I. Anesthesia Record Sheet Management System
1, anesthesia record sheet is a medical file of surgical treatment of the patient, but also valuable information for teaching and research work. Therefore, anesthesiologists are required to fill it out carefully.
2, anesthesiologists should be serious, truthful anesthesia record sheet fill out the complete and clear, clear handwriting.
3, anesthesia record sheet is responsible for the management of a person, according to the date of finishing once a month. The anesthesia record sheet is managed by a special person, and it is organized once a month according to the date.
Two, pre-anesthesia difficult case discussion and consultation system
1, for difficult cases or cases with teaching significance, rare cases, pre-operative discussion under the auspices of the chief of the Department of surgery, the operation of the problems that may occur during the proposed corresponding measures.
2, retrospective summary of surgical anesthesia cases and critical patient rescue process and lessons learned.
3. The out-of-hospital consultation is performed by an associate chief physician or above or a senior attending physician, and the in-hospital consultation is performed by an attending physician or above.
4, because of the condition or insufficient preoperative preparation need to stop anesthesia should be agreed by the attending physician or above consultation.
5. Consultation cases and difficult cases are recorded in a special book.
Three, postoperative anesthesia management system
1, after the end of the operation, the anesthesiologist should be anesthesia record sheet carefully and truthfully filled out clearly, such as the patient's mental recovery, vital signs stable. The anesthesiologist and the surgeon must escort the patient to the ward, and explain the relevant precautions to the ward physician.
2, 72 hours after the operation, the anesthesiologist must follow up the patient and make a record on the medical record. Check for anesthesia complications and deal with them accordingly. Serious complications should be reported to the superior in time. Any problems related to anesthesia should be dealt with in a timely manner.
3. For patients with analgesic devices, the anesthesiologist must check the patient every day until the removal of the analgesic device, and record each check.
4, after the end of the operation, the anesthesiologist must clean up the anesthesia instruments and equipments in a timely manner, and pack them properly for safekeeping.
5, the results of post-anesthesia follow-up must be recorded in detail on the medical record. Including: the patient's postoperative condition, whether there are complications related to anesthesia and anesthesia operation.
6, after anesthesia did not escort the patient to the ward, did not hand over to the ward physician, resulting in patient accidents, the person concerned is responsible for and dealt with in accordance with the relevant provisions.
7. Failure to follow up the patient in time after anesthesia, failure to write the results of the follow-up visit, and writing records that do not meet the prescribed requirements shall be the responsibility of the person concerned and dealt with in accordance with the relevant regulations.
Four, anesthesia drug management system
1, a person is responsible for the management, regular inspection, collection.
2, poisonous anesthetic drugs in addition to a person in custody, anesthesiologists with poisonous anesthetic prescription to receive.
3, first-aid drugs placed in a fixed location, and have a clear sign, in order to facilitate the rescue of the urgent need.
4, special drugs in anesthesia, need to be responsible for the anesthesia of the attending physician agreed before application.
5, anesthesia drugs (poisonous anesthetics) shall not be borrowed, special needs need to be approved by the chief of the department and on time and in full.
5, anesthesia machine and instrument management system
1, anesthesia should be carefully checked before anesthesia anesthesia appliances and instruments used.
2, after anesthesia should be turned off all kinds of switches, remove all kinds of articulated tubes, disinfection of threaded tubes, respiratory capsule and so on.
3, the anesthesia machine, monitor and other valuable instruments are managed by special personnel, regularly checked and maintained, and found to be lost or damaged and immediately reported for repair, so as to ensure the perfect rate of anesthesia equipment.
4, laryngoscopes and other anesthesia instruments are managed by special personnel, and are often overhauled, so as to be ready for application at any time.
6, disinfection system
1, anesthesia instruments: threaded tubes, respiratory air bags, tongue forceps, etc. each time after use, soaking, cleaning, disinfection or fumigation, in order to prevent cross-infection.
2. The containers for soaking alcohol and other solutions are changed regularly.
3, placing anesthesia instrument trays and covers single person one use one disinfection.
4, disposable consumable materials after use, by the user to soak, disfigurement.
Seven, handover system
1, the main shift physician and night shift physician handover daytime anesthesia work and has not yet ended the emergency surgery.
2, the handover of the rescue kit, anesthesia equipment and the use of drugs and anesthetics.
3, the main shift is responsible for daytime emergency surgery patients anesthesia work and the Department of hospital rescue work.
4, the main shift or nurse is responsible for requesting replenishment of drugs used on the day.
VIII, anesthesia recovery room work system
1, anesthesia recovery room is a close observation of anesthesia patients awakening of the place, surgery, post-anesthesia critical patients to monitor the treatment and timely observation of changes in the condition of the patient, to improve the safety of the patient after surgery and anesthesia. After surgery, because of the anesthetics, muscle relaxants and nerve blocking effects have not yet disappeared, often prone to vomiting, aspiration, hypoxia, hypercapnia, water, electrolyte balance disorders, often leading to cardiovascular and respiratory dysfunction. Therefore, close monitoring and treatment should be carried out in the anesthesia recovery room and recorded in time.
2, recovery room patient routine monitoring general items include: blood pressure, respiration, pulse, oxygen saturation, electrocardiogram, blood routine, urine volume, rehydration volume and rate and drainage flow.
3, recovery room should be given to the patient adequate sedation, analgesia to reduce various complications.
4, the patient leaves the recovery room should meet the following criteria:
① general anesthesia need to be fully awake, can correctly answer the question, the airway is open, circulatory function is stable, blood oxygen saturation drop no more than preoperative 3-5%.
②Intervertebral anesthesia patients with satisfactory ventilation, general condition is stable.
5, recovery room in the Department of Anesthesiology under the leadership of anesthesiologists, anesthesiologists preside over the day-to-day work, the scope of its duties with the anesthesiology department of the third level of physician responsibility.
9, pain treatment system
1, pain clinic in addition to comply with all the rules and regulations of the outpatient department, stressing that the writing of medical records should be standardized, and the custody and follow-up should be routine.
2, patients should be clearly diagnosed before treatment, and if necessary, the relevant departments should be consulted.
3, difficult cases should be invited to the higher level of physicians or consult the relevant departments to study the treatment plan.
4, the patient should be observed for 15-30 minutes after treatment before leaving.
5, prepared first aid drugs and equipment.
6, should be the attending physician or more physicians out of the pain clinic.
7, postoperative pain treatment of patients should be timely medical advice, accounting for the nurse to observe the condition, at least once a day rounds the patient, adjust the dose of medication and speed.
Ten, talent training system
1, the director of the Department is responsible for the training of physicians at all levels of the Department, there must be a plan, a clear task, and there is a certain inspection and evaluation system.
2. Residents should rotate to circulatory and respiratory medicine and other departments for six months to one year. Write one paper or translation every year.
3. In addition to clinical work, attending physicians should undertake clinical research projects under the guidance of the department head, and write 1-2 papers or literature reviews every year.
4, to strive for and create conditions for all levels of physicians in batches sent to study foreign languages and further training.
5, by the department head or senior attending physician is responsible for teaching, as the medical students of the teaching task, according to the unified syllabus preparation. Under the direction of the attending physician, senior residents supervise medical students in their apprenticeships and internships.
6. Enrollment of physicians for advanced training is based on clinical practice and theory.
Eleven, business learning and scientific research system
1, the head of the department or a senior physician is responsible for the department's business learning, the contents of which include: exchange of clinical anesthesia experience, discussion of important cases, book reports, literature review, anesthesia, new drugs and new technologies, scientific research topics, such as the report of the meeting.
2. Case discussion is mainly about difficult cases or complication cases. In cases of death within 24 hours after surgery, general practice discussion should be held within one week to summarize the experience, learn lessons and continuously improve the level of anesthesia.
3. The scientific research program is formulated by the chief of the department with the relevant personnel, and the opening report should be made in the department before starting.
4. The results of scientific research should be reported in the department and deposited in the research file.