1, responsibility system for first-time doctors
2, three-level physician rounds system
3, difficult case discussion system
4. Consulting system
5, critically ill patients emergency rescue system
6, surgical grading management system
7, preoperative discussion system
8, death case discussion system
9, check the system
10, medical record writing and management system
1 1, duty and succession system
12, graded nursing system
13, new technology and new project access system
14, critical value reporting system
15, antibacterial drug classification management system
16, operating safety verification system
17, Clinical Blood Audit System
18, Information Security Management System
Extended data:
First, the first diagnosis system
1, the first-visit doctor or department and the first-visit department. The first-visit doctor is responsible for the examination, diagnosis, treatment, rescue, transfer and transfer of patients.
2. The first-time physician must inquire about the medical history in detail, carry out physical examination, necessary auxiliary examination and treatment, and carefully record the medical records. Patients diagnosed should be actively treated or put forward treatment suggestions.
Patients with unclear diagnosis should be treated symptomatically, and should be consulted by doctors at higher levels or doctors in relevant departments in time.
3, the first physician before coming off work, the patient should be handed over to the successor, the patient's condition and matters needing attention, and carefully record the succession.
4, for acute, dangerous and severe patients, the first-time physician should actively take measures to be responsible for the implementation of rescue. In the case of non-professional diseases or cross-professional diseases, relevant departments should be organized for consultation or reported to the competent department of the hospital for consultation.
If critically ill patients need to be examined, hospitalized or transferred, the first-time doctor should accompany them or arrange medical staff to accompany them; If it is necessary to be transferred due to limited hospital conditions, the first-time doctor should contact the transferred hospital and make arrangements for further transfer.
5. When dealing with patients, especially acute, dangerous and severe patients, the first-time physician has the right to organize relevant personnel to consult and decide on the medical behavior of the patient's admission department, and no department or individual may shirk or refuse for any reason.
Two-level and three-level physician rounds system
Ward rounds are conducted at three levels: chief physician, attending physician and resident physician.
In severe cases, a superior doctor should make rounds on the day of admission; After the seriously ill patients are admitted to the hospital at night, the next day, there should be a superior doctor's rounds record, a secondary doctor should write a tertiary doctor's rounds record, and a primary doctor should write a secondary doctor's rounds record.
Before rounds, doctors at all levels should consult relevant documents in advance to improve the quality of rounds.
Third, the discussion system of difficult cases
Difficult cases: two weeks after admission, the diagnosis is not clear; Important findings of laboratory or other auxiliary examinations during hospitalization will lead to changes in the diagnosis and treatment plan; The treatment effect is not good; Hospital infection; Difficult and big surgery.
Critical situation: A person whose situation is critical or suddenly changed.
Fourth, the consultation system
Consultation system is to strengthen medical cooperation between departments, improve medical quality and ensure medical safety; In clinical work, we must apply for consultation in time when we encounter difficult or critical cases or cases with unclear diagnosis and suspected to be related to other disciplines.
The consultant shall:
(1) Read the medical records in detail, understand the patient's condition, check the patient personally, and supplement and improve the necessary examinations.
(2) The consultant shall record the consultation opinions in detail, put forward specific diagnosis and treatment opinions, and issue undergraduate medical advice. The consultation record includes the consultation opinions and suggestions, the department of the consultant, the consultation time, the signature of the consultant, etc.
(3) Patients' right to know must be fully respected. Drugs or medical materials and special usage that need to be paid by the patient at his own expense or partly at his own expense must be indicated in the consultation opinion record, and the patient and his authorized agent shall be informed to perform the signing procedures.
(4) In case of difficult cases, unclear diagnosis or difficult treatment, please ask the undergraduate superior doctor to assist in consultation in time.
(5) In the process of consultation, the diagnosis and treatment norms should be strictly implemented.
(6) It is forbidden for the consultant not to personally check the telephone consultation of patients.
Five, emergency rescue system for critically ill patients
1, the rescue work of critically ill patients, generally by the department director or chief physician is responsible for organizing and presiding over the rescue work. In the absence of the director or chief physician, the doctor with the highest professional title shall preside over the rescue work, but the director or chief physician must be informed in time.
Special patients or patients who need multidisciplinary cooperation should report to the medical department, nursing department and the competent dean in time, so as to organize relevant departments to jointly carry out rescue work.
2. Strictly implement the responsibility system for the first diagnosis of critically ill patients, and do not delay the rescue under any excuse. We must go all out, every minute counts, and all kinds of records are timely and comprehensive. For patients with other diseases, the attending department is responsible for inviting relevant departments to participate in the rescue.
3, to participate in the rescue of critically ill patients, medical staff must have a clear division of labor, close cooperation, carry out their duties, stick to their posts, unconditionally obey the command and doctor's advice of rescuers, but suggestions beneficial to rescue patients can be submitted to rescuers for rescue.
4, to participate in the rescue work of nursing staff should be under the leadership of the head nurse, presided over the rescuer's doctor's advice, and closely observe the condition changes, at any time to report to the rescuer presided over the implementation of the doctor's advice and condition changes.
When executing oral orders, it should be repeated, and the drugs should be checked with the doctor before execution to prevent errors and accidents.
5, strictly implement the system of succession and inspection system, each class should have someone who's in charge, the process of illness rescue and all kinds of drugs should be handed over in detail, and the empty amperage of the drugs used can be checked by two people before leaving.
All kinds of rescue drugs and instruments should be cleaned, detoxified and replenished in time and put back in place for reuse.
6, the need for multidisciplinary rescue of critically ill patients, in principle, organized by the medical department or medical vice President of the rescue work, and specify the rescue personnel, to participate in multidisciplinary rescue of patients in various disciplines physicians should give full play to undergraduate professional expertise, unity and cooperation to do a good job in patient rescue work.
7. The critically ill and seriously ill patients shall fill in the critically ill notice in duplicate, one in the medical record and one in the patient's family. It is necessary to explain the illness and prognosis to the patient's family members in time and seriously, and fill in the illness notice to obtain the cooperation of the family members.
8, due to disputes, fights, traffic or production accidents, suicide, homicide and other reasons, injured patients and suspicious patients, in addition to actively carry out rescue work, at the same time, the implementation of special situation reporting system.
On normal working days, it should report to the medical department and the security department, on non-working days, it should report to the general duty of the hospital and report to the public security department when necessary.
9, do not participate in the rescue work of medical personnel generally do not enter the rescue site, but must do a good job in rescue logistics.
10, in the rescue work, pharmacy, inspection, radiation or other auxiliary departments and logistics departments should meet the needs of clinical rescue work and give full support and guarantee.
Six, grading nursing system
Inpatients are divided into four types: I, II and II nursing and special nursing, which are determined by doctors according to their illness.
Seven, the new technology access system
1, relevant procedures shall be handled in accordance with relevant state regulations before the implementation of new technologies.
2. The implementer shall submit a written application, fill in the Application Form for Developing New Business and New Technology, and provide theoretical basis, detailed rules for implementation, results, risk prediction and countermeasures, which shall be reported to the medical department after being examined and signed by the department director.
3, the medical department organization academic committee experts to demonstrate, put forward opinions, submitted to the competent dean for approval before implementation.
4, the implementation of new business, new technology must sign the corresponding agreement with patients, and should fulfill the corresponding obligation to inform.
5. In the process of implementing new business and new technology, the Medical Department is responsible for organizing experts to conduct regular monitoring, timely organize consultations and academic discussions, and solve some major technical problems found in the implementation process. The daily management work is completed by the corresponding control doctors and monitoring doctors.
6, new business, new technology to complete a certain number of cases, the department is responsible for timely summary, and submit a summary report to the medical department, the medical department held an academic committee meeting to discuss whether the new business, new technology in clinical comprehensive development.
7, department director should directly participate in the development of new business and new technology, and do a good job in the organization and implementation of new business and new technology in the department, pay close attention to all kinds of emergencies that may occur in the implementation of new projects, actively and properly handle and make records.
Eight, clinical "critical value" reporting system
In order to strengthen the management of clinical "critical value" and ensure that "critical value" is reported to clinicians in time, so that clinicians can take timely and effective treatment measures to ensure the medical safety of patients and prevent patients from accidents, this system is formulated.
The "critical value" report covers all outpatients, emergency patients and ward patients, and focuses on critically ill patients in emergency departments, operating rooms and intensive care units.
"Critical value" reporting departments include: laboratory, radiology, CT room, ultrasound department, electrocardiogram room and other medical departments.
Nine, antibacterial drug classification management system
According to the characteristics of antibacterial drugs, clinical efficacy, bacterial resistance, adverse reactions, local economic conditions, drug prices and other factors, antibacterial drugs are divided into three categories: unrestricted use, restricted use and special use for hierarchical management.
X. Operating safety verification system
Surgical safety verification is the work of three parties (hereinafter referred to as the three parties), that is, qualified surgeons, anesthesiologists and nurses in the operating room, to check the patient's identity and surgical site before anesthesia, surgery and before the patient leaves the operating room.
Eleven, clinical blood safety management examination and approval system
Clinical blood use should strictly implement the relevant provisions of the Measures for the Administration of Blood Use in Medical Institutions and the Technical Specification for Clinical Blood Transfusion, advocate scientific and rational use of blood, put an end to waste and abuse of blood, and ensure the quality and safety of clinical blood use.
Before clinical use of blood, patients and their families should be informed of the purpose of blood transfusion, possible blood transfusion reactions and the possibility of infection through blood channels, and relevant items should be tested according to the technical specifications of blood transfusion, and the consent form for blood transfusion treatment should be signed by both doctors and patients and kept in the medical records.
Emergency blood transfusion of coma patients without family members' signatures should be reported to the medical department for approval, filing and recording.
The indication of clinical blood use conforms to the Technical Specification for Blood Transfusion. The indication of blood for clinical use is hemoglobin
Twelve. Information security management system
Hospital computer operators must operate the computer system according to the correct use of computers. Violent use of computers or deliberate destruction of computer hardware and software are strictly prohibited.
Without permission, the computer hardware system shall not be dismantled without authorization. If disassembly is required, the technicians of the Information Department shall be informed.
Hospital computers are limited to the internal work of the hospital, and Internet access is not allowed in principle. If you need to access the Internet because of your work, you need to submit a written application to the Medical Department, and submit it to the Information Department for access after being signed and approved.
References:
Baidu Library-18 Core System