Time flies, and a year has passed in a blink of an eye. Looking back on our work in the past year, we have gained not only years, but also growth. Summarize our work this year and let young people take fewer detours! Do you know what logical order of year-end summary is excellent? The following is the model essay I collected from the annual work summary of internal medicine. Welcome to read the collection.
In the annual work summary 1 year, according to the service tenet of "taking patients as the center, improving the quality of medical care service, consolidating basic nursing and creating a safe hospital" advocated by the hospital management year, and according to the basic requirements and standards of the Hospital Nursing Service Quality Evaluation Standard, the internal medicine department earnestly implemented this year's nursing plan, improved various nursing rules and regulations, improved service processes, improved hospitalization environment, strengthened nursing quality control and continuously improved nursing quality. The nursing work in 20xx years is summarized as follows:
First, the implementation of nursing staff training plan, improve the professional quality of nursing staff.
Carry out three-basic training for nurses at all levels, and organize general nurses to learn various emergency plans for nursing risks and nursing core systems. Questions about basic theoretical knowledge, hospital awareness knowledge and specialized knowledge are asked in early rounds and morning meetings, and theoretical and technical operation examinations are conducted every month. All nurses participate in all kinds of business and skill training organized by the hospital, and each nurse can master the first aid technology of cardiopulmonary resuscitation and various rescue operation skills and processes. Among them, the average score of nursing theory knowledge assessment is above xx; Skill operation assessment: the average score of oral nursing, sputum suction nursing and cardiopulmonary resuscitation is xx.
The second is to improve the service process and improve the service quality.
Standardize the service process of receiving newly admitted patients, implement the standard clauses in the service process, bring convenience to patients, listen to the opinions of patients and caregivers on nursing services extensively, find out the reasons for existing problems, put forward rectification measures, and continuously improve the service quality. There were no complaints and nursing disputes from patients and their families throughout the year, and the patient satisfaction rate was above xx%.
Third, improve the nursing rules and regulations and operating procedures, and put an end to nursing errors and accidents.
Nurses conduct safety awareness education every week, find out potential safety hazards in their work, improve rectification measures, eliminate potential accidents, conscientiously implement various nursing rules and regulations and operating procedures, give play to the role of quality control teams in departments, and regularly and irregularly check the implementation of various nursing systems, so that the incidence of nursing accidents is zero.
Fourth, strengthen and improve the quality requirements of nursing documents, and strive to be accurate, objective and continuous.
Nursing documents are also legal documents, which are the objective basis for judging medical disputes. In the process of writing, every nurse can write carefully according to the patient's condition observed by herself, which can objectively, truly, accurately, timely and completely reflect the patient's condition change, and constantly strengthen the important benefits of formal writing of nursing documents, so that every nurse can strengthen supervision and inspection while correcting her writing attitude. Check whether the records before each shift are defective, and the quality control team will check them regularly. Head nurses regularly and irregularly check and assess the terminal quality of discharged medical records, correct problems in time, analyze the quality of nursing documents every month, put forward rectification measures for existing problems, and continuously monitor them. From x months to x months this year, the writing quality of nursing documents has reached more than x points.
Fifth, standardize ward management, establish a people-oriented hospitalization environment, and enable patients to achieve the best physical and mental state of understanding and treatment.
The ward is ventilated regularly every day, and the ward is quiet, clean and fresh, which brings safe and effective protective measures to patients with consciousness disorder. Nursing patients according to grading nursing standards, implementing health education, strengthening basic nursing and case nursing of critically ill patients, and meeting the reasonable needs of patients and their families. The number of inpatients in 20xx years (from X months to X months) was X, an increase of X over last year. X people were discharged from the hospital, an increase of X people over last year; The first-class nursing and basic nursing were qualified, no nursing complications occurred, and the incidence of bedsore was X.
The intact rate of first-aid articles reaches 100%, and the first-aid articles are subject to "four-fixed" management, and the specialized personnel conduct a comprehensive inspection once a week. The head nurse doesn't make spot checks every week to ensure that the first-aid items are always in an emergency state.
According to the hospital infection management standards, the management of medical waste has been strengthened, the medical waste management system has been improved, and the medical waste treatment process has been organized, so that the hospital infection monitoring nurses can conscientiously perform their duties and make the hospital infection monitoring indicators meet the quality standards.
Six, there are still many shortcomings in the work.
1, the implementation of basic nursing is not in place, the sanitary treatment of newly admitted patients in individual shifts is not timely, and they are uncomfortable lying down. Ward management needs to be improved, and patients bring more items.
2. Individual nurses don't have a strong sterile concept, and disposable sterile articles are not handled in time after use. The learning atmosphere is not strong enough, and there are no academic papers; There are some defects in nursing documents, such as missing items, missing records and lack of continuity of data. Health education is not deep enough and lacks dynamic continuity.
On the basis of continuing the original achievements, continue to work hard: continue to strengthen the study and training of business skills and improve nursing skills; Further improve the nursing service process and quality control scheme and seriously implement it; Strengthen the implementation of basic nursing, strengthen ward safety management, and create high-quality nursing service.
Summary of internal medicine 2 1 year. Strengthen nursing safety management.
Supervise the implementation of various core systems in a planned way, find problems in time, analyze and rectify.
(1) Implementation of inspection system: it was found that after the temporary medical orders were issued, the double check was not in place, the active check of infusion was not in place, and the label was not standardized. The problems existing in the inspection have been continuously improved, and the inspection process of each link has been standardized, and the defects in the inspection have been significantly reduced compared with before.
(B) the implementation of the inheritance system
1. There are some problems in the writing of handover report, such as incomplete lintel, no description or specific description on admission, no classification, incomplete nursing measures, and no continuous observation on the next shift. Standardize the handover report through continuous improvement measures such as training, evaluation, continuous inspection and feedback.
2. There are some problems in bedside handover, such as the unclear handover subject, mainly the head nurse's inspection, the responsible nurse can't take the initiative to take charge of the patient, introduce herself and understand the condition, the skin handover of the bedridden patient is not serious, and the night nurse can't tidy up the bed unit of the critically ill patient before handing over the shift. Through training, inspection and guidance, bedside handover is more standardized than before.
(3) Implementing graded nursing system.
1, graded nursing was not carried out according to the level of nursing, especially for chemotherapy patients, the liquid input and local skin condition were not carefully checked during the shift change, and the hourly patrol situation could not be recorded, especially at noon and afternoon. The content of disease observation is not clear. When carrying out oral medication orders, nurses can't grasp the patient's medication situation, patients can't grasp the function, side effects and medication methods of drugs, nursing guidance such as abdominal circumference measurement of ascites patients and oral care of fasting patients is not in place, and the health education effect is poor. By defining the responsibilities of responsible nurses and responsible team leaders, the implementation of graded nursing system is more standardized than before.
2. Improve the emergency plan, strengthen the emergency plan drills and positioning rescue drills, and improve the emergency handling ability of nurses. The internal medicine department organized emergency drills for hypoglycemia and anaphylactic shock, and each ward organized corresponding content drills according to the characteristics of the region. Two patients with anaphylactic shock in ward 3 were successfully rescued, and 1 ward 1 patient committed suicide. Nurses can rescue and report in an orderly manner according to the pre-plan, and nurses in all wards can carry out rescue in an orderly manner according to the positioning rescue plan, which improves the success rate of rescue and has been affirmed by doctors.
3, organize regular safety meetings, timely analysis of defects found in the inspection, serious rectification.
Second, the continuous improvement of nursing quality
All nursing quality evaluation standards.
(1) Writing quality of nursing documents: the format requirements of nursing documents were trained, the observation points of common diseases in various subjects were made, various scoring methods and applications were trained, and the writing template of nursing records of common diseases was made, which improved the writing quality of young nurses.
(2) Management of rescue articles and drugs: the rescue vehicles were changed into sealed management, and the methods of sealed, handed over and inspected were standardized.
(3) Management of head nurses: Young head nurses were trained to write all kinds of notebooks, which standardized the head nurses' work flow, guided the shift inspection and improved their management ability.
(4) Strengthen the evaluation, early warning and follow-up examination of high-risk patients with pressure ulcer, and pay attention to the dynamic observation of pressure ulcer score when the condition changes. Except pressure ulcer, the incidence of pressure ulcer in hospital was 0.
(5) Quality of basic nursing: By standardizing the admission examination and the examination during the shift change, the problems existing in basic nursing can be found in time. For example, whether the nails are trimmed, whether the bed unit is neat, whether the lying position is appropriate, and whether the infusion is standardized. Each group of nurses has a treatment and nursing list, and the problems found by the responsible team leader and head nurse form nursing instructions in time, telling nurses to write them on the treatment and nursing list and implement them in a planned way, and check and urge them in time to improve the quality of basic nursing.
(VI) Nursing quality of critical illness: check and guide every critical case, and focus on cultivating the ability of nurses to evaluate and observe the condition, find nursing problems, correctly implement nursing measures and communicate with patients and their families. List the observation points and nursing points of critically ill patients, explain the changes of nurses' condition that need to be reported to doctors, and carry out predictive training for possible situations, which is convenient for young nurses to implement and improve the level of critical care.
(7) TCM nursing quality: training and organizing the implementation according to the diseases of TCM nursing programs in various wards formulated by the nursing department. All designated diseases must have TCM nursing measures and TCM treatment techniques. Nurses can master TCM syndrome differentiation and treatment methods, and the utilization rate of TCM nursing techniques is higher than before.
Third, earnestly implement the overall nursing responsibility system and improve the quality of nursing service.
Each ward is equipped with relatively reasonable human resources. Each ward is divided into two major responsibility groups, and each responsibility group is divided into several groups. Each nurse in charge is responsible for a certain number of patients according to the ability level. The responsibilities of the responsible team leader and the responsible nurse are clarified, and the nurses are instructed to plan their working hours reasonably, carry out various treatments and nursing in a planned way, take the initiative to patrol patients, reduce the number of ringing bells, actively communicate with patients and strengthen the relationship with patients. The nurse-patient relationship is more harmonious than before. Strengthen the routine study of specialized diseases, improve the ability of nurses to observe the condition, find and deal with problems, strengthen the operation of basic nursing and the training and on-site guidance of specialized nursing operation, and standardize the operation.
Fourth, strengthen training and assessment to improve the level of nursing ability.
* * * Organize floor nursing rounds for X times, ordinary care rounds for X times, and specialized nursing training for X times. Give X lectures on business learning and training for nurses at all levels, assess the operation of nurses for X times, assess the clinical ability of young nurses for X times, guide nurses to participate in the first-aid technical operation competition in xx city, and win the group X prize.
Verb (abbreviation of verb) has its shortcomings.
1, the academic atmosphere is not enough, and there is no topic paper.
2. The communication skills of junior nurses are insufficient, and patients' satisfaction needs to be improved.
Summary of the annual work of internal medicine 3 Our department insists on "patient first, sincere dedication; People-oriented, pioneering and innovative. " The aim of running a hospital is to take the lead in developing the demonstration project of "consolidating basic nursing and providing satisfactory service". Successfully completed the task objectives set at the beginning of the year. The nursing work in 20xx years is summarized as follows:
First, the completion of nursing management objectives in the Department of Cardiology in 20xx is as follows
Up to now, 20xx has basically completed the task target set at the beginning of the year, and has taken the lead in carrying out the demonstration project of "consolidating basic nursing and providing satisfactory service", which has greatly improved the service consciousness of nursing staff, further improved the quality of nursing, and laid the foundation for developing the stewardess-style demonstration post. In interventional diagnosis and treatment, the development of emergency coronary angioplasty and stent implantation has opened up a green channel for better saving patients' lives. Independent completion of coronary angioplasty and stent implantation, successfully implanted stents for X patients with three-vessel disease, creating another milestone. The independent completion of single-chamber and dual-chamber pacemakers has once again created a precedent. The clinical application of defibrillation pacemaker and three-chamber pacemaker has brought our nursing to a new level. Up to now, nurses have completed X papers, all of which were published in journals above the provincial level. Most of the nursing goals set at the beginning of the year have reached the standard, but efforts are still needed in nursing staff training and nursing safety awareness.
Second, the specific implementation details
(1) Take the system as the criterion and human nature as the foundation.
Each system of the department is clear, and the regular nursing meeting is used to strengthen learning and supervise implementation. At the same time, the process is standardized, so that every nursing staff can put forward reasonable suggestions for the corresponding process and better apply it to clinic. In the demonstration project of "consolidating basic nursing and providing satisfactory service" initiated by our department, nurses expressed their opinions and quickly put their work on the right track. Our department has always adhered to the principle of restraining people by system, inspiring people by emotion and infecting people by atmosphere. Let every nursing staff have rules to follow, work happily and live happily. In the case of shortage of personnel, all tasks were successfully completed. Conscientiously implement the awareness rate of nursing staff on various systems, and ensure 100% awareness.
(2) Focus on improving nursing quality and strive for departments that patients can trust.
1, improving nursing quality.
(1) fully mobilize the consciousness of every nursing staff, strengthen the study of nursing quality, give play to the role of the department quality team, and adhere to the principle of twice-weekly assessment and irregular assessment. Timely rectification when problems are found has greatly improved the quality of nursing this year.
(2) The head nurse makes full use of "five rounds" and holiday rounds, finds problems in time and solves them in time, and formulates effective improvement measures for continuous improvement. If you make mistakes on the same issue twice in a row, you will be deducted from the assessment and linked to the bonus.
(3) Seriously study the problems existing in the monthly inspection of nursing department and departments, find out the reasons, standardize the process, implement the improvement and follow up the evaluation.
(4) The incentive mechanism has been implemented. In the monthly quality inspection, those who have few or no problems will be rewarded appropriately in the bonus, and those who have many problems or do not follow the principle will be fined.
(5) Fully listen to the opinions and suggestions of each nursing staff, and the nursing staff can actively put forward reasonable suggestions on nursing quality, which fully embodies humanized management.
2. Strengthen nursing safety to ensure nursing quality.
(1) Organize the nursing staff to study relevant knowledge seriously, and the head nurse will take the lead in studying relevant laws and regulations and do the work carefully.
(2) Strengthen the usual assessment, focus on discussion and analysis when encountering hidden dangers, and formulate corresponding measures to ensure nursing safety. The "three basics" monthly assessment should have relevant contents to improve safety awareness.
(3) Establish a tradition for many years, strictly implement relevant systems, educate new comrades, analyze and learn past cases, and stimulate everyone's safety awareness. However, the safety awareness of individual nurses still needs to be improved.
(3) Establishing reasonable training and putting it into practice ideologically has made great progress for nurses.
1, implement business ability training
(1) Carefully formulate the training plan, tailor the training plan for different personnel and stick to it. Form a process of training specialist nurses. On the basis of the original specialist nurses, X nurses will be trained this year to become the backbone of the department.
(2) Earnestly implement the monthly study and assessment of the "three basics" theory, implement the training and assessment of professional skills, and achieve the predetermined goal, which not only strengthens theoretical knowledge, but also strengthens practical ability. In order to solve the problem that patients complain about the low success rate of intravenous infusion puncture of individual nurses, mutual help groups and experience teaching groups have been carried out, and great progress has been made in wearing 24-hour dynamic electrocardiogram and ECG recording.
(3) Adhere to monthly business rounds and conduct targeted inspections. Insist on business study once a week, and earnestly implement the morning meeting to ask questions. According to the development of new business and new technology in this department, make a study plan and implement it seriously.
2. Build a reasonable echelon and build an excellent team.
(1) Training X specialist nurses this year. Make corresponding study plans according to their professional titles and abilities, assign them to participate in activities such as department management and business training, and gradually train them to become qualified specialist nurses. According to the needs of the department, X Icu nurses were trained. Take the principle of sending out to study and studying in the hospital.
(2) Make use of the fine tradition of mentoring system to train new nurses in a way of helping one, from department atmosphere to skill operation to words and deeds standardization, so that new nurses can quickly enter the role and integrate into the group. The department has a United atmosphere and good interpersonal relationship. At work, there are scenes of mutual help everywhere, and the sense of collective honor is very strong.
(D) to strengthen the construction of departmental culture, so that departments have cohesion.
Only when the department becomes a stage for employees to give full play to their abilities can employees fully display their intelligence. Based on this concept, we tap the advantages of all employees, find their advantages, make full use of them and abandon their shortcomings. Let them give full play to their talents and find a sense of belonging. In this year's demonstration project of "consolidating basic nursing and providing satisfactory service", we should give full play to team spirit, establish the concept of being proud of science and hospital, provide thoughtful and enthusiastic service to patients and treat patients as relatives and friends. Ideologically, every nursing staff can apply the principle of empathy, take patients as the center, demand themselves with the standard of high-quality service, give full play to the initiative and enterprising spirit of every young person, learn advanced deeds and figures, pay attention to details and constantly improve services. Departments solicit opinions from nursing staff every month, and hold symposiums regularly to listen to patients' opinions and suggestions. Department leaders constantly strengthen their own learning, be strict with themselves and play an exemplary role. Up to now, X thank-you letters and X banners have been received, and the satisfaction throughout the year has been continuously improved. There were no complaints during the telephone follow-up.
(5) Continuously improve the service capacity to meet the needs of patients.
1. The demonstration project activities of "consolidating basic nursing and providing satisfactory service" and "through train for head nurses" were carried out, and the "stewardess demonstration post" was prepared.
2. Pay attention to details, improve nursing and implement seamless nursing. Firmly establish the idea of "seeing the truth in details", follow the principle of people-oriented, and serve patients first before opening their mouths.
3. Gradually improve the communication ability of each nursing staff, through good communication with comrades and learning related content to improve. This year, X people were selected to do basic nursing and health education respectively, and the effect was good.
(six) the implementation of teaching work, strengthen the development of new business and new technology.
1, with the development of new business and new technology:
(1) Nursing care of emergency coronary angioplasty and stent implantation;
(2) Transradial stent implantation;
(3) Carry out the demonstration project of "consolidating basic nursing and providing satisfactory service";
(4) Nursing care of defibrillation pacemaker and three-cavity pacemaker.
2, cooperation to complete two scientific research:
One of (1) departments, to be identified.
(2) Nursing Project 2: Explore the improvement of nursing service by observing the warm water of urinary tract care for flight attendant nursing demonstration posts and male patients with indwelling catheter.
3, to carry out the teaching work, someone who's in charge, nursing students into the department, entrance, school inspection. Every student can learn something in a down-to-earth manner and master the relevant knowledge of cardiology from time to time. And teach students in accordance with their aptitude, and constantly strengthen the ability of teachers, so that every student can learn knowledge. Xx month provided a learning atmosphere for X students. And can teach students in accordance with their aptitude, so that students can absorb knowledge to the maximum extent.
4. Papers, the number of papers published in the whole year is X.
(7) Others
In terms of material storage and instrument maintenance, it can be counted regularly without waste. Strengthen the maintenance, regular inspection and maintenance of instruments. Reduce consumption and continuously improve economic benefits. Strengthen family planning work, do a good job of female workers, and continue to maintain the glorious title of Baotou Women's Civilization Demonstration Post. Adhere to the clean-up work and ensure that it is twice a month. Adhere to daily cleaning, cleaning at any time, keep the ward clean and hygienic.
(VIII) Rectification measures
1, nurses are being trained.
(1) Encourage learning and broaden knowledge by taking self-study exams and adult education. At the same time, all departments should create a learning atmosphere and let them devote themselves to it.
(2) Strengthen the assessment, use the morning meeting to ask questions, conduct spot checks at ordinary times, and conduct assessment.
(3) Strengthen the "three basics" theory and technical training for each nursing staff, and link it with the year-end cadre assessment and bonus, so that they have a sense of urgency.
2. In the aspect of nursing safety awareness.
(1) Strengthen the study of relevant laws and regulations, pay attention to them ideologically, have a correct attitude and be accurate in action.
(2) Strengthen the corresponding case studies, draw lessons from them and learn from them.
(3) From the beginning of entering the department, conduct training in a planned way and make a good demonstration.
(4) cultivate keen observation ability and find hidden dangers in time.
3. In terms of services
(1) Strengthen the consciousness of active service and continuously improve the quality of nursing staff;
(2) Continue to implement humanized service measures, strengthen communication skills, apply empathy, and constantly improve the service ability of nursing staff.
(3) treat yourself as relatives and friends of patients in the hospital.
(4) The head nurse deeply understands the problems that patients need to solve most, and solves them in time. The head nurse conducts a weekly 1 satisfaction survey to solve the existing problems in time and give timely feedback.
(5) Adhere to the follow-up of discharged patients and implement the succession.
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