Request for instructions and reporting system
Where the sick and wounded to carry out the important organ removal or transplantation, cut-off and other major surgery, the first time to carry out the important new business, new technology, the department must be reported to the Department of Medical Services (Division), approved by the leadership of the hospital, and should obtain the sick and wounded and their families in the unit leadership agreed (except in special circumstances), to fulfill the signature procedures.
Accidental disaster first aid, receiving a large number of trauma, poisoning, infectious diseases, should be promptly reported to the Department of Medical Services (Division) and the hospital leadership; treatment of the sick and wounded involved in legal issues should be reported to the Department of Political Affairs (Division); foreign patients, hospitalized in accordance with the provisions of the competent authorities of the foreign affairs of large units, request for instructions to report.
The hospitalization of cadres above division level should be reported to the Medical Department (Division) and the leadership of the hospital; cadres above military level should be reported by the hospital to the Ministry of Health of the major unit or the Office of the Leading Group on Health Care; cadres above the level of the major region should be reported to the Office of the All-Army Leading Group on Health Care.
Outpatient clinics and wards found in the state management of infectious diseases (including sexually transmitted diseases) patients, should be in accordance with the "People's Republic of China *** and the State Infectious Diseases Prevention and Control Law" and "People's Liberation Army Regulations on the Prevention and Control of Infectious Diseases," the strict management of outbreaks of disease reporting, and notify the patient where the unit's health authorities.
When infectious diseases, tetanus, gas gangrene and other special infections occur in the general ward, measures should be taken immediately, and at the same time reported to the Medical Department (Division) and the hospital leadership.
The occurrence of medical accidents, medical disputes or serious medical and nursing errors shall be reported promptly according to the regulations. Damage or theft of valuable medical equipment, loss of valuable medicines or discovery of the deterioration of batches of medicines should be promptly reported to the Medical Department (Division) and the hospital leadership.
When a sick or wounded person is critically ill, the department shall fill in the "critical notice" and send it to the medical department (office) and the outpatient department, and the outpatient department shall notify the sick or wounded person's unit or family. Military and above leading cadres are seriously ill or emergency rescue, the hospital reported to the major units of the Ministry of Health or health care leading group office, and reported to the military health care leading group office.
After the death of the sick and wounded, the department fill in the "death notification form", sent to the medical department (department), hospital affairs department (department) and outpatient clinic, the death of the army cadres should be sent to the Ministry of Politics (department) at the same time, and the outpatient clinic to notify the sick and wounded of the unit or family. Deaths of military cadres above division level should be promptly reported to the hospital leadership; deaths of cadres above military level should be promptly reported by the hospital to the Ministry of Health of the major units or health care team office and the Office of the All-Army Health Care Leading Group. "The casualty death report form" within 10 days after the death of the casualty reported to the Ministry of Medical Affairs (Department), by the Ministry of Medical Affairs (Department) and the hospital leadership to sign the opinion of the case.
Departments report their work to the hospital leadership once a quarter; the hospital reports its medical work to the higher health authorities once every six months.
Duty, handover system
Day and night duty nurses are set up in each department (the clinical department should set up additional preparatory duty personnel on holidays). Nurses on duty must stick to their posts, fulfill their duties, ensure uninterrupted nursing work, and carefully fill out the "duty record".
When the nurse on duty needs to leave her post, she must report to the head nurse, and the head nurse will designate someone to take her place.
The nurse on duty shall closely observe the changes in the condition of the sick and wounded in the department, and complete the treatment and nursing work on time; she is responsible for receiving the newly admitted sick and wounded; and checking and guiding the work of the hygienist (nursing staff).
The nurse on duty should do a good job in the management of the ward during the duty time, and in case of any major problems, promptly report to the superior for instructions.
The department regularly hand over the shift collectively in the morning after work, the director of the department presided over, all the staff on duty to participate. Nurses on duty to report the flow of patients and new admissions, critical, before and after surgery, special checks and other changes in the condition of the sick and wounded, the leadership speech, the layout of the day's work, to convey the spirit of the hospital weekly meeting. The shift handover generally does not exceed 15 minutes.
The shift handover should be bedside for special examination, critical condition of the sick and wounded, and individual handover for special cases. On the provisions of the handover of narcotic drugs, psychotropic drugs, medical toxic drugs and medical equipment should be face to face.
Strict implementation of the shift change inspection system, the requirements of the four look, five check, patrol.
The four look: see whether the medical advice is transcribed, whether the implementation of error-free, three hooks are complete, there is no medical advice left to be implemented; look at the ward to report the flow of patients throughout the day, the new, critical, surgical and special changes in the patient's focus on the condition of the various shifts of the medical treatment and nursing measures given to the record is correct, with or without omissions; look at the temperature book whether to measure the temperature according to the requirements of the patient with or without a high fever or sudden fever; look at all the nursing records are accurate. Patients; see whether the nursing records are accurate, whether the record of in and out is accurate, there are no omissions and errors.
Five checks: check whether the initial treatment of newly admitted patients is perfect, whether special changes in condition have been dealt with in a timely manner; check whether the preparation of surgical patients is perfect, and whether all kinds of items to be brought to the operating room are ready; check whether the critical, serious and paralyzed patients are turned over on time, whether the bed is smooth and free of debris, and whether there are bedsores on the patients; check whether incontinence is properly handled, and whether the skin, clothes and covers are clean and dry; check whether wounds after major surgery are clean and dry; and check whether the patients' wounds after major surgery are clean and dry. Check whether there is blood seepage from the patient's wound after major surgery, whether the dressing is proper, whether the patient is ventilated and urinated, whether the drainage tube is smooth, and whether all the dispositions are proper, timely and safe.
A round: critical, major surgery and special changes in the condition of the patient, shift workers should *** with the tour, bedside shift. In addition to the condition of the rounds, the receiver also need to understand the ward patients and in place and go, pay attention to the ward environment safety.
Disinfection and isolation system
The clinic, treatment room, drug exchange room, dispensing room, resuscitation room, intensive care unit, operating room, preparation room, bacteriological room, maternity ward, neonatal room, neonatal ward, blood bank, blood purification room, aseptic instrument auxiliary room, infusion (blood) apparatus cleaning and packaging room, isolation and observation room, infectious disease area, etc., should be cleaned regularly and disinfected at any time when necessary.
The medical and nursing staff on duty must wear working clothes and hats, and dress neatly. Before and after the diagnosis and treatment work should wash their hands, or use disinfectant soak. Aseptic operation, should wear a mask and strictly abide by the aseptic operation procedures.
Aseptic containers, instruments and dressings should be sterilized and replaced regularly. Medication cups should be fixed for use, cleaned and sterilized regularly. Thermometer each time after use, soaked with disinfectant. Dental drills, mouthwash cups should be thoroughly sterilized after each use. Sputum cups and commodes should be cleaned and sterilized after use.
Any sterile fluid opened for intravenous input shall be marked with the date, time and specific use, and shall not be used after more than 2 hours; all kinds of solvents shall not be used after more than 24 hours after opening and suctioning.
The treatment room should be clearly differentiated between the sterile area, clean area and relatively polluted area, and the date and duration of disinfection must be noted on the sterilized items.
When infectious diseases are suspected, the isolation system should be in the observation room. When infectious diseases are detected in non-infectious disease department, consultation and referral should be made in a timely manner.
The infectious disease patients should be isolated according to the type and condition of the treatment, in the designated range of activities, and are not allowed to be transferred to each other's rooms and go out. When infectious disease patients go to other departments for treatment, they should be isolated and disinfected; after discharge, transfer, transfer to other departments or death, they should be disinfected at the end according to the relevant provisions of the Regulations of the People's Liberation Army on Prevention and Control of Infectious Diseases.
The staff of the infectious disease department should wear isolation clothes and shoes and masks when entering the contaminated area; when contacting different kinds of diseases, they should change the isolation clothes and wash their hands; when leaving the contaminated area, they should take off the isolation clothes and shoes and wash their hands.
The excreta and used articles of infectious patients shall be disinfected in accordance with the Regulations of the Chinese People's Liberation Army on Prevention and Control of Infectious Diseases. Undisinfected articles shall not be taken out of the infectious disease area or given to others for use. Used bedclothes of infectious disease patients shall be sterilized and then washed. Hospital sewage shall be disinfected before discharge.
Anaerobic bacteria, Pseudomonas aeruginosa and other special infections of the sick and wounded, should be closely isolated; used instruments, bedclothes, live in the room, should be thoroughly disinfected; used dressings, cotton balls should be collected separately and incinerated.
Patients should be discharged from the hospital to change the bed sheets and covers and pillowcases, bedside stools, bed frames, bedside cabinets with 0.1% peroxyacetic acid scrubbing and disinfection. After the death of patients or infectious patients discharged from the hospital, the sickroom bedding, pillowcase shall be disinfected with ultraviolet light, exposure or airtight disinfection.
Checking system
Clinical section
When giving medical orders, writing prescriptions or carrying out diagnosis and treatment, the name, gender, age, bed number and case number of the injured or sick patient should be checked.
The implementation of medical advice should be "three checks and seven pairs": after the set of drugs to check: drugs, injections, disposal before checking: drugs, injections, disposal after checking. The bed number, name, drug name, dose, concentration, time, usage.
When counting drugs and before using drugs, should check the quality, labeling, expiration date and batch number, if not in line with the use, shall not be used.
Before administering medicines, one should inquire about any history of drug allergy. The use of narcotic drugs, psychotropic drugs, toxic drugs for medical use, should be repeatedly checked. Intravenous administration, check for deterioration, and when using multiple drugs, attention should be paid to the contraindications of compounding.
Intravenous infusion should pay attention to check: ① infusion bottles, tubes, Murphy's dropper is clean, there is no foreign matter; disposable medical infusion set with or without expiration date, bag damage, leakage; ② check the name of the liquid and the expiration date; ③ glass bottles with or without cracks, caps with or without loosening; ④ liquid with or without discoloration, turbidity, precipitation.
Before blood transfusion, it should be checked by two people before entering; during transfusion, it should be closely observed to ensure safety; after blood transfusion, the remaining blood in the bottle should be kept for 24 hours before disposal.
Operating room
When picking up the injured, the department, bed number, name, gender, diagnosis, name of the operation, preoperative medication should be checked.
Before surgery, check name, gender, diagnosis, and site of surgery.
For body cavity or deep tissue surgery, the number of gauze, gauze pads, gauze (cotton) balls, instruments, suture needles, and spools of thread should be counted before surgery and suturing; after surgery, the count should be double-checked once more.
The specimens retained for surgery should be registered in a timely manner and checked for department, name, site and specimen name.
Medication and blood transfusion should be checked according to the requirements of the clinical department checking system. Narcotic drugs, psychotropic drugs, and toxic drugs for medical use shall be used only after checking by two persons.
Attached: blood transfusion checking system
Strengthening the education and management of blood transfusion norms, and strictly supervising the implementation of the "three checking and seven checking" system.
When the blood transfusion department issues blood, it should check with the person who takes the blood*** with the department, the case number, the bed number, the name, the blood type, the result of the cross-matching test, the blood vial number, the date of blood collection, the quality of the blood, the amount of blood, the blood type, and the signatures of both parties before taking it away.
After issuing blood, the recipient's blood specimen should be kept for 24 hours for examination.
The blood should be withdrawn from the blood bank by the nurse or the physician with the blood withdrawal slip, and checked and signed with the person who issued the blood***, and the vibration should be avoided in the process of withdrawing the blood to prevent rupture of the red blood cells.
Before the blood transfusion, two health care workers should check the contents of the cross-matching report form, blood type test form and the label of the blood bag, and check whether the blood bag is damaged or leaking, whether the color of the blood is normal or not, and whether the plasma is turbid or not, and if there is any doubt, they should contact with the blood bank immediately.
The blood transfusion shall be carried out by two or more executives with case *** with to the patient's bedside to check the patient's name, sex, age, case number, bed number, blood type, etc., to confirm that the matching report with the match, and then again after checking the blood, the blood transfusion with the blood transfusion device that meets the standard under strict aseptic operation.
Before and after blood transfusion, intravenous saline was used to flush the transfusion channels, and in the case of continuous transfusion of blood from different donors, intravenous saline should be used in the middle to flush the transfusion apparatus.
The blood transfusion must be carried out within 30min after the collar bleeding and finished within 3~4h (200~300ml).
After transfusion, blood transfusion card or blood transfusion registration form should be filled out, and the blood bag should be retained for 2~4h, in case of delayed transfusion reaction for testing specimens.
Nurse station management system
Nurse station is the nurse's office, to maintain indoor quiet, no smoking.
Nurse station items should be placed neatly, positioning, orderly, keep the desktop and floor clean and clean.
Staff must be neatly dressed and presentable during working hours.
Staff members are not allowed to chat at the nurses' station and non-staff members are not allowed to enter the nurses' station.
Working hours are always in Putonghua on duty, use civilized language, no special circumstances are not allowed to make personal phone calls.
Hearing the patient call signal, should be on call.
Timely fill out and replace the patient hospitalization card, keep the number of hospitalization, patient information, nursing level of accuracy.
Ward management system
Ward is managed by the head nurse, with active assistance from ward staff and the sick and injured.
Keep the ward quiet, walk lightly, talk lightly, open and close the door lightly, operate lightly.
Ward unit furnishings and other items should be positioned to place, neat and tidy, without the consent of the head nurse, shall not be moved at will. Hospitalized patients should wear hospital gowns, change and wash 1~2 times a week; bed unit covers, sheets, pillowcases 1~2 weeks change and wash 1 time, keep clean and hygienic.
Insist on daily cleaning on time, keep the sick area clean and hygienic, pay attention to ventilation. Smoking is prohibited in the ward.
In the shift medical personnel, must wear work clothes, cap, dress neatly. Aseptic operation must wear a mask.
Strengthen the management of camping equipment and sanitary clothing, the establishment of accounts, special custody, regular inventory. When the management personnel change, they should complete the handover procedures.
After being discharged from the hospital, the sick and wounded are promptly wiped down with disinfectant, the bed units are changed, and drinking cups, basins and spittoons are disinfected.
Establishing organizations for the sick and wounded, assisting in the management of the sick and wounded in their thinking and life, regularly organizing the sick and wounded to learn about politics, current affairs and health care, and urging the sick and wounded to consciously abide by the "rules of hospitalization", and not to enter the medical office without the permission of the medical and nursing staff.
Medical staff are not allowed to chat, joke and play cards in the medical office during the shift, and they are not allowed to make personal phone calls, do private work and read non-medical books, newspapers and magazines without special circumstances. The refrigerator in the ward is not allowed to place personal belongings.
Do a good job in the management of escorts, strictly control the number of escorts.
Graded care system
After the admission of the sick and wounded, the physician will decide the level of care according to the condition and give medical advice. The level of care is divided into special care and first, second and third level of care, and respectively set up a unified marking on the list of the sick and wounded and the bedside sign. During the period of hospitalization, the level of care should be changed in accordance with the changes in the condition of the patient.
Special care: patients in critical condition or after major surgery, who may have accidents at any time. Sent special guards around the clock, develop care plans, closely observe the changes in condition, prevent complications, prepare a variety of monitoring instruments and first aid equipment, medicines, ready for first aid at any time, timely and accurate fill in the "special care record", and according to the specified time to make a summary and summary. The red triangle is the symbol of special care.
Primary care: serious illnesses, major surgery after the need for strict bed rest or have a consciousness disorder of the injured and sick. Life to give close care, if necessary, to develop a nursing plan and make nursing records; close observation of changes in the condition, the 15th ~ 30 minutes to patrol 1 time; carefully do the morning and evening care; according to the condition of the regular change of position, bath, shampooing, prevention of complications. The first level of care is marked by a red vertical bar.
Second level of care: the sick and wounded who are in serious condition or recovering from serious illnesses, or who are old and weak and cannot take care of themselves completely. Appropriate indoor activities, life to give the necessary assistance; pay attention to the observation of changes in the condition, every 1 ~ 2 hours to visit once. The second level of care symbolizes the blue vertical bar.
Tertiary care: the condition is mild or recovery period of the sick and wounded. Under the guidance of the medical staff to take care of their own life, pay attention to the observation of the condition, every 3~4 hours rounds; according to the condition to participate in some indoor and outdoor activities. Do a good job of hygiene and health guidance before discharge.
Resuscitation system for critically ill and injured patients
Resuscitation of critically ill and injured patients must be a clear division of labor, close cooperation, active treatment, close observation and detailed records. After the end of the rescue should be seriously summarize the experience.
The rescue of critically ill and injured patients in the department is organized and implemented by the head of the department, the chief physician or attending physician, and reported to the medical department (office).
Each clinical department should have a first aid room and guardianship room, medicines, equipment, positioning placed in a special person to keep, regular inspection, and keep in good condition.
The first aid room or monitoring room should have common critical illnesses rescue plan, medical staff should be skilled in common rescue techniques and the use of instruments.
Nursing checkup system
Nursing Department checkup, monthly focused nursing administrative checkup (routine evaluation checkup) or quality checkup (clinical operational checkup), quarterly arrangement of 1 teaching checkup.
The chief nursing officer conducts weekly focused routine evaluative rounds or clinical operational rounds, and arranges 1 teaching round per month.
The chief nurse of the ward conducts daily focused clinical operational rounds and arranges 1 teaching guidance round or routine evaluation round per week.
Specialty group leaders conduct daily focused routine evaluative rounds or clinical operational rounds.
The personnel at all levels should strengthen the rounds for the newly admitted, critically ill, before and after major surgery and special examination and treatment of the sick and wounded, keep abreast of the changes in the condition, observe the effect of nursing, and report and deal with the situation in a timely manner.
Teaching rounds, if necessary, can ask the director of the department, the main (deputy) chief physician or attending physician guidance, check the quality of care, study and solve the difficult problems of nursing.
The time of the checkup is generally not more than 30 minutes.
Nursing checkups at all levels should correctly use the steps of the nursing process, there should be registration and record, department checkups, nursing department checkups should be summarized and recorded in the nursing course or checkup record book.
Medical implementation system
All kinds of medicines used for the sick and wounded and all kinds of examination and operation items should be issued medical advice and recorded in the "medical advice record sheet". The transcription and organization of medical advice must be accurate and not be altered.
After the physician issued the medical advice, the nurse was transcribed in the "medical advice record sheet" and the implementation of the single (card), on the suspicious medical advice, should be investigated and then executed. In addition to first aid, no oral medical advice shall be given. When the oral will, the nurse should be recited once by the physician check before execution, the physician should be timely after the incident to make up for the doctor's orders.
After the doctor gives the will on the computer, the nurse should check the name of the will, the use method, the execution time, the billing attribute, the implementation of the department and so on, especially the pharmacological will should check the bed number, name, name of the drug, the dose, concentration, time, usage and the specification of the drug, the frequency of the execution of the treatment or disposition of the medical will should be checked, and the nursing will should be checked on the bed, the level of nursing care and the system set up in line with the situation, checking the error before the execution of the will, the nurse should check the bed, the level of nursing care and the system set up in line with the situation. Nursing orders should be checked for bed position, nursing level and system settings, and should be saved, proofread and signed only after checking for correctness.
Temporary medical orders must be executed within 15 minutes of the specified time. It is required to be disposed of first, then signed and time signed. Determines medication time according to treatment needs after execution of medical orders, edits and prints out all types of treatment orders and nursing orders for each patient.
Cumulative charges according to the medical advice and the charges of each disposal content. Checks inpatient medical expenses at any time, makes supplemental charges in a timely manner, and categorizes them by billing section, item, and date.
After the implementation of medical advice, in addition to my check, each shift nurses must check the last shift of the implementation of medical advice and sign; night shift nurses should be on the day of the doctor's orders, medication orders, infusion orders, injection orders and small treatment orders for the total checking; the head nurse of all the medical advice should be weekly total checking once and signing.
Nurses should check the medical orders every shift, and after taking over the shift, they should check whether the medical orders of the previous shift have been dealt with properly; they should enter the workstation at any time during the shift to check whether there are any new medical orders.
Surgery, childbirth, transfer, discharge or death, should stop the previous medical advice. For patients who have been hospitalized for a long period of time, the doctor's orders should be reorganized when there are too many pages on the doctor's order sheet.
Any temporary medical advice that needs to be carried out by the next shift of nurses should be clearly explained and recorded.
Treatment room work system
Treatment nurses must wear uniforms, caps and masks. Wash hands and wear masks before operation, strictly implement the aseptic operating procedures, so that one person, one needle, one tube.
When carrying out various therapeutic operations, the operating procedures and checking system should be strictly enforced, and the history of allergy should be inquired before injecting penicillin, animal serum, iodine and other drugs. Allergy test should be done according to the regulations.
Instruments and medicines should be categorized and positioned, with obvious labels and clear handwriting. Narcotic drugs, toxic drugs for medical use and valuable drugs should be locked for safekeeping, and carefully counted and registered during the shift handover.
Indoors should be divided into clean and contaminated areas. Sterile goods and non-sterile goods, should be placed in a fixed position. After the treatment, the used items will be cleaned and put in the designated place. Infectious patients used instruments, dressings and timely disinfection. Disposable therapeutic products after use, in accordance with the requirements of the disfigurement disinfection treatment.
Aseptic holding forceps (tweezers) and their soaking solution and containers, dressing jars, iodine and alcohol bottles and other weekly autoclave disinfection. Soak sterile forceps disinfectant solution plane should be maintained in the sterile shaft section above 2 ~ 3cm, regular replacement of used syringes, infusion apparatus, first by the disinfectant solution soaked, and then with the disinfection and supply room replacement.
Regularly check the expiration date of various treatment kits and sterile items, and re-disinfect and sterilize them beyond the expiration date.
The room is kept tidy. Every day wet cleaning and ventilation, object surfaces and air daily electronic sterilization lamp or ultraviolet radiation for 30 minutes and registered signature, once a week thoroughly disinfected, monthly air bacterial culture, the report card to be retained for examination.
The items in the treatment room are generally not borrowed; in special cases, the head nurse agrees to go through the borrowing procedures and ask for them back in time.
The working system of the monitoring room
Any critically ill patient who needs to live in the monitoring room is determined by the attending physician or above, and strictly enforces the hierarchical examination and diagnosis by the treating physician, the attending physician, the chief physician, and the head of the department, and formulates the monitoring and resuscitation plan. Nurses practice a three-shift system with 24-hour continuous custodial care. Accompaniment and visitation are not allowed.
Medical personnel engaged in guardianship work, before taking up the job must be trained in the relevant professional knowledge, proficiency in first aid technology, as well as indoor first aid equipment performance and use.
The on-duty medical personnel should hold their posts, closely observe the condition, accurately monitor vital signs, and record them in a timely manner, in case of any changes in the condition, they should be dealt with in a timely manner.
Keep the room quiet and tidy. The personnel entering the room are dressed according to the regulations. Strictly implement the aseptic technique operation process. Sterile containers, instruments and dressings are disinfected regularly, and disinfectant is changed regularly. Air disinfection and airborne bacterial culture are carried out regularly in the room, and the report card is kept for examination.
Valuable medical instruments and equipments should be formulated and managed by specialized personnel, and files should be established for regular inspection and maintenance. All kinds of instruments and medicines should be fixed, positioned, quantitative storage, timely replenishment after use, to maintain the state of perfection.
Principles of disinfection and sterilization
Medical supplies that enter human tissue or sterile organs must be sterilized.
The instruments and supplies that contact the mucous membranes of the skin must be sterilized.
Used medical equipment and articles should be thoroughly cleaned and then disinfected or sterilized; of which the infected patients used medical equipment and articles should be disinfected first, thoroughly cleaned and then disinfected or sterilized.
All medical equipment should be disinfected or sterilized before servicing.
Disinfection or sterilization method is chosen according to the properties of the item. For example:
High-heat-resistant items preferred physical sterilization method. Such as surgical instruments, a variety of puncture needles, syringes, etc. preferred pressure steam sterilization method: oil, powder, paste, etc. preferred dry heat sterilization method.
Non-heat-resistant items can be selected chemical sterilization method. Such as a variety of catheters, precision instruments, endoscopes, artificial implants, etc. Choose ethylene oxide sterilization or 2% glutaraldehyde immersion sterilization method.
Chemical disinfection, sterilization principles are:
Reasonable choice of high-efficiency, medium- and low-efficiency disinfectants and sterilizers according to different situations;
The use of chemical disinfectants must master the performance of disinfectants, the role of disinfectants, the method of use, and factors affecting disinfection effect. Such as formaldehyde can not be used for air disinfection. Formaldehyde fuming box can be used for non-heat-resistant, non-moisture-resistant items of surface disinfection, but can not be used for sterilization; disinfection should be used to add heat or add catalyst, can not be used to fumigate the natural volatilization method.
The preparation of chemical disinfectants must be tested for effective concentration and regularly monitored;
Containers used to soak disinfected and sterilized items must be disinfected and sterilized when replacing the disinfectant and sterilizer.