Eighteen core systems:
1, the first physician responsibility system
2, the third-level physician checking system
3, the difficult cases discussion system
4, the consultation system
5, the rescue system for acute and critical patients
6, surgical grading classification management system
7, preoperative discussion system
8, death case discussion system
9, checking system
10, medical record writing and management system
11, duty and shift handover system
12, hierarchical nursing system
13, new technology and new project access system
14, critical value reporting system
15, antibacterial drug classification management system
Extended information:
A. First Consultation Responsibility System
1, the first physician or department of the first visit is the first physician and the first department, the first physician is responsible for the patient's examination, diagnosis, treatment, resuscitation, transfer and referral.
2, the first physician must ask a detailed medical history, physical examination, necessary auxiliary examination and treatment, and carefully record the medical records. Patients with a clear diagnosis should be actively treated or proposed treatment.
The diagnosis is not yet clear patients should be in symptomatic treatment at the same time, should be timely to ask the superior physician or the relevant department physician consultation.
3, the first physician before the end of the shift, the patient should be handed over to the physician on duty, the patient's condition and the matters needing attention, and carefully make a good record of the shift.
4, the emergency, critical, serious patients, the first physician should take active measures to implement rescue. If it is a non-professional diseases or multidisciplinary diseases, should organize the relevant departments or report to the hospital authorities to organize consultation.
Critical 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.
5, the first physician in dealing with the patient, especially emergency, critical, serious patients, have the organization of the relevant personnel consultation, the decision of patients admitted to the department of the right to decide on medical behavior, any department, any individual shall not be any reason to shirk or refuse.
Second, three-stage physician check-up system
Check-ups are carried out by the chief physician, attending physician, resident three-stage check-ups.
The day after the admission of the critically ill, there should be a superior physician checkup; night sickness after admission, the next day there should be a superior physician checkup record, the second physician to write the third level of physician checkup record, the first level of physician checkup record written by the second level of physician checkup record.
Physicians at all levels need to discuss the diagnosis and treatment of the case before the room visit, should consult the relevant literature beforehand to make full preparation to improve the quality of the room visit.
Three, difficult cases discussion system
Difficult cases: two weeks after admission to the hospital diagnosis is not clear; hospitalization laboratory or other auxiliary tests have important findings that will lead to changes in diagnosis and treatment; treatment effect is not good; nosocomial infections; difficult major surgery.
Serious cases: those whose condition is critical or whose condition has suddenly changed.
Fourth, consultation system
Consultation system, in order to strengthen the medical cooperation between departments, improve medical quality, ensure medical safety; in clinical work, in case of difficult, critical cases or diagnosis is not clear, suspected of other disciplines related to the case, must apply for consultation in a timely manner.
Consulting physicians must do:
(1) Read the medical records in detail, understand the patient's condition, personally diagnose the patient, supplement and improve the necessary tests.
(2) The consulting physician must record the consultation opinion in detail, put forward the specific diagnosis and treatment advice and prescribe the medical advice of this section, the consultation record includes the consultation opinion and recommendation, the consultation physician's department, consultation time and consultation physician signature.
(3) The patient's right to information must be fully respected, the patient needs to be self-paying or partially self-paying drugs or medical materials and special usage must be indicated in the consultation record, and inform the patient and the patient's authorized agent to perform the signature procedure.
(4) In case of difficult cases, unclear diagnosis or difficulties in treatment, the superior physician of the department shall be requested to assist in the consultation in a timely manner.
(5) The consultation process should strictly implement the diagnosis and treatment standard.
(6) It is strictly prohibited for the consulting physician not to personally view the patient telephone consultation.
V. Emergency and critical patient rescue system
1, emergency and critical patient rescue work, generally by the chief of the department or the (deputy) chief physician is responsible for organizing and presiding over the rescue work. In the absence of the head of the department or the head (deputy) chief physician, the physician with the highest title will preside over the rescue work, but the head of the department or the head (deputy) chief physician must be notified in a timely manner.
Special patients or patients needing multidisciplinary rescue, should be promptly reported to the Medical Department, Nursing Department and the dean in charge, in order to organize the relevant departments **** with the rescue work.
2, the emergency and critical patients are strictly responsible for the implementation of the system of first diagnosis, shall not be postponed on any pretext, must go all out, every minute and every second, all kinds of records in a timely and comprehensive manner, there are other sections of the condition of the attending department is responsible for inviting the relevant departments to participate in the resuscitation.
3, to participate in the rescue of critical patients, medical personnel must be clear division of labor, close cooperation, each in its own way, and adhere to their posts, unconditional obedience to the command of the presiding rescue personnel and the medical advice, but for the rescue of the patient's beneficial suggestions, can be submitted to the presiding rescue personnel recognized for use in the rescue of the patient.
4, participate in the rescue work of nursing staff should be under the leadership of the head nurse, the implementation of the presiding rescue personnel's medical advice, and closely observe changes in the condition, at any time will be the implementation of medical advice and changes in the condition of the report presided over by the resuscitator.
The execution of verbal medical advice should be repeated, and with the physician to check the medicines after the execution, to prevent the occurrence of errors and accidents.
5, the strict implementation of the shift handover system and checking system, each class should be responsible for the class, the condition of the resuscitation and a variety of drugs to be detailed shift, the drugs used in the empty ampere by two people check before leaving.
A variety of rescue medicines, equipment should be cleaned up in a timely manner after use, purging, replenishment, return to the original place, in order to prepare for reuse.
6, the need for multidisciplinary collaboration in the rescue of critical patients, in principle, by the medical department or medical vice president of the organization of the rescue work, and designate the presiding rescue personnel, multidisciplinary rescue of the patient's various disciplines should be the use of undergraduate expertise, unity and cooperation is committed to the patient's rescue work.
7, critically ill, seriously ill patients to fill out the critical notification form, in duplicate, a copy into the medical record, a copy to the patient's family. The patient's family members should be informed of the condition and prognosis in a timely and serious manner, and fill in the notification of the condition, in order to obtain the cooperation of the family members.
8, due to disputes, fights, traffic or production accidents, suicide, homicide and other causes of injury to patients and suspected patients, in addition to active rescue work, while the implementation of special circumstances report system.
In normal working days should be reported to the Medical Department and the Security Section, non-working days to the hospital general duty report, if necessary, report to the public security departments.
9, not to participate in the rescue work of the medical staff generally do not enter the rescue site, but must do a good job of rescue logistics.
10, rescue work, pharmacy, testing, radiology or other auxiliary departments and logistics departments, should meet the needs of clinical rescue work, to give full support and guarantee.
Sixth, graded care system
Hospitalized patients by the physician according to the condition of the decision level of care and give medical advice, divided into I, II, II level of care and special care four.
Seven, new technology access system
1, new technology should be in accordance with the relevant provisions of the state for relevant procedures before implementation.
2, 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 of review and sign the consent to the Medical Department.
3, the Medical Department of the organization of the Academic Committee experts to demonstrate, put forward the views of the Dean in charge of the approval of the implementation can be carried out only after the approval.
4, the implementation of new services, new technologies must sign the corresponding agreement with the patient, and should fulfill the corresponding obligation to inform.
5, new services, new technologies in the 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 larger technical problems found in the implementation process. Daily management is completed by the corresponding control physicians and monitoring physicians.
6, 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 Services Section, the Medical Services Section to convene a meeting of the Academic Committee, to discuss and decide whether the new business, the new technology in the clinic is fully carried out.
7, the director of the department should be directly involved in the development of new business, new technology, and make the 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 be a variety of unforeseen circumstances, and actively deal with the proper, good records.
VIII, clinical "critical value" reporting system
In order to strengthen the management of clinical "critical value", to ensure that the "critical value" timely report clinicians, so that clinicians can take timely and effective measures to ensure the safety of the patient.
In order to strengthen the management of clinical "critical value" to ensure that the "critical value" will be reported to the clinician in a timely manner, so that the clinician can take timely and effective treatment measures to ensure the patient's medical safety, and to prevent the patient from accidents, the development of this system.
"Critical value" report involves all outpatient, emergency and ward patients, focusing on the emergency department, operating room, all kinds of intensive care unit and other departments of acute and critical patients.
"Critical value" report departments include: laboratory, radiology, CT room, ultrasound, electrocardiography and other medical departments.
Nine, antibacterial drug management system
According to the characteristics of antibacterial drugs, clinical efficacy, bacterial resistance, adverse reactions, the local economic situation, the price of medicines and other factors, antibacterial drugs are divided into non-restricted use, restricted use and special use of the three categories of graded management.
X. Surgical Safety Verification System
Surgical safety verification is a tripartite (hereinafter referred to as tripartite) verification of the patient's identity and surgical site by a qualified surgeon, anesthesiologist and operating room nurse, respectively, before anesthesia, before the start of surgery and before the patient leaves the operating room, **** with the verification of the patient's identity and surgical site and other content.
Xi, clinical blood safety management and approval system
Clinical blood should be strictly implemented in the "Measures for the Administration of Blood in Medical Institutions" and "Clinical Blood Transfusion Technical Specification" of the relevant provisions of the promotion of scientific and rational use of blood, to eliminate the waste and misuse of blood, to ensure the quality and safety of clinical blood.
Before using blood in clinic, patients and their families should be informed of the purpose of blood transfusion, possible transfusion reaction and the possibility of infected diseases through the blood route, and the relevant items should be tested according to the technical specifications for blood transfusion, and both the doctor and the patient should sign the consent for blood transfusion and deposit it in the medical record.
The emergency blood transfusion for patients without autonomy without family members' signatures shall be reported to the Medical Department for consent and record, and shall be recorded in the medical record.
Clinical indications for blood use are implemented according to the "Blood Transfusion Technical Specification", clinical indications for blood use: Hb<100g/1, and Hc1<30%.
XII, information security management system
Hospital computer operators must operate the computer system in accordance with the correct use of computers. Violent use of computers or intentional destruction of computer hardware and software is strictly prohibited.
Without permission, may not disassemble the computer hardware system, if necessary, then notify the information technology staff.
Hospital computers are limited to the internal work of the hospital, in principle, not allowed to access the Internet. If you need to access the Internet for your work, you need to apply in writing to the Medical Department and submit the application to the Information Department for access after signing and approving the application.
Reference:
Baidu Library - 18 Core Systems