Monthly summary of medical quality assessment
Summary is a certain stage of the situation within the analysis of research, to make a guiding experience and methodology as well as the conclusion of the written material, it can prompt us to think, it is time to write a summary. The first thing you need to know is how to write a summary of the situation. The following is my carefully organized monthly summary of medical quality assessment, welcome to share.
Medical quality assessment monthly summary 1
First, the basic situation
20xx the first quarter of the first quarter there are medical office, pharmacy, hospital sense of the Office of the first quarter of the law, the implementation of the core system of medical care, medical quality, medical safety, rational use of medication and other aspects of the work of the inspection. In accordance with the "Medical Quality Management Assessment Standards", "Medical Record Quality Evaluation Standards", "Hospital Prescription Review Rules and Scoring Standards", the inspection and scoring were carried out one by one. The results of the inspection are notified as follows:
(a) legal practice
Through the on-site inspection and check the scheduling form of the legal practice of inspection, the overall situation is better, no illegal practice was found.
(B) the implementation of the core medical system
Most departments can consciously and seriously implement the core system and medical rules and regulations, especially the first-responsibility system, the third-level physician check-up system, checking system, to ensure medical safety.
2. Some departments do not discuss death cases in a timely manner, and the content of death case discussion is simple.
3. Part of the difficult and critical case discussion in form, the purpose of the discussion is not clear, the content is simple.
4. Blood transfusion and blood products can basically be strictly controlled, but there are blood transfusion records are not standardized, and there are individual transfusion results are not evaluated in time after transfusion.
5. Consultation still exists in the general consultation completed by the resident, the consultation content is too simple phenomenon.
(C) Medical quality and safety
Improving medical quality and ensuring patient safety is the most important aspect of hospitals' diagnostic and treatment activities. During the inspection, it was found that most of the departments lack of medical quality management, medical quality control within the department there are incomplete records, empty content, quality control is not comprehensive phenomenon. For patients hospitalized for more than thirty days, there is a lack of effective evaluation.
In the medical record, some of the contents of the third-level physician's office are copied and pasted, which is not targeted to specific patients. The overall implementation of the critical value reporting system is good, but the tracking of critical value is not timely. Hand hygiene department medical staff implementation is good.
The adverse event reporting system could be hospital-wide.
(4) The quality of archived medical records
From the overall situation, the quality of archived medical records has improved, but there are problems as follows:
(1) The description of the history of the present illness is not rigorous.
(2) There are omissions in the patient's past history, allergy history, surgical history, and so on.
(3) Differential diagnosis of the content of the more obvious copy and paste content, lack of relevance.
(4) The content of the superior physician's examination for the patient's condition lacks individuality.
(5) A small number of consultation content in the medical record is not recorded in a timely manner.
(6) Appointments for follow-up for discharged patients are not well organized.
(E) rational use of drugs
(1) antibiotic use has been strictly controlled.
(2) The use of antibiotics in individual cases lacked the corresponding specimens.
(3) The use of antibiotics in individual cases has been overstepped.
Second, the reasons for the analysis
1. Although the department staff know the relevant system, but because of the busy work and the existence of laxity, the subjective idea of saving trouble.
2. The department of medical quality management is not in place, lack of attention to the details of the work.
3. Management of the clinical department. Quality supervision is not timely, which is an objective factor of the department's laxity in medical quality management.
Third, the improvement measures
1. Strengthen the training of the relevant systems of the department, strengthen the clinical department's own secondary training, so that the department staff are familiar with the relevant systems (especially the core system).
2. Supervise the departmental quality controller to strengthen the departmental internal medical quality management self-examination work.
3. The Medical Department and the Quality Control Office will strengthen the supervision of medical quality management in the clinical departments, and implement irregular and unscheduled spot checks to discover problems in medical activities in a timely manner.
4. In order to further strengthen medical quality management, medical quality management into the performance appraisal system.
Medical Quality Assessment Monthly Summary 2On February 27, a 1-day medical quality assessment inspection was conducted for all clinical and auxiliary departments of the hospital. The inspection was based on the "Daying County Hospital of Traditional Chinese Medicine medical quality assessment standards (for trial implementation)", and took a combination of viewing information and implementation records, on-site sampling, and on-site patient satisfaction surveys to assess the management of the department, the quality of the work, the level of business, and the service attitude. The results of the assessment feedback is as follows:
Basic situation analysis
Problem analysis
First, the quality of medical records management
The quality of the current medical records has improved over the last month, the medical record writing format, content, and connotation have made a big difference. However, there are still some problems that need to be improved:
1, the superior physician to check the record did not put forward guiding opinions, a few check the record without differential diagnosis.
2, difficult and critical case history discussion record is too simple, scribbling.
3, admission records have differential significance of signs, negative symptoms record is insufficient; Chinese medicine four diagnosis information is incomplete.
4, a small number of medical records of Chinese medicine and Western contradict each other, a small number of medical records of Chinese medicine diagnosis is wrong, or no diagnosis of the name of the disease, symptoms diagnosis.
The quality of clinical medication
1, antibiotic use without corresponding records.
2, stopping the drug, change the drug, plus or minus the use of the disease process is not recorded.
3, the ratio of traditional Chinese medicine to Western medicine is low.
4, the use of proprietary Chinese medicines in the course of the disease is not dialectical or dialectical incorrect.
5, Chinese medicine prescription record format and writing does not meet the requirements.
Third, the clinical path, the quality of advantageous diseases
1, some of the clinical path has been implemented in accordance with the implementation of the path table.
2, some doctors do not have a complete grasp of the clinical path of Chinese medicine, Chinese medicine advantageous disease diagnosis and treatment program.
3, the regular analysis, summarization and evaluation of the Chinese medicine advantageous disease diagnosis and treatment plan is not comprehensive.
Four, medical quality management
1, the departmental quality control team management is not in place.
2, the various record books of medical activities in various departments are incomplete records.
3, the doctor shift book records are incomplete or not signed.
4, inadequate communication of the patient's condition. V. Hospital infection management
1, Fan writing medical staff hand hygiene system is not in place
2, disinfection and isolation management measures are not in place
3, the use of medical waste, registration, destruction records are not perfect
V. Rectification measures
1, to further implement the rules and regulations, diagnostic guidelines, operating procedures, and other measures. regulations, diagnosis and treatment guidelines, operating procedures, standardize the medical behavior of medical staff.
2, to give full play to the role of the departmental quality control team, and actively mobilize the enthusiasm of all medical staff, so that all the work is carried out in an orderly manner.
3, the quality of the medical record to monitor the focus on the link quality monitoring, strengthen the resident self-check, departmental quality control group monitoring, case room monitoring, case quality management committee monitoring measures.
4, standardize the "clinical blood management", "medical waste management", "disinfection and isolation management" system, improve the "ward" and "infusion card" and "medical waste management" system.
The medical quality assessment of the month summary 3
February 27, the whole hospital clinical and auxiliary departments carried out a one-day medical quality assessment inspection. The inspection was based on the "Daying County Hospital of Traditional Chinese Medicine medical quality assessment standards (for trial implementation)", and took a combination of viewing information and implementation records, on-site sampling, on-site patient satisfaction surveys, etc., to assess the management of the department, the quality of the work, the level of business, and the attitude of the service and so on. The results of the assessment feedback is as follows: Basic situation analysis
Problems in the analysis of a medical record quality management
The quality of the current medical record has improved over the last month, the medical record writing format, content, and connotation of a greater improvement. However, there are still some problems that need to be improved: 1, the superior physician to check the record did not put forward guiding opinions, a few check records without differential diagnosis.
2, difficult and critical case history discussion record is too simple, scribbling.
3, admission records have differential significance of signs, negative symptoms record is insufficient; Chinese medicine four diagnosis information is incomplete.
4, a small number of medical records of Chinese medicine and Western contradict each other, a small number of medical records of Chinese medicine diagnosis is wrong, or no diagnosis of the name of the disease, symptoms diagnosis.
Second, the quality of clinical medication
1, the use of antibiotics without corresponding records.
2, stopping the drug, change the drug, increase or decrease the use of the disease process is not recorded.
4, the use of proprietary Chinese medicines in the course of the disease is not dialectical or dialectical incorrect. 5, Chinese medicine prescription record format and writing does not meet the requirements.
Third, the clinical path, the quality of advantageous diseases
1, some of the clinical path cases have been implemented in accordance with the path table is not implemented.
2, some doctors do not have a complete grasp of the clinical path of Chinese medicine, Chinese medicine advantageous disease diagnosis and treatment program.
3. Regular analysis, summarization, and evaluation of the Chinese medicine advantageous disease diagnosis and treatment plan are not comprehensive.
Fourth, medical quality management
1, the departmental quality control team management is not in place.
2, the medical activities of various departments of various record book records are incomplete. 3, the doctor shift book records are incomplete or not signed.
4, inadequate communication of the patient's condition. V. Hospital infection management
1, medical staff hand hygiene system is not in place 2, disinfection and isolation management measures are not in place
3, the use of medical waste, registration, destruction of records is not perfect Rectification measures
1, the further implementation of the rules and regulations, diagnostic and treatment guidelines, operating procedures, regulating
regulate the medical behavior of medical staff.
2, to give full play to the role of the departmental quality control group, and actively mobilize the enthusiasm of all medical staff, so that all the work is carried out in an orderly manner.
3, the quality of the medical record to monitor the focus on the link quality monitoring, strengthen the resident self-check, departmental quality control group monitoring, case room monitoring, case quality management committee monitoring measures.
4, standardize the "clinical blood management", "medical waste management", "disinfection and isolation management" system, improve the "ward" and "infusion card" and "medical waste management" system. The "infusion card" and "identity marking" management.
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