What are the contents of the research items about the health care system

Hospital core system a first consultation is responsible for the system (a), the first time to receive the physician or department for the first physician and the first department, the first physician is responsible for the patient's examination, diagnosis, treatment, resuscitation, transfer and transfer to the department. (b) The first physician must ask for detailed medical history, conduct physical examination, necessary auxiliary examination and treatment, and carefully record the medical record. Patients with a clear diagnosis should be actively treated or put forward treatment opinions; patients whose diagnosis is not yet clear should be treated symptomatically at the same time, and should promptly ask for a consultation with a superior physician or a physician of the relevant department. (C), the first physician off duty, the patient should be handed over to the physician on duty, the patient's condition and matters needing attention, and carefully make a good record of shift handover. (D), the emergency, critical, serious patients, the first physician should take active measures to implement rescue. If it is a non-affiliated professional disease or multidisciplinary disease, the relevant departments should be organized to consult or report to the competent department of the hospital to organize a consultation. Critically ill patients in need of examination, hospitalization or transfer, the first physician should accompany or arrange for medical personnel to accompany the escort; such as the receiving hospital conditions, the need for transfer, the first physician should be transferred to the hospital contact arrangements before transfer. (E), the first physician in dealing with patients, especially emergency, critical and serious patients, have the organization of the relevant personnel consultation, decide to admit patients to the department and other medical acts of the right to decide, any department, any individual shall not be for any reason to shirk or refuse. Second, the three-stage physician check-up system (a), medical institutions should establish a three-stage physician treatment system, the implementation of the chief physician (or deputy chief physician), attending physicians and residents of the three-stage physician check-up system. (B), the chief physician (deputy chief physician) or attending physician room visits, should be attended by residents and related personnel. The chief physician (deputy chief physician) room check twice a week; attending physician room check once a day. Residents are responsible for the patients under their charge 24 hours a day, morning and evening room checks. (c) For acute and critical patients, the resident shall observe the change of condition at any time and deal with it in a timely manner, and if necessary, he/she may ask the attending physician and the chief physician (deputy chief physician) to check the patients temporarily. (d) For newly admitted patients, the resident shall check the patient within 8 hours of admission, the attending physician shall check the patient within 48 hours and put forward the treatment opinion, and the chief physician (deputy chief physician) shall check the patient within 72 hours and put forward the guideline for the diagnosis, treatment, and handling of the patient. (E), before checking the room, full preparations should be made, such as medical records, X-rays, all relevant examination reports and required examination equipment. During the room visit, the resident should report the summary of the medical record, the current condition, the results of examinations and laboratory tests, and the problems that need to be solved. The superior physician can do the necessary examination according to the situation, put forward the diagnosis and treatment opinions, and make clear instructions. (F), the contents of the examination: 1, resident examination, required to focus on rounds of acute and critical, difficult, to be diagnosed, new admissions, post-surgery patients, while rounds of general patients; check the laboratory report card, analysis of the results of the examination, and put forward further examination or treatment advice; verification of the day of the implementation of the doctor's orders; to give the necessary temporary instructions, the next morning, the special examination of the doctor's orders; questioning, checking the patient's diet; take the initiative to seek the patient's views on medical, dietary and other aspects. Patients' opinions on medical treatment and diet, etc. 2. The attending physician's checkups require systematic checkups of the patients under his/her care. Especially for the newly admitted, acute and critical, diagnosis is not clear and the treatment effect of patients to focus on the examination and discussion; listen to residents and nurses; listen to the patient's statement; check the medical records; understand the patient's condition changes and seek advice on medical treatment, nursing care, diet and so on; verification of the implementation of the medical advice and the effect of the treatment. 3, the chief physician (deputy chief physician) room visit, to solve the problem and difficult cases and problems; review of new admissions, critical patients, diet and other aspects of the patients. Newly admitted, critically ill patients diagnosis, diagnosis and treatment plan; decide major surgery and special tests and treatments; randomly check the medical advice, medical records, medical, nursing quality; listen to physicians, nurses on the diagnosis and treatment of care; necessary teaching work; decide to discharged patients, such as transfer. Third, difficult cases discussion system (a), in all cases of difficult cases, admission within three days without a clear diagnosis, poor treatment results, serious conditions should be organized to discuss the consultation. (B), consultation by the chief or chief physician (deputy chief physician) presided over the convening of the relevant personnel to participate in serious discussions, as early as possible to clarify the diagnosis, put forward treatment programs. (C), the physician-in-charge must be prepared in advance, the material will be organized and perfect, write a summary of the medical record, ready to speak. (D), the physician in charge should make a written record, and the results of the discussion will be recorded in the difficult cases discussion notebook. Records include: the date of discussion, the host and the participants of the professional and technical positions, condition report and the purpose of the discussion, the participants of the speech, discussion of the views, etc., certainty or concluding observations recorded in the case record. Consultation system (a), medical consultation includes: emergency consultation, departmental consultation, inter-departmental consultation, hospital-wide consultation, and out-of-hospital consultation. (B), emergency consultation can be notified by phone or in writing to the relevant departments, the relevant departments should be in place within 15 minutes after receiving the consultation notice. The consulting physician should indicate the time (specific to the minute) when signing the consultation opinion. (c) Intra-departmental consultation should be held once a week in principle, with the participation of the whole department. The consultation is mainly for difficult cases, critical cases, surgical cases, cases with serious complications or cases with research and teaching value. The consultation is organized and convened by the department head or chief resident. During the consultation, the physician in charge will report the medical history, diagnosis and treatment as well as the purpose of the consultation. Through extensive discussion, the diagnosis and treatment opinions will be clarified and the business level of the departmental staff will be improved. (D), inter-departmental consultation: the patient's condition is beyond the scope of the specialty, need other specialties to assist in diagnosis and treatment, need to carry out inter-departmental consultation. Interdisciplinary consultation is proposed by the physician in charge, fill in the consultation form, write down the consultation requirements and purposes, and send it to the invited department. The invited department should send an attending physician or above for consultation within 24 hours. The supervising physician should be present during the consultation, introduce the condition and listen to the consultation opinions. The consultation record should be filled in after the consultation. (E), hospital-wide consultation: difficult and complex conditions and the need for multidisciplinary *** with collaborators, public *** health emergencies, major medical disputes or some special patients should be hospital-wide consultation. Hospital-wide consultation is proposed by the director of the department, reported to the Medical Affairs (Services) Section agreed or by the Medical Affairs (Services) Section to designate and decide the date of the consultation. The consultation department shall report the summary of the condition of the consultation case, the purpose of the consultation, and the persons to be invited to the consultation to the Medical Affairs Section in advance, which will notify the relevant departments to attend. Consultation by the medical government (services) or apply for consultation department director presided over the convening of the vice president of business and medical government (services) should in principle participate in and summarize, should strive to unify and clarify the diagnosis and treatment of the views. The physician in charge of the consultation records, and will be summarized in the medical record. Medical institutions should be selective on the hospital's death cases, disputes, such as academic, retrospective, learning from the summary analysis and discussion, in principle, held ≥ 2 times a year, chaired by the Medical Administration (Services) Section, the participants for the hospital's quality control and management of medical care committee members and relevant departments. (F), out-of-hospital consultation. Invite physicians from other hospitals for consultation or send physicians to other hospitals for consultation, in accordance with the Ministry of Health, "Interim Provisions on the Management of Physicians' Outpatient Consultations" (Decree No. 42 of the Ministry of Health) relevant provisions of the implementation. V. Critical patient rescue system (a), the development of the hospital emergency response plan for public **** health emergencies and the rescue of common critical patients of various specialties technical specifications, and establish a regular training and assessment system. (B), the critical patients should be actively rescued, normal working hours by the patient in charge of the third-level physician medical team is responsible for non-normal working hours or special circumstances (such as the physician in charge of surgery, outpatient duty or leave, etc.) by the physician on duty is responsible for the major rescue event should be the chief of the department, the medical administration (business) section or the hospital leadership to participate in the organization. (C), the physician in charge should be based on the patient's condition and the patient's family (or entourage) to communicate in due course, oral (rescue) or written notice of the critical illness and sign. (D), in the rescue of critical illness, must strictly implement the rescue procedures and plans to ensure that the rescue work is timely, rapid, accurate and error-free. Medical personnel should work closely with each other, verbal medical advice should be accurate and clear, and nurses must repeat the verbal medical advice when executing it. In the process of resuscitation should be made to record while resuscitation, record time should be specific to the minute. Failure to record in time, the relevant medical personnel should be in the end of the rescue within 6 hours according to the record, and to explain. (E), the rescue room should be a perfect system, fully equipped, good performance. First aid supplies must implement the "five", namely, a fixed number, a fixed location, a fixed personnel management, regular disinfection and sterilization, regular inspection and maintenance. Sixth, surgical classification management system (a), surgical classification according to the complexity of the surgical process and the requirements of surgical technology, the operation is divided into four categories: 1, four types of surgery: surgical process is simple, surgical technology is difficult to low common minor surgery. 2, three types of surgery: the surgical process is not complex, surgical technology is not very difficult to all kinds of intermediate surgery; 3, two types of surgery: the surgical process is more complex, surgical technology has a certain level of difficulty A variety of major surgery; 4, a class of surgery: the surgical process is complex, surgical technical difficulties of a variety of surgeries. (B), the surgeon grading all surgeons should be licensed in accordance with the law, and the place of practice in the hospital. According to the health technology qualification and its corresponding position, the grading of the surgeon. 1, resident 2, attending physician 3, deputy chief physician: (1) low seniority deputy chief physician: as deputy chief physician for less than three years. (2) senior associate physician: more than 3 years as an associate physician. 4, chief physician (3), the scope of surgery at all levels of physicians 1, residents: under the guidance of the supervising physician, to gradually carry out and proficiency in the four types of surgery. 2, attending physician: proficiency in the three, four types of surgery, and under the guidance of the supervising physician, to gradually carry out the second type of surgery. 3, low seniority associate physician: proficiency in the second, third, fourth type of surgery, under the guidance of the participation of the supervising physician, gradually carry out the second type of surgery. 3, low seniority associate physician: proficiency in the second, third, fourth type of surgery, under the guidance of the participation of the supervising physician, the second, third, fourth type of surgery. Senior associate chief physician: master two, three, four types of surgery, and under the guidance of the supervising physician, gradually carry out one type of surgery. 4, senior associate chief physician: skillful completion of two, three, four types of surgery, under the guidance of the chief physician, carry out one type of surgery. Also according to the actual situation alone to complete part of a class of surgery, to carry out new surgeries. 5, chief physician: skilled to complete all types of surgery, especially to complete the development of new surgeries or the introduction of new surgeries, or major exploratory scientific research projects. (D), surgery approval authority 1, normal surgery: in principle, the department pre-operative discussion, by the section chief or section chief authorized by the deputy director of the approval. 2, special surgery: any one of the following can be regarded as a special operation, subject to serious pre-operative discussion by the department, signed by the section chief, reported to the medical administration (business) section for the record, if necessary, by the hospital consultation or reported to the head of the hospital for approval. However, in an emergency or emergency situation, in order to save the patient's life, the physician in charge shall make the decision on the spot, scramble for time and seconds, actively resuscitate the patient, and report to the superior physician and the general duty in a timely manner, and shall not delay the time of resuscitation. (1) surgery may lead to disfigurement or disability; (2) the same patient needs to be operated again due to complications; (3) high-risk surgery; (4) the unit's newly launched surgery; (5) patients without a master, surgery that may cause or involve judicial disputes; (6) the operated person is a foreign guest, an overseas Chinese, a compatriot in Hong Kong, Macao, Taiwan, and a special person, etc.; (7) physicians from other hospitals come to the hospital to participate in surgery, and the practice of medicine in other places must be conducted in accordance with the "Chinese People's Republic of China*** and the State of China". People's Republic of China **** and the State Medical Practitioners Law" relevant provisions of the relevant procedures. VII. Pre-operative discussion system (a), for major, difficult, disabling, vital organ removal and new surgery, pre-operative discussion must be carried out. (2) The preoperative discussion shall be presided over by the chief of the department, and all the physicians in the department shall participate in it, and the surgeon, the head nurse and the nurse in charge shall participate in it. (C), the discussion includes: diagnosis and its basis; indications for surgery; surgical methods, points and precautions; possible dangers, accidents, complications and their preventive measures; whether to fulfill the surgical consent signing formalities (need to be responsible for the conversation of the physician in charge of the hospital signatures); anesthesia selection, the operating room with the requirements; postoperative precautions, the patient's ideological situation and requirements, etc.; checking the completion of the preoperative Check the completion of the preparatory work. The discussion is recorded in the medical record. (D) For difficult, complicated and major surgeries with complex conditions that require the cooperation of related departments, the Department of Anesthesiology and related departments should be invited for consultation 2-3 days in advance, and adequate preoperative preparations should be made. VIII. Checking System I. Clinical Departments 1. When issuing medical instructions, prescriptions or treatments, patients' names, genders, bed numbers, and hospitalization numbers (outpatient numbers) should be checked. 2. When executing medical instructions, "three checks and seven pairs" should be carried out: before, during, and after the operation; bed number, name, name, medicine name, dosage, time, usage, and concentration. 3. When counting medicines and before using medicines, quality, labels, expiration dates, and batch numbers should be checked, and if they do not meet the requirements, they shall not be used. 4, before giving drugs, pay attention to ask whether there is a history of allergy; the use of drugs, poison, anesthesia, limit the use of drugs should be repeatedly checked; intravenous drug should pay attention to whether there is no deterioration of the bottle mouth is loose, cracks; to a variety of drugs, pay attention to the contraindications of compounding. 5, blood transfusion to be strictly three checks and eight system (see nursing core system - six, check the system) to ensure that the transfusion of blood safety. Second, the operating room 1, pick up the patient, to check the department, bed number, name, age, hospitalization number, gender, diagnosis, name of the operation and surgical site (left, right). 2, before the operation, you must check the name, diagnosis, surgical site, blood dispensing report, preoperative medication, drug allergy test results, anesthesia and anesthesia medication. 3, where the body cavity or deep tissue surgery, to be preoperative with the suturing of the pre- and post-counting All dressings and instruments count. 4. The specimen taken off by surgery should be checked by the roving nurse and the surgeon before filling out the pathology test and sending it for examination. Pharmacy 1, formula, check the content of the prescription, drug dosage, contraindications. 2, when issuing drugs, check the name of the drug, specifications, dosage, usage and the content of the prescription is consistent; check the label (bag) and the content of the prescription is consistent; check whether the drugs have deteriorated, whether the expiration date is exceeded; check the name, age, and account for the use of drugs and precautions. Blood bank 1, blood typing and cross-matching test, two people work to "double checking and double signing", one person work to redo a. 2, when issuing blood, with the person who took blood *** with the check section, ward, bed number, name, blood type, cross-matching test results, blood vials (bags) number, date of blood collection, blood type and dosage, the quality of blood. V. Laboratory 1. When taking specimens, check the department, bed number, name, and purpose of the test.2. When collecting specimens, check the department, name, sex, union number, number and quality of specimens.3. When testing, check the reagents, items, and whether the lab sheet matches the specimen.4. After the test, check the purpose, and the result.5. When issuing the report, check the department, and the ward. When collecting specimens, check the unit, name, sex, union number, specimen and fixative. 2. When preparing specimens, check the number, specimen type, number and quality of sections. 3. When diagnosing, check the number, specimen type, clinical diagnosis and pathological diagnosis. 4. When issuing reports, check the unit. 5. When issuing reports, check the department and ward. 6. When examining, check the department, ward, name, age, film number, site, and purpose. 2. When treating, check the department, ward, name, site, condition, time, angle, and dosage. 3. When issuing reports, check the department and ward. VIII. Physiotherapy Department and acupuncture room 1. When various treatments are given, check the department, ward, name, site, type, dose, time and skin. 2. When low-frequency treatments are given, and check the polarity, flow rate and number of times. 3. When high-frequency treatments are given, and check the body surface and the body for any metal abnormality. 4. Before acupuncture treatments are given, check the quantity and quality of needles, and when removing the needles, check the number of needles and for broken needles. 5. When acupuncture treatment is given, check the number of needles, and check the number of needles, and check for broken needles. 6. IX. (Electrocardiogram, electroencephalogram, ultrasound, basic metabolism, etc.) 1. When examining, check the department, bed number, name, gender, and the purpose of the test. 2. When diagnosing, check the name, number, clinical diagnosis, and examination results. 3. When issuing reports, check the department and ward. 4. Other departments should also be based on the above requirements to develop their own work checking system. Doctors handover system I. Ward duty needs to have a first, second and third line duty personnel. The first-line duty officer is the resident who has obtained the qualification of physician, the second-line duty officer is the attending physician or deputy chief physician, and the third-line duty officer is the chief physician or deputy chief physician. The trainee physicians on duty shall carry out medical work under the guidance of the physicians of the hospital. The 24-hour duty system is implemented in all wards. The physician on duty shall take over the shift on time, listen to the introduction of the duty situation by the physician on duty, and accept the medical work assigned by the physician on duty. For patients with acute, critical and serious diseases, they must do a good job of bedside handover. The physician on duty shall explain clearly to the physician on duty about the condition of the emergency, critical and serious patients and all the matters that should be dealt with, and both parties shall sign the handover of responsibility and indicate the date and time. Fourth, the physician on duty is responsible for all the temporary medical work in the ward and the handling of patients' temporary situation, and make a good record of the observation of the condition of emergency, critical and serious patients and the medical measures. The first-line duty personnel should promptly consult the second-line duty physician when they encounter difficulties or questions in the diagnosis and treatment activities, and the second-line duty physician should promptly guide the treatment. If the second-line physicians cannot solve the difficulties, they should ask the third-line physicians to guide them. In case of special problems that need to be handled by the supervising physician, the supervising physician must actively cooperate. In case of problems that need to be solved by the administrative leaders, they should report to the general duty or medical administration (service) section of the hospital in a timely manner. Fifth, the first and second line of physicians on duty at night must stay in the duty room, may not leave their posts without authorization, and should go to the clinic immediately when they encounter a situation that needs to be dealt with. If there is a need to leave the ward in case of emergency rescue or consultation, they must explain to the nurse on duty where they are going and how to get in touch with them. The third-line physician on duty can live at home, but must leave contact information, and should go immediately when receiving the request call. Sixth, the physician on duty can not "double duty", such as duty and outpatient clinic, surgery, etc., except for emergency surgery, but in the hospital district has an emergency treatment matters, should be prepared for the class to deal with in a timely manner. Seven, daily morning meeting, the physician on duty should be the key patients to the ward medical staff report, and to the physician in charge of the critical patient informed of the situation and the problems that remain to be dealt with. X. New technology access system I. New technology should be in accordance with relevant state regulations for the relevant procedures before implementation. Second, the implementer of a written application, fill out the "to carry out new business, new technology application form", provide the theoretical basis and specific implementation details, results and risk prediction and countermeasures, the director of the department reviewed and signed the consent to report to the medical administration (business) section. Third, the medical administration (business) section of the organization's academic committee experts to demonstrate, put forward the views, reported to the dean in charge of the approval of the implementation can be carried out. Fourth, the implementation of new services, new technologies must sign the corresponding agreement with the patient, and should fulfill the corresponding obligation to inform. Fifth, the new business, new technology implementation process by the medical administration (business) section is responsible for organizing experts to carry out stage monitoring, timely organization of consultation and academic discussions, to solve some of the implementation of some of the larger technical problems found in the process. Daily management by the corresponding control physicians and monitoring physicians to complete. Sixth, the 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 Affairs (Services) Section, the Medical Affairs (Services) Section to convene a meeting of the Academic Committee, to discuss and decide whether the new business, new technology in the clinic to fully carry out. Seven, the director of the department should be directly involved in the development of new business, new technology, and make a good department of new business, new technology to carry out the organization and implementation of the work, pay close attention to the implementation of the new project may appear in a variety of unforeseen circumstances, and actively and properly dealt with, and make a good record. XI, the medical record management system, the establishment of a sound hospital medical record quality management organization, improve the hospital's "four-level" medical record quality control system and work on a regular basis. Four-level quality control system of medical records: 1, a quality control group consists of the department director, case committee (attending physician title or above), the head nurse. Responsible for the quality inspection of medical records in the department or the ward. 2, the second level of quality control department consists of relevant personnel from the hospital administrative departments, responsible for outpatient medical records, running medical records, archived medical records, etc., monthly spot check assessment, and the quality of medical record writing into the medical staff of the comprehensive objectives of the assessment content, quantitative management. 3, the third level of quality control department consists of full-time quality control physicians from the hospital's medical records office, is responsible for the inspection of the filed records. 4, the fourth level of quality control team consists of department chiefs, case committee members (attending physician or above), departmental nurse manager. The four-level quality control organization consists of the president or vice president of business and experienced and responsible senior medical, nursing and technical personnel and the heads of major business management departments. Evaluation of the quality of medical records of all departments in the hospital is carried out at least once a quarter, with special emphasis on the review of the quality of the connotations of the force. Second, the implementation of the Ministry of Health, "the basic norms of medical record writing (for trial implementation)" (WeiMaFa [2002] 190), "medical institutions, medical records management regulations" (WeiMaFa [2002] 193) and the province of the "standardization and management of medical documents" of the requirements, focusing on the newly assigned, newly transferred to the physician and refresher physicians on the knowledge and skills training in the writing of medical records. C. Strengthen the management and quality control of running medical records and archived medical cases. 1, the first medical record, pre-operative conversation, pre-operative summary, surgical records, post-operative (postpartum) records, important rescue records, special invasive examination, pre-anesthesia conversation, pre-transfusion conversation, discharge diagnostic certificates, and other important records should be written by the physician in charge of this hospital, or review the signatures. Surgical records shall be written by the operator or the first assistant, and if the first assistant is a trainee physician, it shall be examined and signed by the physician of this hospital.2. After the admission of the patients with general diagnosis, the physician in charge shall check the patients, ask for medical history, write the first record of the course of the disease and deal with the medical orders within 8 hours. Emergency patients should be viewed and processed within 5 minutes, inpatient medical records and the first record should be completed within 2 hours in principle, due to the rescue of the patient failed to complete in time, the relevant medical staff should be within 6 hours after the end of the rescue to make up the record according to the facts, and to be noted. 3, the new patients admitted to the hospital, within 48 hours should be attending physician or above the title of the physician check-up records, general patients should be 2 times a week the chief physician (or deputy chief physician) check-ups, should be signed by the hospital physician review. The chief physician (or deputy chief physician) should have 2 times a week to check the room record, and be noted. 4, the critical patient's course of record at least 1 time a day, when the condition changes, record at any time, the record time should be specific to the minute. For seriously ill patients, at least 2 days to record a record of the course of the disease. For stabilized patients, the patient history should be recorded at least once every 3 days. For patients with stable chronic disease, at least 5 days to record a record of the course of the disease. 5, a variety of laboratory tests, reports, blood orders should be posted in a timely manner, and is strictly prohibited from being lost. Medical documents from outside hospitals, if used as the basis for diagnosis and treatment, should be entered into the medical record, while the treatment documents should be attached to the medical record of the hospital. If the imaging data or pathological data of the foreign hospital are needed to be used as the basis for diagnosis or treatment, the physicians of the relevant departments of the hospital should be asked to consult with each other, and written consultation opinions should be written out and stored in the inpatient medical record of the hospital. Discharged medical records should generally be filed within 3 days, special medical records (such as death, typical teaching medical records) filed no more than 1 week, and timely report to the case room for the record. Fifth, strengthen the safety of medical records to prevent damage, loss, theft, etc., copying medical records, should be escorted by medical staff or then the case room copying. Sixth, according to the "provincial quality management evaluation of medical records, rewards and punishments interim measures" requirements and regulations, the establishment of the department and individual quality evaluation of medical records writing notification system and rewards and penalties mechanism. Thirteen, medical record writing standards 1, unified with blue and black ink, the contents of the requirements of objective, true, accurate, timely and complete. 2, the use of standardized Chinese characters; numbers with Arabic numerals; drug names can be written in Chinese, Latin, English; unit of measurement using the national legal unit of measurement. 3, medical records can not be written deletion, cutting and pasting, digging and mending, individual typographical errors can be used with the same pen and ink double line on the misprints; the superior physician Modification of all red ink pen, sign the date of modification and full name. More than 3 changes per page need to be rewritten. 4, general patients within 24 hours to complete the admission medical records, critical patients within 6 hours to complete; the first record of the course of the shift to complete, emergency surgery patients completed before surgery. 5, the course of the record is generally 1 / 2 ~ 3 days, admission and postoperative 3 days at least 1 time a day, the critically ill patients 1 time / day, there are changes in the condition of the record at any time, the chronic patients can be 1 / week, stage Small section 1 time / month. 6, 3 days before admission to the third level of physician check-up records: new admissions of general patients within 48 hours of the attending physician or more check-up and record, within 72 hours of the deputy director of the physician or more check-up and record. 7, pre-operative attending physician or more check-up records or records of the discussion. 8, difficult and critical patients have a record of the discussion, and major surgery has a record of the pre-operative discussion. 9, specialty patients to have a record of the transfer to and from the record and completed in a timely manner, Transfer records, and timely completion. 10, the implementation of the signature system: all need to perform surgery, blood transfusion and other special tests, special treatment, need to sign informed consent. 11, where diagnostic and treatment operations, pre-operative and post-operative operator's records. 12, auxiliary examination report card within 24 hours to be posted back to the medical record, the lintel columns of the posting sheet should be filled out. Fourteen, clinical blood audit system 1, clinical blood audit system is the implementation of medical quality and medical safety of the core system, strict implementation of the clinical blood audit system to ensure that patients safe and standardized use of blood. 2, the blood bank must be in accordance with the local health administrative department designated by the blood collection and supply institutions to purchase blood, and shall not be used without the name of the blood station (bank) and the license marking of the blood. 3, the blood used in each department, must be based on the principles of blood transfusion, the blood supply. Appointment of blood: When a patient needs blood transfusion, the physician in charge of the clinic shall fill in the blood transfusion list item by item, and the nurse on duty shall take cross blood from the patient according to the doctor's instruction, and the test tube shall be labeled with the section, name, bed number, hospital number, and sent to the blood bank one day before the blood transfusion (with the exception of the emergency cases). 5. Blood bank The staff should contact with the blood station in time according to the booked blood volume of each clinical department to prepare all types of blood and ensure the clinical blood volume without error.6. When the staff of the blood bank accepts the specimens, they should check carefully one by one and accept the specimens for preparation of blood after there is no error.7. All the blood prepared by the blood bank for each type of blood should have obvious signs, be stored in the refrigerator at 4 degrees Celsius in separate compartments, and the changes of the temperature in the refrigerator should be observed at any time.8. Blood bank The staff should strictly follow the operation regulations of blood cross-testing to carry out cross-testing, recheck the blood type if necessary, and observe the whole blood, which should be free of fat blood and hemolysis, and the blood bag should be sealed and absolutely free of error before it is issued. 9. When taking blood, the nurse should carefully check the name of the recipient, bed number, hospitalization number, blood type and cross-results, the blood storage number, and the name of the donor, the time of blood collection, the type of blood, etc., before sending out the blood. 10. The blood bank staff should carefully check the name of the recipient, bed number, hospitalization number, blood type and crossover result and the name of the blood donor, blood collection time, blood type and other items on the transfusion order, and should not take out the blood from the blood bank until there is no error.10 If there is a reaction to the transfusion, the physician in charge of the clinic should explain the situation to the blood bank and find out the reason with the blood bank.11 The staff of the blood bank must ensure that the amount of incoming and outgoing blood, the inventory of the amount of blood in the account is clear, and should keep it carefully, and shall not be destroyed without authorization of the head of the hospital.