第一篇：醫(yī)院管理制度目錄

醫(yī)院管理制度清單

第一章 行政、后勤管理制度

一、會議制度

（1）醫(yī)療質(zhì)量自查通報會

（2）院周會

（3）晨會

（4）科務(wù)會

（5）職工大會

二、請假制度

三、對員工的基本要求

四、員工宿舍管理規(guī)定

五、院辦公室工作制度

六、醫(yī)務(wù)科工作制度

七、護理部工作制度

八、衛(wèi)生工作制度

九、環(huán)衛(wèi)清潔工作管理制度

十、洗衣房工作制度

第二章 基本醫(yī)療管理制度

一、門、急診管理制度

1.門診工作制度2.門診導醫(yī)工作制度

3.急診科（室）工作制度4.急診觀察制度

5.急診搶救工作制度6.門診收費室工作制度

7.腸道門診工作制度8.發(fā)熱門診工作制度

二、醫(yī)療技術(shù)管理制度

1.院總值班制度2.請示報告制度

3.三級醫(yī)師查房制度4.醫(yī)囑制度

5.病例討論制度6.會診制度

7.醫(yī)師值班、交接班制度8.首診負責制度

9.轉(zhuǎn)院制度10.轉(zhuǎn)科制度

11.危重病人搶救報告制度12.病歷書寫制度

13.危重病人、特殊情況家屬談話簽字制度

14.病人入院、出院管理制度15.病案管理制度

16.醫(yī)療差錯事故管理制度17.投訴管理制度

18.換藥室工作制度19.治療室工作制度

20.監(jiān)護室工作制度

三、手術(shù)管理制度

1.手術(shù)室工作制度2.手術(shù)室管理要求

3.手術(shù)管理制度4.手術(shù)室消毒隔離制度

5.手術(shù)室查對制度6.手術(shù)中無菌技術(shù)規(guī)則

7.手術(shù)室藥品保管制度8.麻醉管理制度

四、輸血管理制度

1.輸血治療同意書制度2.血庫工作制度

3.輸血前檢查和交叉配血制度4.臨床輸血的監(jiān)護制度

5.血庫技術(shù)管理制度

6.血庫血液及制品的領(lǐng)取制度

7.輸血品回收制度8.清潔消毒制度

五、藥劑管理制度

1.藥房管理制度2.西藥房工作制度

3.門診中藥房工作制度4.處方制度

5.醫(yī)院藥品采購管理制度6.藥品庫房管理制度

7.藥品質(zhì)量管理制度

（1）西藥管理

（2）中藥管理

（3）特殊藥品的管理

8.麻醉藥品和精神藥品管理制度

六、傳染病管理制度

1.疫情報告制度

3.傳染病知識培訓制度

七、醫(yī)技科室管理制度

1.檢驗科工作制度

3.放射科工作制度

5.心電圖室工作制度

第三章

一、護理工作制度

1.護理工作制度

3.交接班制度

5.差錯事故管理制度

7.護理文件書寫制度

二、醫(yī)院感染管理制度2.傳染病報卡制度4.傳染病報告自查及獎懲制度2.檢驗標本查對管理制度4.B超室工作制度 護理工作制度2.查對制度4.消毒隔離制度6.搶救工作制度8.病房管理制度

1.院內(nèi)感染管理制度2.醫(yī)院感染工作制度

3.醫(yī)院感染控制制度4.醫(yī)院感染監(jiān)測報告制度

5.一次性使用醫(yī)療用品管理制度6.醫(yī)院消毒隔離工作的規(guī)定（要求）

7.消毒隔離制度8.醫(yī)院感染管理的重點要求

9.醫(yī)院消毒供應(yīng)室的感染管理10.醫(yī)院手術(shù)室的感染管理

11.醫(yī)院治療室、處置室、注射室的感染管理

12.醫(yī)院病房的感染管理13.醫(yī)院門、急診的感染管理

14.醫(yī)院檢驗科的感染管理15.醫(yī)療廢物管理制度

第二篇：醫(yī)院管理制度目錄（范文）

醫(yī)院管理制度匯編

目錄

第一章 醫(yī)療規(guī)章制度

第一節(jié) 共同制度

一、請示報告制度·······································1

二、醫(yī)師值班交接班制度·································1

三、院總值班制度·······································2

四、消毒隔離制度·······································2

五、處方制度···········································3

六、查對制度···········································4

第二節(jié) 醫(yī)療行政管理制度

一、行政會議制度·······································7

二、醫(yī)務(wù)科工作制度·····································9

三、醫(yī)療質(zhì)量管理制度···································9

四、醫(yī)療經(jīng)費管理·······································10

五、院領(lǐng)導深入科室制度·································10

第三節(jié) 醫(yī)療信息工作制度

一、醫(yī)療登記、統(tǒng)計制度·································10

二、病案管理制度·······································11

三、醫(yī)學圖書管理制度···································11

第四節(jié) 醫(yī)院感染管理工作制度

一、醫(yī)院感染管理制度···································12

二、醫(yī)院傳染源管理制度·································13

三、醫(yī)療場所、環(huán)境衛(wèi)生管理制度·························13

四、抗生素使用制度·····································14

第五節(jié) 科室工作制度

一、門診工作制度·······································15

三、住院處工作制度·····································16

四、觀察室工作制度·····································16

第六節(jié) 臨床工作制

一、檢診制度···········································17

二、病歷書寫制度·······································17

三、醫(yī)囑制度···········································19

四、查房制度···········································19

五、會診制度···········································20

六、病例討論制度·······································21

七、中醫(yī)工作制度·······································22

八、麻醉工作制度·······································22

九、手術(shù)室工作制度·····································23

第七節(jié) 護理工作制度

一、護理部工作制度·····································24

二、護理值班制度·······································24

三、差錯事故登記報告處理制度···························25

四、護理文件書寫制度···································25

五、分級護理制度·······································26

六、責任護理制度·······································26

七、病房管理制度·······································26

八、病人轉(zhuǎn)院轉(zhuǎn)科制度···································27

九、病人出入院制度·····································27

十、治療室工作制度·····································28

十一、換藥室工作制度···································29

第八節(jié) 醫(yī)技科工作制度

一、檢驗科工作制度·····································29

二、放射科工作制度·····································30

三、超聲檢查工作制度···································

31第九節(jié) 藥品器材供應(yīng)管理工作制度

一、藥劑科工作·········································32

二、醫(yī)療器械設(shè)備管理制度·······························35

三、麻醉藥品、毒性藥品與精神藥品管理制度···············36

四、供應(yīng)室工作制度·····································38

第二章 醫(yī)院其他方面工作制度

第一節(jié) 行政管理制度

一、院辦公室工作制度··································40

二、信訪接待制度······································40

三、加強醫(yī)德醫(yī)風建設(shè)的措施····························40

四、醫(yī)德醫(yī)風考核辦法··································41

五、社會監(jiān)督制度······································42

六、職工考勤管理制度··································42

七、傳達門衛(wèi)制度······································43

第二節(jié) 醫(yī)院人事工作制度

第三節(jié) 后勤工作制度

一、總務(wù)科工作制度····································44

二、財產(chǎn)物資管理制度··································44

三、各種耗材審批請領(lǐng)制度······························45

四、職工食堂管理制度··································45

五、汽車司機管理制度··································46

六、安全保衛(wèi)制度······································46

第四節(jié) 醫(yī)院財務(wù)工作制度

一、財務(wù)科工作制度····································47

二、財務(wù)管理規(guī)定······································47

三、門診收費處工作制度································49

四、門診病人退費規(guī)定··································49

第三章 醫(yī)院各級人員工作職責

第一節(jié) 院級委員會職責

一、院務(wù)委員會職責····································50

二、學術(shù)指導委員會職責································50

三、醫(yī)院感染管理委員會職責····························51

四、藥品管理委員會職責································51

五、愛國衛(wèi)生運動委員會職責····························51

六、安全和質(zhì)量管理委員會職責······························52

第二節(jié) 行政管理人員職責

一、院長職責··········································52

二、業(yè)務(wù)副院長職責····································53

三、院辦公室主任職責··································53

四、醫(yī)務(wù)科科長職責····································54

五、護理部主任職責····································54

六、人事科長職責······································55

七、財務(wù)科長職責······································55

八、總務(wù)科科長職責····································56

第三節(jié) 門診部人員職責

一、門診部主任職責····································56

二、門診部主任醫(yī)師(副主任醫(yī)師)職責····················57

三、門診部主治醫(yī)師職責································57

四、門診部醫(yī)師職責····································57

五、門診部護士長職責··································58

六、門診部護師(士)職責································58

七、導診人員工作職責 ·································59

八、門診掛號工作人員職責······························59

第四節(jié) 臨床科人員職責

一、臨床科主任職責····································60

二、臨床科主任(副主任)醫(yī)師職責························60

三、臨床科主治醫(yī)師職責································60

四、臨床科住院醫(yī)師職責································61

五、臨床科護士長職責··································61

六、臨床科護師(士)職責································62

七、麻醉科醫(yī)師職責····································62

八、手術(shù)室護士長職責··································63

九、手術(shù)室護師(士)職責································63

第五節(jié) 醫(yī)技科人員職責

一、檢驗科主任職責····································64

二、檢驗科技師(士)工作職責····························64

三、放射科醫(yī)師的職責··································65

四、功能科技師(醫(yī)師)職責······························65

五、藥劑科主任職責····································65

六、藥劑師(中西藥)職責································66

七、消毒供應(yīng)室護士長職責······························66

八、消毒供應(yīng)室護士職責······································67

第六節(jié) 財會人員的工作職責

一、會計工作職責······································67

二、出納員職責········································68

三、門診收費員職責····································68

四、住院處會計職責····································69

第七節(jié) 后勤人員職責

一、保管員職責········································69

二、電工職責··········································70

三、職工食堂炊事員職責································70

四、汽車司機職責······································70

五、門衛(wèi)保安人員職責··································71

第三篇：醫(yī)院感染管理制度目錄

6.2.1醫(yī)院感染管理制度

目錄

1.醫(yī)院感染組織建設(shè)及其責任制度………………………………………… 1 2.醫(yī)院感染知識培訓制度…………………………………………………… 3 3.醫(yī)院感染病例監(jiān)測制度…………………………………………………… 4 4.醫(yī)院感染病例報告制度…………………………………………………… 5 5.醫(yī)院感染暴發(fā)及醫(yī)院感染 突發(fā)事件監(jiān)測、上報及控制制度 ………… 7 6.重點部門和重點部位醫(yī)院感染預防與控制制度…………………………10 7.感染性疾病科的醫(yī)院感染管理制度………………………………………11 8.產(chǎn)房、母嬰同室的醫(yī)院感染管理制度……………………………………12 9.手術(shù)室的醫(yī)院感染管理制度………………………………………………14 10.消毒供應(yīng)中心的醫(yī)院感染管理制度…………………………………… 16 11.檢驗科的醫(yī)院感染管理制度…………………………………………… 18 12.口腔科門診的醫(yī)院感染管理制度……………………………………… 19 13.內(nèi)鏡室的醫(yī)院感染管理制度…………………………………………… 20 14.清潔制度………………………………………………………………… 22 15.無菌操作制度…………………………………………………………… 23 16.安全注射制度…………………………………………………………… 24 17.醫(yī)源性感染登記、暴發(fā)報告制度……………………………………… 25 18.醫(yī)院感染管理小組職責………………………………………………… 26 19．醫(yī)院管理專（兼）職人員職責………………………………………… 27 20．手術(shù)部位感染預防與控制制度………………………………………… 28 21.導尿管相關(guān)尿路感染預防與控制制度………………………………… 30 22.下呼吸道感染的預防與控制制度……………………………………… 32 23.皮膚、軟組織感染預防與控制制度…………………………………… 33 24.消毒滅菌與隔離制度……………………………………………………35 25.環(huán)境衛(wèi)生學及消毒滅菌效果監(jiān)測與質(zhì)量持續(xù)改進制度………………37 26.一次性無菌醫(yī)療用品使用制度…………………………………………39 27.一次性使用醫(yī)療用品、消毒藥械進貨檢查驗收制度…………………41 28.消毒藥械管理制度………………………………………………………43 29.手衛(wèi)生制度………………………………………………………………44 30.抗菌藥物合理應(yīng)用管理制度……………………………………………46 31.生物安全管理制度………………………………………………………48 32.醫(yī)療廢物管理制度………………………………………………………50 33.醫(yī)務(wù)人員職業(yè)衛(wèi)生安全防護制度………………………………………52 34.醫(yī)院感染質(zhì)量控制與考評制度…………………………………………54 35.終末消毒制度……………………………………………………………56 36.治療室消毒隔離制度……………………………………………………57 37.急救室制度………………………………………………………………59 38.處置室制度………………………………………………………………60 39.醫(yī)院感染監(jiān)測制度………………………………………………………63

第四篇：醫(yī)院感染管理制度目錄

巍山院區(qū)醫(yī)院感染管理制度目錄

一、醫(yī)院感染預防與控制制度

醫(yī)院感染管理制度……………………………………………………………………1 醫(yī)院感染委員會的職責………………………………………………………………3 醫(yī)院感染管理科專職人員的職責……………………………………………………4 醫(yī)院感染監(jiān)測登記報告制度…………………………………………………………5 醫(yī)院感染管理知識培訓制度…………………………………………………………6 醫(yī)院內(nèi)感染病例漏報處理制度………………………………………………………10 多重耐藥菌菌株醫(yī)院感染控制………………………………………………………11醫(yī)務(wù)人員職業(yè)暴露防護管理暫行規(guī)定………………………………………………13 消毒滅菌與隔離管理總則……………………………………………………………16 消毒滅菌與隔離管理細則……………………………………………………………17 各類消毒隔離預防實施………………………………………………………………19 一次性使用無菌醫(yī)療用品的管理制度………………………………………………21 醫(yī)院消毒滅菌藥械管理制度…………………………………………………………23 消毒滅菌效果監(jiān)測制度………………………………………………………………24 外來手術(shù)器械管理規(guī)定………………………………………………………………25 洗手規(guī)范………………………………………………………………………………27 巍山院區(qū)規(guī)范洗手制度………………………………………………………………30

二、重點部門的醫(yī)院感染管理

病房的醫(yī)院感染管理…………………………………………………………………31 換藥室、治療室的醫(yī)院感染管理……………………………………………………33 急診室的醫(yī)院感染管理………………………………………………………………34 輸液室的醫(yī)院感染管理………………………………………………………………35 監(jiān)護室的醫(yī)院感染管理………………………………………………………………36 門診的醫(yī)院感染管理…………………………………………………………………37 供應(yīng)室的醫(yī)院感染管理………………………………………………………………38 手術(shù)室的醫(yī)院感染管理………………………………………………………………40 麻醉科的醫(yī)院感染管理………………………………………………………………44

產(chǎn)房的醫(yī)院感染管理…………………………………………………………………45 隔離產(chǎn)房的醫(yī)院感染管理……………………………………………………………46 母嬰同室的醫(yī)院感染管理……………………………………………………………48 口腔科的醫(yī)院感染管理………………………………………………………………49 康復理療室的醫(yī)院感染管理…………………………………………………………50 高壓氧艙的醫(yī)院感染管理……………………………………………………………51 針灸科的醫(yī)院感染管理………………………………………………………………52 兒科門診的醫(yī)院感染管理……………………………………………………………53 五官科門診的醫(yī)院感染管理…………………………………………………………54 皮膚科門診的醫(yī)院感染管理…………………………………………………………55 婦科、人流室門診的醫(yī)院感染管理…………………………………………………56 腸道門診醫(yī)院感染管理………………………………………………………………57 腸道門診工作制度……………………………………………………………………58 病理檢驗科的醫(yī)院感染管理…………………………………………………………59 內(nèi)窺鏡室的醫(yī)院感染管理……………………………………………………………60 食堂的醫(yī)院感染管理…………………………………………………………………61 洗衣房的醫(yī)院感染管理………………………………………………………………62 新風機房的醫(yī)院感染管理……………………………………………………………63

三、醫(yī)院污物的管理

醫(yī)療廢物管理責任制度………………………………………………………………64 醫(yī)療廢物管理工作人員的職責………………………………………………………66 醫(yī)療廢物管理知識培訓制度…………………………………………………………69 醫(yī)院污水處理感染管理制度…………………………………………………………70

四、發(fā)熱門診管理

傳染病的預檢分診制度………………………………………………………………72 發(fā)熱門診消毒隔離制度………………………………………………………………73 發(fā)熱門診護士工作職責及流程………………………………………………………74 疑似甲型 H1N1流感病人接送專車的消毒隔離制度………………………………75

第五篇：醫(yī)院感染管理制度目錄2016.4

醫(yī)院感染管理職責目錄（2016.4）

1.醫(yī)院感染監(jiān)控小組職責 2.感控醫(yī)生職責 3.感控護士職責

4.醫(yī)務(wù)人員醫(yī)院感染管理職責

醫(yī)院感染管理制度流程目錄（2016.4）

1.NICU、EICU、RICU醫(yī)院感染管理制度 2.醫(yī)院感染培訓制度

3.醫(yī)院感染病例監(jiān)測、報告制度

4.醫(yī)院消毒滅菌效果及環(huán)境衛(wèi)生學監(jiān)測與質(zhì)量改進制度 5.醫(yī)院消毒隔離制度

6.消毒藥械的管理制度與一次性使用無菌醫(yī)療用品管理制度

7.醫(yī)院隔離技術(shù)制度 8.醫(yī)務(wù)人員職業(yè)安全防護制度

9.醫(yī)務(wù)人員手衛(wèi)生制度

10.醫(yī)院空氣潔凈設(shè)施維護制度

11.無菌操作技術(shù)規(guī)范

12.多重耐藥菌醫(yī)院感染防控、預警及培訓制度

13.重點部位感染預防與控制制度

14.呼吸道傳染病及外科特異性感染手術(shù)醫(yī)院感染管理制度 15.醫(yī)療廢物管理制度

16.常用物品、環(huán)境及物體表面的清潔、消毒或滅菌方法 17.常用消毒劑濃度和使用方法 18.微生物標本采集流程

醫(yī)院感染管理預案目錄（2016.4）

1.醫(yī)療廢物流失、泄漏、擴散和意外事故應(yīng)急處置預案 2.醫(yī)院感染暴發(fā)及醫(yī)院感染突發(fā)事件報告及應(yīng)急處置預案 3.醫(yī)務(wù)人員血源性傳播疾病職業(yè)暴露應(yīng)急處置預案