于醫(yī)務(wù)人員報告。良）事件的制度與工作流 a.報告制度《醫(yī)療安全不良事件報告制度》文檔程。（★）b.報告流程（08，《醫(yī)療安全管理》、各臨床科室專門成立醫(yī)療安全管理小組，發(fā)11 Y 生醫(yī)療不良事件首先科室調(diào)處，醫(yī)院專家委員會每季度對醫(yī)療安全不良事件討論及 分析，有防患預(yù)案）2.有對員工進(jìn)行不良事件報告制度的教育和培訓(xùn)。a.有培訓(xùn)通知，課件，培訓(xùn)，考核 3.每百張開放床位年報告≥10 件。

a.有 報告表下發(fā)各科室 未收集 【B】符合“C”，并 1.有指定部門統(tǒng)一收集、核查、分析醫(yī)療安全（不良）事件，采取防范措施。a.醫(yī)務(wù)處 b.不良事件收集、分析、處理、防范措施 2.有指定部門向相關(guān)機(jī)構(gòu)上報醫(yī)療安全（不良）事件。a.醫(yī)務(wù)處 3.每百張開放床位年報告≥15 件。a.有報告 但數(shù)量不足 4.醫(yī)護(hù)人員對不良事件報告制度的知曉率≥95。a.有培訓(xùn)、考試

【A】符合“B”，并 1.建立院內(nèi)網(wǎng)絡(luò)醫(yī)療安全（不良）事件直報系統(tǒng)及數(shù)據(jù)庫。a.無 2.每百張開放床位年報告≥20 件。a.無 3.改進(jìn)安全（不良）事件報告系統(tǒng)的敏感性，有效降低漏報率。a.無3.9.2 有激勵措施，鼓勵醫(yī)務(wù)人員通過“醫(yī)療安全（不良）事件報告系統(tǒng)”開展網(wǎng)上報告工作。3.9.2.1 【C】有激勵措施鼓勵醫(yī)務(wù)人員 1.建立有醫(yī)務(wù)人員主動報告的激勵機(jī)制。對不良事件呈報實行非懲罰制度。參加“醫(yī)療安全（不良）事 a.有主動報告激勵制度，08 《醫(yī)療安全不良事件報告制度》件報告系統(tǒng)”網(wǎng)上自愿報告 2.嚴(yán)格執(zhí)行衛(wèi)生部《醫(yī)療質(zhì)量安全事件報告暫行規(guī)定》的規(guī)定。

第三篇：二甲復(fù)審制度目錄

1.2.2.1 住院醫(yī)師規(guī)范化培訓(xùn)制度、臨床住院醫(yī)師規(guī)范化培訓(xùn)實施

方案

1.3.2.1 傳染病報告管理流程預(yù)檢分診流程 1.3.4.1 1.4.2.1 1.4.3.2 1.4.5.1 1.5.3.1 2.1.2.1 2.2.1.1 2.2.3.1 2.2.4.1 2.3.2.1 2.3.2.2 2.3.3.1 2.3.3.2 2.3.4.3 2.3.5.2 醫(yī)院信息報送前審核程序及問責(zé)制 醫(yī)院新聞發(fā)言人制度 醫(yī)院應(yīng)急預(yù)案手冊

應(yīng)急物資和設(shè)備的管理制度，審批程序

繼續(xù)醫(yī)學(xué)教育管理組織_管理制度和繼續(xù)醫(yī)學(xué)教育規(guī)劃、實施方案

預(yù)約診療工作制度和規(guī)范流程

門診管理制度 急危重癥患者有限處置制度 門診醫(yī)療資源調(diào)配方案 人力資源應(yīng)急調(diào)配制度 急診首診負(fù)責(zé)制度

急診工作在緊急情況下，各科室、各部門協(xié)調(diào)機(jī)制與協(xié)作流程

急診預(yù)檢、分診制度

急診留觀制度與流程 急診留觀病人分級查房制度 急診搶救與會診制度 急診醫(yī)護(hù)人員培訓(xùn)與考核制度

2.4.1.1 患者入院、出院、轉(zhuǎn)科、轉(zhuǎn)院制度及相應(yīng)服務(wù)流程 2.4.2.1 急診患者入院制度及流程 2.4.3.1 雙向轉(zhuǎn)診制度及流程

2.4.4.1 轉(zhuǎn)診、轉(zhuǎn)科患者病情、病歷等資料交接班制度（無）2.4.5.1 住院病人出院指導(dǎo)及隨訪工作制度及流程 2.5.1.1 基本醫(yī)療保障管理制度 2.6.1.1 保障患者合法權(quán)益的相關(guān)制度

2.6.3.1 實驗性臨床醫(yī)療管理制度及審核程序、2.6.4.1 保護(hù)患者隱私權(quán)的制度及具體措施 尊重民族習(xí)慣和宗教信仰制度及具體措施

2.7.1.1 執(zhí)行院長接待日制度及投訴處理制度、處理流程 首訴負(fù)責(zé)制 醫(yī)療糾紛界定范圍、處理制度及流程

2.7.1.2 醫(yī)療糾紛發(fā)言人制度 2.8.1.1 首問負(fù)責(zé)制

3.1.2.1 患者身份識別制度和程序

3.1.3.1 住院患者關(guān)鍵科室間轉(zhuǎn)科身份識別及轉(zhuǎn)接流程 3.1.4.1 使用“腕帶”作為識別身份標(biāo)識的患者和科室有明確制度

3.2.1.1 開具醫(yī)囑相關(guān)制度與規(guī)范

3.2.2.1 緊急情況下口頭醫(yī)囑的制度與執(zhí)行流程

3.2.3.1 臨床危急值報告制度及流程 3.3.1.1 手術(shù)患者術(shù)前準(zhǔn)備相關(guān)管理制度 3.3.2.1 手術(shù)部位標(biāo)識識別標(biāo)識相關(guān)制度與流程 3.3.3.1 手術(shù)安全核查與手術(shù)風(fēng)險評估制度與流程 3.4.1.1 手衛(wèi)生管理制度實施規(guī)范 3.5.1.1 特殊藥品使用管理制度及程序

3.5.2.1 藥師審核處方或用藥醫(yī)囑制度

藥品安全性監(jiān)測制度 3.6.1.1 臨床危急值報告制度制度與工作流程 3.7.1.1 防范患者跌倒、墜床的相關(guān)制度

3.7.2.1 患者跌倒、墜床等意外事件報告相關(guān)制度、處置預(yù)案與工作流程

3.9.1.1 醫(yī)療安全（不良）事件報告制度及流程 3.9.2.1 不良事件呈報實行非懲罰制度

4.1.1.1 醫(yī)院質(zhì)量管理組織 醫(yī)院質(zhì)量管理組織架構(gòu)圖 醫(yī)療質(zhì)量與醫(yī)療安全管理和持續(xù)改進(jìn)方案 4.1.1.2 科室醫(yī)療質(zhì)量與安全管理制度 4.1.3.1 多部門質(zhì)量安全管理協(xié)調(diào)制度

4.2.1.1 醫(yī)療質(zhì)量管理和持續(xù)改進(jìn)實施方案及相配套制度、考核標(biāo)準(zhǔn)、考核辦法、質(zhì)量指標(biāo)

醫(yī)療質(zhì)量管理實施方案、考核體系及管理流程

4.2.1.2 醫(yī)療質(zhì)量關(guān)鍵環(huán)節(jié)管理標(biāo)準(zhǔn)與措施 重點部門管理標(biāo)準(zhǔn)與措施

4.2.2.2 醫(yī)療核心制度

4.2.3.1 各專業(yè)、各崗位“三基”培訓(xùn)及考核制度 4.2.4.1 醫(yī)療風(fēng)險管理方案 醫(yī)療風(fēng)險管理制度 4.2.4.3 醫(yī)療風(fēng)險防范工作制度、流程及預(yù)案 4.3.2.1 醫(yī)療技術(shù)分級管理制度

4.3.3.1 醫(yī)療技術(shù)風(fēng)險處置與損害處置預(yù)案

4.3.3.2 新技術(shù)、新項目準(zhǔn)入管理制度及風(fēng)險處置預(yù)案 4.3.4.1 臨床科研項目中使用醫(yī)療技術(shù)的相關(guān)管理制度 臨床科研項目中使用醫(yī)療技術(shù)保障患者安全的措施和風(fēng)險處置預(yù)案 4.3.5.1 有創(chuàng)操作規(guī)章制度及有創(chuàng)技術(shù)操作衛(wèi)生技術(shù)人員授權(quán)管理制度

4.4.1.1 臨床路徑管理制度及實施流程 4.4.2.1 臨床路徑知情同意告知管理制度

4.4.4.1 對執(zhí)行“臨床路徑”病例有關(guān)指標(biāo)列入監(jiān)測范圍的規(guī)定與程序

4.5.1.1 患者病情評估管理制度

4.5.2.3 抗菌藥物使用規(guī)范及管理制度

抗菌藥物處方點評制度

4.5.4.1 院內(nèi)會診管理制度及流程 醫(yī)師外出會診相關(guān)制度與流程

4.5.5.1 住院病人出院指導(dǎo)及隨訪工作制度與流程

4.5.6.4 出院患者平均住院日的要求及醫(yī)院縮短患者平均住院日具體措施

4.5.6.5 住院時間超過30天的患者管理與評價制度 4.5.7.3 新生兒科醫(yī)院感染預(yù)防與控制

4.5.9.1 住院患者各類膳食適應(yīng)癥和膳食應(yīng)用原則手冊 4.6.1.1 手術(shù)醫(yī)師資格分級授權(quán)管理制度與程序 4.6.1.2 手術(shù)醫(yī)師能力評價與再授權(quán)制度及程序 4.6.2.1 4.6.4.1 4.6.4.2 4.6.5.1 4.6.6.2 4.6.7.1 4.6.8.3 4.7.1.1 4.7.1.2 4.7.2.1 4.7.3.1 4.7.4.2 4.7.4.3 4.7.7.1 4.8.2.1 操作規(guī)程

4.8.3.1 患者病情評估制度與術(shù)前討論制度 重大手術(shù)報告審批管理制度 急診手術(shù)管理制度及工作流程 手術(shù)預(yù)防性抗菌藥物應(yīng)用管理制度 手術(shù)病理標(biāo)本檢查管理制度 術(shù)后患者管理制度

非計劃再次手術(shù)管理制度與流程及監(jiān)管措施 麻醉醫(yī)師資格分級授權(quán)管理制度與程序 麻醉醫(yī)師能力評價與再授權(quán)制度及程序 麻醉前病情評估制度 麻醉前知情同意制度

麻醉過程中的意外與并發(fā)癥處理規(guī)范與流程 麻醉效果評定的規(guī)范與流程 手術(shù)中用血制度與輸血流程

重癥醫(yī)學(xué)科各項規(guī)章制度、崗位職責(zé)和相關(guān)技術(shù)規(guī)范、重癥醫(yī)學(xué)科醫(yī)護(hù)人員技術(shù)能力準(zhǔn)入及授權(quán)制度、程序

4.8.3.2 重癥患者分級查房及多科聯(lián)合查房制度 4.8.5.2 醫(yī)療安全(不良)事件的無責(zé)上報制度 4.9.2.1 感染性疾病科各項規(guī)章制度與流程（無）4.9.3.2 醫(yī)院污水感染垃圾污物處理管理制度

4.9.4.1 突發(fā)公共衛(wèi)生事件和傳染病疫情信息監(jiān)測報告的制度與流程

傳染病報告責(zé)任獎懲制度 4.10.2.1 有中醫(yī)科的工作制度

4.10.2.2

中醫(yī)與西醫(yī)臨床科室的會診、轉(zhuǎn)診制度 4.10.3.1 中藥質(zhì)量管理制度

4.11.2.2 康復(fù)意外緊急處置預(yù)案與流程

4.11.2.3 康復(fù)患者及家屬滿意度評價的制度與流程 4.11.3.1 對患者病情及所能承受能力確認(rèn)規(guī)定 4.11.4.2 住院患者醫(yī)療安全管理制度和措施 4.12.1.1 疼痛科制度

4.12.3.1 疼痛科醫(yī)療風(fēng)險防范及應(yīng)急預(yù)案

4.14.2.1 藥品遴選制度 藥品采購供應(yīng)管理制度與流程 4.14.2.2 藥品質(zhì)量管理相關(guān)制度

藥品質(zhì)量報告途徑與流程

4.14.2.3 藥品儲存管理制度 藥品有效期管理相關(guān)制度與處理流程

4.14.2.4 特殊藥品管理制度 “麻、精”藥品實行三級管理和“五專”管理的制度與程序

4.14.2.5 急救、備用藥品管理和使用及領(lǐng)用、補(bǔ)充管理制度及

流程

4.14.2.6 藥品的調(diào)劑制度與操作規(guī)程 4.14.2.9 藥品召回管理制度與處置流程 4.14.3.1 處方點評管理制度

4.14.3.2 用藥交待的制度與程序 超說明書用藥規(guī)定 4.14.3.3 醫(yī)院處方管理辦法實施細(xì)則 4.14.3.4 患者自帶藥品管理制度

4.14.3.6 發(fā)(用)藥差錯登記、報告的制度與程序 差錯分析制度與改進(jìn)措施

4.14.5.1 抗菌藥物臨床應(yīng)用管理工作制度和監(jiān)督管理機(jī)制 4.14.5.3 抗菌藥物分級管理制度 抗菌藥物分級管理制度實施方案及措施

4.14.5.7 醫(yī)師抗菌藥物處方權(quán)限制度與程序 藥師抗菌藥物調(diào)劑資格管理制度與程序

4.14.6.1 藥品不良反應(yīng)監(jiān)測與藥害事件監(jiān)測報告制度 4.14.6.2 突發(fā)事件藥事管理應(yīng)急預(yù)案 4.15.2.1 實驗室安全管理制度和流程 4.15.2.4 易燃、易爆物品的儲存使用制度 4.15.2.9 化學(xué)危險品管理制度

4.15.4.2 檢驗報告雙簽字制度（急診除外）

檢驗科復(fù)檢制度 4.15.4.4 檢驗報告單書寫制度

4.15.4.5 檢驗科與臨床科室定期溝通制度

4.15.5.1 檢驗科試劑與校準(zhǔn)品管理制度 4.16.2.2 病理醫(yī)生專業(yè)水平定期考核制度

4.16.3.1 工作中產(chǎn)生的廢棄有害液體統(tǒng)一回收的制度與程序（無）

4.16.4.1 病理診斷的相關(guān)制度與流程 上級醫(yī)師會診制度（無）

4.16.4.3 病理診斷報告補(bǔ)充、更改、遲發(fā)管理制度

4.16.4.4 細(xì)胞學(xué)篩查與細(xì)胞學(xué)診斷有相關(guān)的制度與流程（無）4.16.5.1 病理醫(yī)師與臨床醫(yī)師隨時溝通的相關(guān)制度與流程 4.16.6.1 醫(yī)療廢物、危險化學(xué)品和生物安全管理制度（無）

新增病理診斷技術(shù)應(yīng)用的審批與管理制度

4.16.6.3

病理科不合格標(biāo)本處理制度與程序

4.16.6.4 病理醫(yī)師承擔(dān)標(biāo)本的檢查和取材的相關(guān)制度與流程 4.16.6.9 試劑與儀器設(shè)備管理制度

4.17.3.1 放射科診斷報告書寫規(guī)范、審核制度及流程 4.17.3.2 影像科重點病例隨訪與反饋制度 4.17.4.1 放射安全管理相關(guān)制度與落實措施（無）4.18.1.2 臨床輸血管理制度

4.18.4.1 用血申報登記、血液入出庫管理、血液核對、血液貯存及相容性檢測的制度（無）4.18.4.2 輸血前檢驗和核對制度

4.18.5.1 血液貯存質(zhì)量監(jiān)測、信息反饋制度 血液出入庫的核

對、領(lǐng)發(fā)登記制度

4.18.5.1 輸血前和輸血期間的血液管理制度 4.18.5.4 控制輸血感染方案

4.18.5.5 輸血不良反應(yīng)處理預(yù)案及制度 4.18.6.1 輸血相容性監(jiān)測實驗質(zhì)量管理制度 4.19.1.2 醫(yī)院重點科室醫(yī)院感染預(yù)防與控制制度

4.19.3.2 手術(shù)部位、導(dǎo)尿管尿路、血管導(dǎo)管相關(guān)血流、皮膚軟組等主要部位感染具體預(yù)防控制措施 4.19.3.3 醫(yī)院感染暴發(fā)報告與處置預(yù)案

4.19.6.1 抗菌藥物合理應(yīng)用管理制度及獎懲辦法 抗菌藥物分級管理制度及措施方案與措施 4.19.7.1 重點部門消毒隔離制度 4.20.2.2 血液透析室接診制度

4.20.3.1 醫(yī)院感染管理各項有關(guān)制度完整版 4.20.3.2 血液透析室接診制度 4.20.6.1 透析器復(fù)用的管理制度和流程 4.23.3.1 病案室病歷管理工作制度 4.23.6.1 病案服務(wù)管理制度與程序

第四篇：二甲醫(yī)院門診部復(fù)審實施方案

門診部二甲復(fù)審實施方案和步驟

一、實施方案

（一）門診各科室成立二甲復(fù)審小組，明確復(fù)審中的工作任務(wù)，確保各項復(fù)審工作落到實處。

（二）醫(yī)院二甲復(fù)審，處處都是評審范圍，事事都是評審內(nèi)容，人人都是評審對象。門診各科室主任要積極多次召開科室會議，使本科職工認(rèn)識到二甲復(fù)審工作的重要性，增強(qiáng)自覺性，從而為二甲復(fù)審奠定堅實的基礎(chǔ)。

（三）認(rèn)真學(xué)習(xí)《聊城市二級綜合醫(yī)院評審細(xì)則》中有關(guān)本科室的各類指標(biāo)?？剖邑?fù)責(zé)人及二甲復(fù)審小組成員首先深刻學(xué)習(xí)和領(lǐng)會標(biāo)準(zhǔn)，吃透精神，隨后組織科室成員逐條學(xué)習(xí)、逐條領(lǐng)會，各述已見，發(fā)揮群策群力，已達(dá)正確解讀細(xì)則標(biāo)準(zhǔn)。同時，組織科室人員進(jìn)行學(xué)習(xí)講解，根據(jù)具體情況采取走出去或邀請有關(guān)專家來院進(jìn)行講解，幫助大家理清思路，找準(zhǔn)問題，明確重點和方向，有的放矢的做好各項準(zhǔn)備工作。

（四）各科室按照《聊城市二級綜合醫(yī)院評審細(xì)則》中要求逐條梳理認(rèn)真理解，科室主任就是責(zé)任人,按照“誰主管、誰負(fù)責(zé)、講實效、重實績”的原則實行目標(biāo)、責(zé)任追究制管理，要求各各科室主任切實肩負(fù)起“第一責(zé)任人”職責(zé)，限時組織實施，確保各自科室有計劃、有步驟的按期完成任務(wù)，整體推進(jìn)醫(yī)院二甲復(fù)審工作。

（五）各科室根據(jù)評審細(xì)則，詳細(xì)制定出切實可行的階段性目標(biāo)上報門診部和醫(yī)院，門診部加強(qiáng)督促檢查，隨時收集各方意見，及時向分管院長匯報。并不斷的進(jìn)行自查，出現(xiàn)問題或不足及時整改，對于未能按期完成階段性目標(biāo)任務(wù)的科室和個人將全院通報批評，并對責(zé)任人給予處罰。

二、實施步驟

（一）2月1-2月11日

科室成立二甲復(fù)審小組，學(xué)習(xí)《聊城市二級綜合醫(yī)院評審細(xì)則》，分解任務(wù)，落實責(zé)任。

（二）2月11日-2月25日

召開科室會議，組織學(xué)習(xí)或?qū)ｎ}講座，力爭達(dá)到人人掌握標(biāo)準(zhǔn)。

（三）2月25日-3月4日

各科室根據(jù)評審細(xì)則要求，整理出所需準(zhǔn)備材料（包括各種擋案夾、記錄本及其他材料），并制定出各自階段性目標(biāo)上報門診部和醫(yī)院。

（四）3月3-3月18日 全面規(guī)范

1、建立健全科內(nèi)質(zhì)量管理組織和質(zhì)控小組

2、完善各項管理制度和崗位職責(zé)

3、制定各種規(guī)范操作規(guī)程

4、落實各項應(yīng)急預(yù)案和危急值報告程序

5、上報門診部統(tǒng)一整理裝訂、印發(fā)。

（五）3月18日-4月29日 全面實施階段

1、各科室按照制度與規(guī)范要求，全面開展二甲復(fù)審準(zhǔn)備

2、詳細(xì)作好原始資料的記錄、整理，分類存放保管。

3、科室及時匯報，加強(qiáng)督導(dǎo)檢查、定期通報。

（六）4月29-5月12日 自查階段

1、門診部組織相應(yīng)人員全面檢查

2、科室整理出檢查出現(xiàn)的問題，及時上報醫(yī)院

3、下發(fā)整改通知

（七）5月12日-6月31日整改階段

各科室根據(jù)整改通知全面整改，然后接受醫(yī)院初評，并根據(jù)初評結(jié)果再進(jìn)行整改。

第五篇：二甲醫(yī)院麻醉科復(fù)審實施方案

麻醉科二甲復(fù)審實施方案和步驟

一、實施方案

（一）麻醉科成立二甲復(fù)審小組，明確復(fù)審中的工作任務(wù)，確保麻醉科各項復(fù)審工作落到實處。

（二）醫(yī)院二甲復(fù)審，處處都是評審范圍，事事都是評審內(nèi)容，人人都是評審對象。積極多次召開科室會議，使本科醫(yī)護(hù)人員認(rèn)識到二甲復(fù)審工作的重要性，增強(qiáng)自覺性，從而為二甲復(fù)審奠定堅實的基礎(chǔ)。

（三）認(rèn)真組織學(xué)習(xí)《海南省二級綜合醫(yī)院評審標(biāo)準(zhǔn)》中有關(guān)本科室的各類指標(biāo)?？剖邑?fù)責(zé)人及二甲復(fù)審小組成員首先深刻學(xué)習(xí)和領(lǐng)會標(biāo)準(zhǔn)，吃透精神，隨后組織科室成員逐條學(xué)習(xí)、逐條領(lǐng)會，各述已見，發(fā)揮群策群力，已達(dá)正確解讀細(xì)則標(biāo)準(zhǔn)。同時，組織科室人員進(jìn)行學(xué)習(xí)講解，根據(jù)具體情況采取走出去或邀請有關(guān)專家來院進(jìn)行講解，幫助大家理清思路，找準(zhǔn)問題，明確重點和方向，做好各項準(zhǔn)備工作。

（四）按照《海南省二級綜合醫(yī)院評審標(biāo)準(zhǔn)》中要求逐條梳理認(rèn)真理解，科主任切實肩負(fù)起“第一責(zé)任人”職責(zé)，限時組織實施，確?？剖矣杏媱?、有步驟的按期完成任務(wù)，整體推進(jìn)醫(yī)院二甲復(fù)審工作。

二、實施步驟

（一）3月1日

科室成立二甲復(fù)審小組，學(xué)習(xí)《海南省二級綜合醫(yī)院評審標(biāo)準(zhǔn)》，分解任務(wù)，落實責(zé)任。曾釗任組長、桂茶華任副組長、組員為：符明君、蔡親東、鐘雅、林詩發(fā)。

（二）3月1日-3月2日

召開科室會議，組織學(xué)習(xí)或?qū)ｎ}講座，力爭達(dá)到人人掌握標(biāo)準(zhǔn)。

（三）3月3日-3月5日

根據(jù)評審標(biāo)準(zhǔn)要求，整理出所需準(zhǔn)備材料（包括各種擋案夾、記錄本及其他材料），并制定出各自階段性目標(biāo)上報醫(yī)院二甲復(fù)審辦公室。

（四）3月5－25日 全面規(guī)范

1、建立健全麻醉質(zhì)量數(shù)據(jù)庫與安全管理組織和質(zhì)控小組工作記錄

2、完善麻醉科各項管理制度和麻醉科醫(yī)師職責(zé)及權(quán)限制度

3、制定麻醉各種規(guī)范操作規(guī)程

4、與醫(yī)院二甲復(fù)審小組溝通，落實解決麻醉恢復(fù)室與疼痛門診相關(guān)問題。

5、完善及認(rèn)真做好麻醉術(shù)前防視、術(shù)后隨防、麻醉記錄單、麻醉知情同意書等工作。

6、接受醫(yī)院二甲復(fù)審辦公室第二次大檢查及評分

（五）3月25日-4月1日 全面實施階段

1、按照制度與規(guī)范要求，全面開展二甲復(fù)審準(zhǔn)備

2、詳細(xì)作好原始資料的記錄、整理，分類存放保管。

3、及時定期給科主任匯報，科主任加強(qiáng)督導(dǎo)檢查。

（六）4月2-5日 自查階段

1、科室二甲復(fù)審小組人員全面檢查

2、科室整理出檢查出現(xiàn)的問題，及時上報醫(yī)院

3、出現(xiàn)的問題及時整改

（七）4月5日整改階段

接受醫(yī)院二甲復(fù)審辦公室第三次大檢查及評分，并根據(jù)初評結(jié)果再進(jìn)行整改。