Eighteen medical core system is what time was promulgated

The full text is as follows: First, the first diagnosis is responsible for the system (a), the first physician or department to receive the first consultation is 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 and so on.　(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), China, critical, serious patients, the first physician should take active measures to implement rescue. If it is a non-affiliated professional disease or multi-specialty 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 Chinese, critical and serious patients, have organized consultations with relevant personnel, decide to admit patients to the department and other medical acts of the right to decide, any department, any individual shall not be any reason to shirk or refuse.　(a) Medical institutions shall establish a three-tier physician treatment system and implement a three-tier physician check-up system for the chief physician (or deputy chief physician), attending physicians and residents.　(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 visits two times a week; attending physician room visits daily. Residents are responsible for the patients under their charge for two to four hours and carry out room checks in the morning and evening.　(For Chinese patients in critical condition, 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 or the chief physician (deputy chief physician) to check the patient temporarily.　(d) For newly admitted patients, the resident shall check the patient within four bar hours of admission, the attending physician shall check the patient within four bar hours and give advice on treatment, and the chief physician (deputy chief physician) shall check the patient within two bar hours and give guidance on the patient's diagnosis, treatment, and handling.　(E), room visits should be fully prepared before, such as medical records, X-rays, all relevant examination reports and the required examination equipment. During the room visit, the resident should report the summary of the medical record, the current condition, the results of the examination 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 room: Yi, resident room visit, required to focus on the inspection of China's critical, difficult, to be diagnosed, newly admitted, post-surgery patients, while inspecting the general patients; check the laboratory report card, analyze the results of the examination, and put forward the views of further examination or treatment; verification of the day of the implementation of the medical advice; to give the necessary temporary medical advice, the next morning, the special examination of the medical advice; questioning, checking the patient's diet; and take the initiative to seek the patient's views on medical, dietary and other aspects of the medical care. Ask the patient for his/her opinion on medical treatment and diet.　II. The attending physician's checkups require systematic checkups of the patients under his/her care. In particular, they should focus on checking and discussing patients who are newly admitted to the hospital, critically ill in China, with unknown diagnosis and poor therapeutic effect; listen to the opinions of residents and nurses; listen to the patients' statements; check the medical records; learn about the changes in the patients' conditions and seek opinions on medical treatment, nursing care, diet, etc.; and verify the implementation of medical advice and therapeutic effect.　Third, the chief physician (deputy chief physician) room, to solve difficult cases and problems; review of new admissions, diagnosis of critically ill patients, diagnostic and treatment plans; to decide on major surgery and special tests and treatments; random checks of medical advice, medical records, medical, nursing quality; listening to physicians, nurses on the diagnosis and treatment of the views of the nursing; to carry out the necessary teaching; to decide on the patients discharged, transferred to the hospital, and so on.　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 record book. 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, the discussion of opinions, etc., certainty or concluding observations recorded in the medical record.　Consultation system (1) Medical consultation includes: Chinese consultation, intra-departmental consultation, inter-departmental consultation, hospital-wide consultation, and out-of-hospital consultation.　(B), China consultation consultation can be Chinese or written form of notice to the relevant departments, the relevant departments in the consultation notification, should be in place within 5 minutes according to. Consulting physicians should indicate the time (specific to the minute) when signing the consultation opinion.　(C), the consultation should be held once a week in principle, the whole department to participate. 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 records, diagnosis and treatment, and the purpose of the consultation. Through extensive discussion, it will clarify the diagnosis and treatment opinions and improve the business level of the departmental staff.　(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 competent physician, who will fill in the consultation form, stating the requirements and purpose of the consultation, and send it to the invited department. The invited department should send an attending physician or above for consultation within 24 hours. The physician in charge of the consultation should be present to 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 carried out hospital-wide consultation. Hospital-wide consultation is proposed by the director of the department, reported to the Medical Affairs (Services) agreed or designated by the Medical Affairs (Services) 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 ≥ two times a year, presided over 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" (Ministry of Health Decree No. 4.2) relevant provisions of the implementation.　V. Critical patient rescue system (a), the development of the hospital emergency public **** health emergency response plan and various professional common technical specifications for the rescue of critical patients, and the establishment of 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 section chief, medical administration (business) section or 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 a timely manner, orally (rescue) or in writing to inform the danger 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 land hours after the end of the resuscitation according to the record, and to explain.　(E), the rescue room should be a perfect system, complete equipment, good performance. China's rescue supplies must implement the "five", namely, a fixed number, a fixed location, a fixed personnel management, regular disinfection and sterilization, regular inspection and maintenance.　VI. Surgical classification management system (a), the classification of surgery According to the complexity of the surgical process and the requirements of surgical technology, the operation is divided into four categories: Yi, four types of surgery: simple surgical process, surgical technology, low difficulty of ordinary common minor surgery.　II, three types of surgery: the surgical process is not complex, surgical technology is not difficult to a variety of moderate surgery; III, two types of surgery: the surgical process is more complex, surgical technology has a certain degree of difficulty in a variety of major surgery; IV, a type of surgery: the complexity of the surgical process, surgical technology, the difficulty of a variety of surgeries.　(B), the classification of surgeons All surgeons should obtain the qualification of practicing physicians in accordance with the law, and the place of practice in the hospital. According to the health technology qualification and its corresponding employed position, the grading of the operating physicians is stipulated.　(i) Residents (ii) Attending Physicians (iii) Associate Physicians: (i) Lower seniority Associate Physicians: within three years of becoming Associate Physicians. (II) Senior associate physician: serving as an associate physician for more than three years.　(iii) Chief Physician (iii) Scope of surgery for physicians at all levels Yi. Residents: under the guidance of a superior physician, gradually carry out and become proficient in four types of surgeries.　II. Attending physicians: proficient in three or four types of surgeries, and under the guidance of higher-level physicians, gradually carry out two types of surgeries.　III. Low seniority associate chief physician: proficient in two, three and four types of surgeries, and under the guidance of the participation of the superior physician, gradually carry out one type of surgeries.　Fourth, senior associate chief physician: skilled in two, three, four types of surgery, under the guidance of the chief physician, to carry out a type of surgery. According to the actual situation, he/she can also complete part of one type of surgery alone and carry out new surgeries.　5, chief physician: skilled to complete all types of surgery, especially to complete the development of new surgery or the introduction of new surgery, or major exploratory research project surgery.　(D), surgery approval authority Yi, normal surgery: in principle, by the department pre-operative discussion, by the section chief or section chief authorized by the deputy director of the approval.　II, special surgery: any one of the following can be regarded as a special surgery, subject to serious pre-operative discussion by the department, signed by the chief of the department, reported to the Medical Administration (Services) Section for the record, if necessary, by the hospital consultation or reported to the competent hospital leadership for approval. However, in the Chinese diagnosis or tight Chinese situation, in order to save the patient's life, the physician in charge shall make a decision on the spot, scramble for time and seconds, and actively rescue, and promptly report to the superior physician and the general duty, shall not be delayed in the time of resuscitation.　(I) surgery may lead to disfigurement or disability; (II) the same patient needs to be operated again due to complications; (III) high-risk surgery; (IV) new surgery carried out by the unit; (5) patients with no owner, surgery that may cause or involve judicial disputes; (Luk) the person to be operated on is a foreign guest, an overseas Chinese, a compatriot in Hong Kong, Macao, Taiwan, or a special person, etc.; (Lac) physicians from foreign hospitals who come to the hospital to participate in the surgery, and those practicing in other places must be in accordance with the "Chinese People's Republic of China" and "China's National Health Insurance Law". People's Republic of China **** and the State Medical Practitioners Law" relevant provisions of the relevant procedures.　Pre-operative discussion system (a), major, difficult, disabling, vital organ removal and new surgery, must be pre-operative discussion. (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, head nurse and nurse in charge shall participate in it.　(C), the discussion includes: diagnosis and its basis; surgical indications; 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, major surgery, complex conditions requiring the cooperation of related departments, the anesthesiology department and related departments should be invited two to three days in advance for consultation, and make adequate preoperative preparations.　Clinical departments should check the patient's name, gender, bed number and hospitalization number (outpatient number) when issuing medical advice, prescription or treatment.　The implementation of medical advice should be "three checks and seven pairs": before, during and after the operation; bed number, name, drug name, dosage, time, usage, and concentration.　When counting the drugs and before using them, check the quality, label, expiration date and lot number; if they do not meet the requirements, they shall not be used.　Fourth, before giving drugs, pay attention to ask whether there is a history of allergy; the use of drastic, poisonous, anesthetic, limited drugs should be repeatedly checked; intravenous drug should pay attention to whether there is no deterioration, whether the bottle mouth is loose, cracks; to give more than one kind of drug, pay attention to the contraindications of compounding.　5, blood transfusion should be strictly three check eight system (see nursing core system - six, check system) to ensure the safety of blood transfusion.　Second, the operating room 依、接病人时，要查对科别、床号、姓名、年龄、住院号、性别、诊断、手术名称及手术部位(左、右)。　II. Before surgery, name, diagnosis, surgical site, blood dispensing report, preoperative medication, drug allergy test result, anesthesia method and anesthesia medication must be checked.　III. Where body cavity or deep tissue surgery is performed, the number of all dressings and instruments should be counted before and after preoperative and suturing.　IV. Specimens removed by surgery should be checked by the roving nurse and the surgeon before filling out the pathology test and sending it for examination.　Pharmacy When formulating, check the content of the prescription, drug dosage, and contraindications.　When issuing medicines, check whether the name, specification, dosage and usage of the medicine are consistent with the content of the prescription; check whether the label (medicine bag) is consistent with the content of the prescription; check whether the medicine has deteriorated and exceeded the expiration date; check the name and age, and explain the usage and precautions.　Blood bank: For blood typing and cross-matching test, two persons should "double check and double sign" when working, and one person should redo the test when working.　When issuing blood, check with the person taking the blood*** for department, ward, bed number, name, blood type, cross-matching test result, vial (bag) number, date of blood collection, blood type and dosage, and blood quality.　V. Laboratory Department Yi. When taking specimens, check the department, bed number, name, and purpose of the test.　II. When collecting specimens, check the section, name, sex, union number, quantity and quality of specimens.　III. When testing, check the reagents, items, and whether the lab sheet matches the specimen.　Fourth, after the test, check the purpose and results.　When issuing reports, check the department and ward.　When collecting specimens, check the unit, name, sex, union number, specimen and fixative.　When preparing specimens, check the number, type of specimen, number of sections and quality.　When making a diagnosis, check the number, specimen type, clinical diagnosis, and pathologic diagnosis.　When issuing reports, check the unit.　When examining, check the department, ward, name, age, slice number, site and purpose.　When treating patients, check the department, ward, name, site, condition, time, angle, and dose.　III. When issuing report, check the department and ward.　Physical Therapy and Acupuncture Room When giving treatments, check the department, ward, name, location, type, dose, time, and skin.　Low-frequency treatment, and check the polarity, current flow, and frequency.　III. When high-frequency treatment, and check the body surface and body for metal abnormalities.　IV. Before acupuncture treatment, and check the number and quality of needles, and when removing needles, and check the number of needles and any broken needles.　IX. (Electrocardiogram, electroencephalogram, ultrasound, basic metabolism, etc.) IX. When examining, check the department, bed number, name, gender, and purpose of the test.　When making a diagnosis, check the name, number, clinical diagnosis, and test result.　When issuing the report, the department and ward should be checked.　Other departments should also be based on the above requirements to develop their own work checking system.　Doctors handing over 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. Trainee physicians on duty should carry out medical work under the guidance of physicians of the hospital.　All the wards have implemented the two-four hour duty system. 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 Chinese, critically and seriously ill patients, bedside handover must be done. The physician on duty shall explain clearly to the physician on duty the condition of the critically ill or seriously ill patients and all the matters to 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 the patients' temporary situation, and make a good record of the Chinese, critical and serious patients' condition observation and medical measures. The first-line duty personnel shall 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 shall 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 for rescue or consultation in China, they must explain to the nurse on duty where they are going and how to get in touch with them. The third-line duty physician can live at home, but must leave contact information, and should go immediately when receiving a request for China.　Sixth, the duty physician can not be "a post double responsibility", such as duty and clinic, surgery, etc., except for the Chinese clinic surgery, but in the hospital area there are Chinese clinic to deal with matters, should be prepared for the class to deal with in a timely manner.　Seven, daily morning meeting, the duty physician should focus on the patient's situation to the ward medical staff report, and to the physician in charge of the situation of the critically ill patients and the problems that remain to be dealt with.　X. New technology access system I. New technology should be in accordance with the relevant provisions of the state 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 before the implementation of the implementation.　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 department director 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 work, pay close attention to the implementation of the new project may appear in a variety of unforeseen circumstances, and actively and appropriately dealt with, make a good record.　XI, the medical record management system A, the establishment of a sound hospital medical record quality management organization, improve the hospital "four-level" medical record quality control system and work on a regular basis.　Four-level quality control system of medical records: yi, a quality control group consists of the department director, case committee (attending physician or above), the head nurse. It is responsible for the quality check of medical records in the department or the ward.　Second, the quality control department of the second level by the hospital administrative functions of the relevant personnel, 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 comprehensive goal assessment content, quantitative management.　Third, the three-level quality control department consists of full-time quality management physicians in the hospital case room, responsible for the inspection of archived medical records.　Fourth, four-level quality control organization by the president or business vice president and experienced, responsible senior title of the medical, nursing, technical staff and the main business management department in charge of the composition. 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 connotation of the force.　Second, the implementation of the Ministry of Health, "the basic norms of medical record writing (for trial implementation)" (Wei medical hair [II 00 II] Yi 90), "medical institutions, medical records management regulations" (Wei medical hair [II 00 II] Yi 9 three) and the province of the "standardization and management of medical documents" of the requirements, focusing on the newly assigned, the new transfer to the physician and refresher physicians in the relevant knowledge and skills training in the writing of medical records.　Third, strengthen the management and quality control of running medical records and archived cases.　According to the medical record, the first medical record, preoperative conversation, preoperative summary, surgical record, postoperative (postpartum) record, important rescue record, special invasive examination, preanesthesia conversation, pre-transfusion conversation, discharge diagnostic certificate and other important records should be written or examined and signed by the physician in charge of the hospital. Surgical records shall be written by the operator or the first assistant. If the first assistant is a trainee physician, it shall be examined and signed by a physician of this hospital.　II. After the admission of the plain-clinic patients, the physician-in-charge shall view the patients, inquire about the medical history, write the first medical record and process the medical orders within bar hours. Chinese diagnosis of patients should be viewed within five minutes and deal with patients, hospitalized medical records and the first record of the course of the disease should be completed in principle within two hours, due to the rescue of the patient failed to complete in time, the relevant medical staff should be in the end of the rescue of the land within six hours to make up for the record according to the facts, and to be noted.　Newly admitted patients, within four bar hours should have attending physician above the title of physician room records, general patients should be two times a week chief physician (or deputy chief physician) room records, and be noted.　Fourth, the critical patient's medical record at least once a day, when the condition changes, record at any time, record time should be specific to the minute. For seriously ill patients, at least two days to record a medical record. For stabilized patients, at least once every three days. For patients with stable chronic disease, at least five days to record a record of the course of the disease.　5、All kinds of laboratory tests, report cards, and blood distribution sheets should be pasted in time and are 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.　Fourth, the discharge medical records should be filed within three days, special medical records (such as death, typical teaching medical records) filing time is not more than weeks, and timely report to the case room for the record.　Fifth, to 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 requirements and provisions of the Interim Measures for Evaluation of Quality Management of Provincial Medical Records and Rewards and Punishments, a notification system for evaluating the quality of medical record writing and reward and punishment mechanism shall be established for the departments and individuals.　XII. Specification of medical record writing Yi, unified with blue and black ink, the contents of which are required to be objective, true, accurate, timely and complete.　Use standardized Chinese characters; use Arabic numerals for figures; the names of medicines can be written in Chinese, Latin and English; and the national legal units of measurement are used for units of weights and measures. III. Medical record writing can not be deleted, cut and paste, digging and mending, individual wrong words can be used in the same pen and ink double line on the wrong word; the superior physician to modify all with red ink pen, sign the date of modification and full name. More than three revisions per page need to be rewritten.　Fourth, general patients within two or four hours to complete the admission medical records, critical patients within six hours to complete; the first record of the course of the shift to complete, Chinese clinic surgery patients completed before surgery. 5, the course of the record in general in order / two to three days, admission and three days after the operation at least every day in order to record, critically ill patients in order to record / day, there is a change in the condition of the record at any time, the chronic patients can be in order to record / week, the stage of the section in order to / month.　Lu, three days before admission to the hospital with three-level physician check-up records: new admissions of general patients within four bar hours of the attending physician or more check-up and record, paint within two hours of the deputy director of the physician or more check-up and record.　Before the surgery, there is a record of the attending physician or above checking the room or discussing the record.　Bar, difficult and critical patients have a record of discussion, major surgery has a record of pre-operative discussion.　9、Specialized patients should have records of transferring in and out, and complete them in time.　依0、implementation of the signature system: where surgery, blood transfusion and other special tests, special treatment, need to sign an informed consent.　YiYi, all diagnostic and therapeutic operations, preoperative and postoperative records of the operator.　The report card of auxiliary examination should be posted back to the medical record within 24 hours, and the lintel column of the posted card should be filled in completely.　Clinical blood use audit system The clinical blood use audit system is the core system for the implementation of medical quality and safety, and the strict implementation of the clinical blood use audit system ensures that patients use blood in a safe and standardized manner.　The blood bank must purchase blood in accordance with the blood collection and supply institutions designated by the local health administrative department, and must not use blood without the name of the blood station (bank) and the license mark.　III. Blood used in each department must be in accordance with the principle of blood transfusion, and abuse of blood supply is strictly prevented.　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 carefully, 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 department, name, bed number, hospital number, and sent to the blood bank one day before the blood transfusion (except for the disease of China).　5. The staff of blood bank should contact with the blood station in time according to the booking of blood volume of each clinical department to prepare all types of blood and ensure the clinical blood volume without any mistake.　When accepting the specimens, the staff of blood bank should check the specimens carefully one by one, and accept the specimens for blood preparation after there is no error.　The blood bank staff should keep the blood of each type in the refrigerator at four degrees Celsius and observe the temperature change in the refrigerator at any time.　Bar, the staff of blood bank 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 undergraduate recipient, bed number, hospitalization number, blood type and crossover results, blood storage number and the name of the blood donor, time of blood collection, blood type, and other items on the transfusion order, and the blood can be taken out of the blood bank only after there is no error.　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 together with the blood station.　The staff of the blood bank must ensure that the amount of incoming and outgoing blood, the inventory of blood is clearly accounted for and carefully kept, and may not be privately destroyed without the approval of the head of the hospital

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