One, the first diagnosis is responsible for the system 2
Second, the third-level physician check-up system 3
Third, the difficult case discussion system 4
Fourth, the consultation system 5
Fifth, the emergency consultation system 6
Fourth, the system of emergency patients 7
Seventh, the surgical grading system 8
Eight, preoperative discussion system 10
Nine, fatal case discussion system 11
Ten, checking system 12
Eleven, doctor handover system 15
Twelve, new technology access system 16
Thirteen, medical record management system 17
Fourteenth, graded care system 19
The first consultation is the responsibility of the first patient.
Second, 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; patients with a diagnosis that is not yet clear should be treated symptomatically at the same time, and should be promptly asked to higher-level physicians or physicians of the relevant departments for consultation.
Third, the first physician before the end of the day, the patient should be handed over to the physician, the patient's condition and matters needing attention to be clear, and carefully do a good job of handover records.
Fourth, the emergency, critical, serious patients, the first physician should take active measures to implement rescue. If the disease is a non-professional disease or multidisciplinary disease, should report to the department head and the hospital authorities in a timely manner to organize consultations. 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 reception conditions, the need for transfer, the first physician should be transferred to the hospital contact arrangements before transfer.
Fifth, the first physician in dealing with patients, especially emergency, critical and 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.
Three-stage physician room system
First, the establishment of three-stage physician treatment system, the implementation of the chief physician (or deputy chief physician, section chief), attending physicians and residents three-stage physician room system.
Second, the chief physician (deputy chief physician, department director) or attending physician room visits, should be attended by residents and related personnel. The chief physician (deputy chief physician, chief of department) room check twice a week; attending physician room check once a day. Residents are responsible for the patients under their care 24 hours a day, the implementation of morning and evening room checks.
Third, for acute and critical patients, residents should always observe the changes in the condition and deal with them in a timely manner, and if necessary, they can ask the attending physician, the chief physician (deputy chief physician, chief of department) to check the patients temporarily.
Fourth, for newly admitted patients, the resident should check the patient again within 8 hours of admission, the attending physician should check the patient within 48 hours and put forward processing advice, and the chief physician (deputy chief physician, chief of department) should check the patient within 72 hours and put forward guidance on the patient's diagnosis, treatment and processing.
Fifth, before the room visit to make adequate preparations, such as medical records, X-rays, all relevant examination reports and the required examination equipment. During the examination, the resident should report the summary of the medical record, the current condition, the results of the examination and the need to solve the problem. The superior physician can do the necessary checks according to the situation, put forward the diagnosis and treatment of opinions, and make clear instructions.
Sixth, the content of the room:
1, the resident room, required to the patients under the management of the system check. Requirements focus on rounds of acute and critical, difficult, to be diagnosed, new admissions, post-surgery 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 implementation of the day's medical advice; to give the necessary temporary medical advice, the next morning, special examination of the medical advice; questioning, checking the patient's diet; and take the initiative to seek the patient's views on medical care, diet, etc.
2, resident check-ups, require systematic check-ups of patients under their care.
2, the attending physician checkups, requirements for new admissions, acute and critical, diagnosis is not clear and poor treatment results of patients focus on the examination and discussion; listen to residents and nurses; listen to the patient's statement; check the medical records; understand the patient's condition changes and seek advice on medical care, nursing, diet, etc.; verification of the implementation of the medical advice and the effect of treatment.
3, the chief physician (deputy chief physician, chief of department) 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 inspection of medical prescriptions, medical records, medical care, quality of care; listening to physicians, nurses on the diagnosis of the views of the treatment and nursing care; to carry out the necessary teaching; to decide on the patients discharged, transferred to the hospital, and so on.
Three, difficult cases discussion system
First, 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.
Second, the consultation is chaired by the chief of the department or the chief physician (deputy chief physician), convened by the relevant personnel to participate in a serious discussion, as soon as possible to clarify the diagnosis and put forward a treatment plan.
Third, 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.
Fourth, the physician in charge should make a written record, and the results of the discussion will be recorded in the record book of difficult cases. Records include: the date of discussion, the host and participants of professional and technical positions, condition reports and the purpose of the discussion, the participants of the speech, the discussion of opinions, etc., certainty or concluding observations recorded in the course of the record.
Four, consultation system
I. Medical consultation includes: emergency consultation, intra-disciplinary consultation, inter-disciplinary consultation, hospital-wide consultation, and out-of-hospital consultation.
Second, emergency consultation can be notified by phone or in writing to the relevant departments, the relevant departments should be in place within 15 minutes after receiving the consultation notice. The consulting physician should indicate the time (specific to the minute) when signing the consultation opinion.
Third, the department consultation should be held once a week in principle, the whole department to participate. Mainly for the Department of difficult cases, critical cases, surgical cases, cases of serious complications or cases with research and teaching value of the Department of consultation. The consultation is organized and convened by the department head or chief resident. During the consultation, the physician in charge will report the medical history, diagnosis and treatment as well as the purpose of the consultation. Through extensive discussion, clear diagnosis and treatment opinions, improve the department's personnel's business level.
Fourth, the inter-disciplinary 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-disciplinary consultation. Interdisciplinary consultation by the physician in charge of the proposed, fill out the consultation form, write the consultation requirements and purposes, sent to the invited department. The invited department should send an attending physician or above for consultation within 24 hours. The supervising physician should be present during the consultation to introduce the condition and listen to the consultation opinions. After the consultation to fill in the consultation record.
Fifth, the hospital 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 consultation. The director of the department of hospital consultation, reported to the Department of Medical Services agreed to or designated by the Department of Medical Services and decide the date of the consultation. The consultation department should report the summary of the condition of the consultation case, the purpose of the consultation and the personnel to be invited to the Medical Services Department in advance, who will then notify the relevant departments to attend the consultation. The consultation is held under the chairmanship of the Department of Medical Services or the director of the department applying for consultation, and the vice president of business and the Department of Medical Services should, in principle, attend and summarize the consultation, and should strive to unify and clarify the diagnosis and treatment opinions. The physician in charge of the consultation records, and will be summarized in the medical record.
Should be selective on the hospital's death cases, disputes, etc. Academic, retrospective, reference summary analysis and discussion, in principle, held ≥ 2 times a year, hosted by the Department of Medical Services, the participants for the hospital's quality control and management of medical care committee members and the relevant departments.
Sixth, out-of-hospital consultation. Invite physicians from outside hospitals for consultation or send our physicians to outside hospitals for consultation, shall be in accordance with the Ministry of Health "Interim Provisions on the Management of Physicians' Outside Consultation" (Decree No. 42 of the Ministry of Health) relevant provisions.
V. Emergency consultation system
I. In case of emergency, critical and serious patients, the first medical staff shall not shirk their responsibilities, and shall take the most basic rescue measures in a race against time, and then inform the corresponding departments to participate in the treatment, and make a record of shift handover, and write a record of resuscitation.
Second, in case of emergency, the emergency department personnel can call for emergency consultation, the invited department on duty physician must arrive at the consultation room within 3 to 5 minutes, not on duty invited consultation physician must arrive at the consultation room within 10 minutes, and at the same time to bring the necessary rescue treatment and examination of this specialty instruments and equipment.
Specifically, when it comes to the rescue of critically ill patients and patients with multiple injuries involving multiple disciplines, it is necessary to ask for a multidisciplinary emergency consultation in a timely manner, and request to arrive at the earliest possible time to cooperate with the rescue. When the condition has been alleviated or afterward in the consultation list to write the invited departments to deal with the views.
Three, not more than 24 hours of observation patients need to consult, can be noted in the emergency medical record "has been invited × × emergency consultation", and by the observation room nurses on duty to contact with the consultation department by phone, the consultation department shall not be shirked, and come to the consultation in a timely manner.
More than 24 hours of observation patients need consultation, in addition to writing the observation medical records, should also fill out the emergency consultation order, by the observation room nurses on duty and consultation department telephone contact, invited consultation department should be as soon as possible to determine the consulting physician and arrive at the emergency department in a timely manner.
Four, consultation, emergency physicians should be prepared for the consultation of the necessary clinical information, and accompanied by the examination, the introduction of the condition, the invited physician to fill out the consultation record.
Fifth, after the consultation needs to be admitted to the hospital for treatment, the receiving or consulting physician to issue a certificate of admission, the nurse on duty to contact the hospital bed by phone. The doctor or nurse escorted to the hospital.
Sixth, invited to participate in emergency consultation physicians, should be arranged in the undergraduate work to go to the consultation; in the event of special reasons can not participate in emergency consultation, should be promptly assigned to the appropriate specialty qualifications of the physician to participate.
Six, critical patient rescue system
First, the development of the hospital emergency response plan for public **** health emergencies and the various specialties of the common critical patient rescue technical specifications, and the establishment of regular training and assessment system.
Second, 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, the major rescue events should be organized by the section chief, the Department of Medical Services or the hospital leadership to participate.
Third, 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, verbal (rescue) or written notice of the danger and sign.
Fourth, in the rescue of critical illness, must strictly implement the rescue procedures and plans to ensure that the rescue work timely, rapid, accurate and error-free. Medical personnel should work closely together, oral medical advice requires accurate, clear, the nurse in the implementation of oral medical advice must be repeated. 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 rescue within six hours after the fact to record, and to explain.
Fifth, the rescue room should be a perfect system, fully equipped, good performance. First aid supplies must be implemented "five", that is, a fixed number, a fixed location, a fixed personnel management, regular disinfection and sterilization, regular inspection and maintenance.
VII, surgical classification management system
A surgical classification
Based on the complexity of the surgical process and the requirements of surgical technology, the operation is divided into four categories:
1, a class of: surgical process is simple, surgical technology is low in the difficulty of the simple and small-scale surgery.
2, Category 2: small surgery and surgical process is not complex, the technical difficulty of medium surgery;
3, Category 3: medium-sized surgery and general large-scale surgery;
4, Category 4: difficult and serious major surgery and scientific research surgery, new surgery, multidisciplinary joint surgery.
Second, the classification of surgeons
All surgeons should be licensed in accordance with the law, and the place of practice in the hospital. According to their health qualifications and their corresponding positions, the grading of the surgeon.
1, resident
2, attending physician
3, deputy chief physician
4, chief physician
3, the scope of surgery at all levels of physicians
1, resident: to take charge of a type of surgery operator, the second and third types of surgical assistants.
2, attending physician: to take charge of the operator of the second type of surgery, with the help of the deputy chief physician, can take charge of the operator of the third type of surgery, the fourth type of surgery assistant.
3, deputy chief physician: take the operator of three types of surgery, with the help of the chief physician, can take the operator of four types of surgery.
4, chief physician: to take the operator of three or four types of surgery.
Fourth, the approval authority of surgery
1, a second type of surgery: in principle, by the department pre-operative discussion, by the chief of the department or the chief of the department authorized by the deputy director of the approval.
2, three, four types of surgery and special surgery: must be carefully pre-operative discussion by the department, signed by the director of the department, reported to the Department of Medical Services for the record, if necessary, by the hospital consultation or reported to the head of the hospital for approval. However, in case of emergency or emergency situation, in order to save the patient's life, the physician in charge shall make immediate decision, scramble for time and seconds, and actively save the patient, and report to the superior physician and the general duty in a timely manner, and shall not delay the time of saving the patient's life. Any of the following can be regarded as special surgery:
(1) surgery may lead to disfigurement or disability.
(2) The same patient needs to be operated again due to complications.
(3) High-risk surgery.
(4) The unit's new surgery.
(5) no master patient, may cause or involve judicial disputes.
(6) The patient is a foreign guest, overseas Chinese, Hong Kong, Macao, Taiwan compatriots, special people.
(7) foreign physicians to participate in the hospital surgery, foreign medical practice must be in accordance with the "People's Republic of China *** and the State Medical Practitioners Law," the relevant provisions of the relevant procedures.
Eight, preoperative discussion system
First, the major, difficult, disabling, vital organ removal and new surgery, preoperative discussion must be carried out.
Second, the preoperative discussion will be chaired by the director of the department, all physicians in the department to participate in, the surgeon, the head nurse and the nurse in charge must participate.
Third, the discussion includes: diagnosis and its basis; surgical indications; surgical methods, points and precautions; surgery may occur dangers, accidents, complications and their preventive measures; whether to fulfill the surgical consent signing procedures (need to be responsible for the conversation of the hospital physician in charge of the signatures); the choice of anesthesia, the operating room with the requirements; postoperative precautions, the patient's ideological situation and requirements, etc.; Check the completion of all preoperative preparations. The discussion is recorded in the medical record.
Fourth, for difficult, complex, major surgery, the complexity of the condition requires the cooperation of the relevant departments, should be invited to the Department of Anesthesiology and the relevant departments 2-3 days in advance of the consultation, and make adequate preoperative preparation.
Nine, the death of the case discussion system
First, the death of the case, in general, should be organized within one week to discuss; special cases (the existence of medical disputes) should be discussed within 24 hours; autopsy cases, to be discussed within one week after the issuance of the pathology report.
Second, the discussion of death cases, chaired by the director of the department, the medical staff of this section and related personnel to participate, if necessary, please ask the Department of Medical Services to send people to participate.
Third, the death of the case discussion by the physician in charge of the report of the condition, diagnosis and treatment and rescue, preliminary analysis of the cause of death and death of the preliminary diagnosis. Death discussion includes diagnosis, treatment, cause of death, death diagnosis and lessons learned.
Fourth, the discussion record should be recorded in detail in the death of the discussion of a special record book, including the date of discussion, the host and the names of participants, professional and technical positions, discussion of opinions, and the formation of a unanimous summary of concluding observations recorded in the medical record.
Ten, checking system
I. Clinical departments
1, medical advice, prescriptions or treatment, should check the patient's name, gender, bed number, hospitalization number (outpatient number).
2, the implementation of medical advice to carry out "three checks and seven right": before, during and after the operation; bed number, name, drug name, dosage, time, usage, concentration.
3. When counting the drugs and before using the drugs, we should check the quality, label, expiration date and batch number, if it does not meet the requirements, it should not be used.
4, before the administration of drugs, pay attention to ask whether there is a history of allergy; the use of dramatic, poisonous, anesthetic, limited drugs should be repeatedly checked; intravenous drug should pay attention to whether there is no deterioration of the bottle, whether the bottle mouth is loose, cracked; to give more than one kind of drug, pay attention to the contraindications of the pairing.
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
1, pick up the patient, to check the department, bed number, name, age, hospitalization number, gender, diagnosis, name of the operation and surgical site (left, right).
2, before surgery, must check the name, diagnosis, surgical site, blood dispensing report, preoperative medication, drug allergy test results, anesthesia methods and anesthesia medication.
3, where the body cavity or deep tissue surgery, to be preoperative and suture before and after the count of all dressings and instruments.
4, the specimen taken off the surgery, should be checked by the traveling nurse and the operator, and then fill out the pathology test sent for examination.
Third, the pharmacy
1, formula, check the content of the prescription, drug dosage, contraindications.
2, the issue of drugs, check the name of the drug, specifications, dosage, usage and the contents of the prescription is consistent; check the label (bag) and the contents of the prescription is consistent; check whether the drugs have deteriorated, whether the expiration date is exceeded; check the name, age, and account for the use of and precautions.
Fourth, the blood bank
1, blood typing and cross-matching test, two people work to "double check and double sign", a person working to redo.
2, the issue of blood, with the person who took blood *** with the check section, ward, bed number, name, blood type, cross-matching test results, blood vial (bag) number, date of blood collection, blood type and dose, blood quality.
V. Laboratory
1, to take the specimen, to check the section, bed number, name, test purpose.
2. When collecting specimens, check the department, name, gender, union number, specimen quantity and quality.
3, the test, check the reagents, items, labs and specimens are consistent.
4, after the test, check the purpose, results.
5, when the report is issued, check the section, ward.
Six, the Department of Pathology
1, the collection of specimens, check the unit, name, gender, joint number, specimen, fixative.
2. When making sections, check the number, specimen type, number of sections and quality.
3, diagnosis, check the number, specimen type, clinical diagnosis, pathological diagnosis.
4. When sending the report, check the unit.
VII, Radiology
1, examination, check the section, ward, name, age, film number, site, purpose.
2, treatment, check the section, ward, name, location, conditions, time, angle, dose.
3. When sending reports, check the department and ward.
VIII. Physical Therapy and Acupuncture Room
1. When various treatments are given, check the right section, ward, name, site, type, dose, time, and skin.
2, low-frequency treatment, and check the polarity, electric flow, the number of times.
3, high-frequency treatment, and check the body surface, the body has no metal abnormalities.
4, before and after acupuncture treatment, and check the number and quality of needles and whether there is any broken needle.
IX. (Electrocardiogram, electroencephalogram, ultrasound, basal metabolism, etc.)
1. When checking, check the department, bed number, name, gender, and the purpose of the test.
2. For diagnosis, check the name, number, clinical diagnosis, and test results.
3. When issuing reports, check the department and ward.
Other departments should also be based on the above requirements, to develop their own work checking system.
Eleven, the doctor handover system
First, the ward duty need to have a first, second and third line duty personnel. The first line of duty for the qualification of residents, the second line of duty for the attending physician, low seniority deputy chief physician, the third line of duty for the department head, chief physician or seniority deputy chief physician. The trainee physician on duty should carry out medical work under the guidance of the hospital's physicians.
Secondly, 24-hour duty system is implemented in all wards. The physician on duty should take over the shift on time, listen to the shift of the physician on duty, and accept the medical work assigned by the physician on duty.
Third, for patients with acute, critical and serious illnesses, it is necessary to do a good job of bedside handover. The physician on duty should be the emergency, critical, serious patient's condition and all the matters should be dealt with, to the physician on duty to explain clearly, the two sides for the responsibility of the handover sign, and indicate the date and time.
Fourth, the physician on duty is responsible for all temporary medical work in the ward and the patient's temporary situation, and make a good observation of the condition of emergency, critical and serious patients and medical measures to record. The first-line duty officer in the diagnosis and treatment activities encountered difficulties or questions should be promptly asked the second-line duty doctor, the second-line duty doctor should be timely guidance to deal with. If the second-line on-duty physician cannot solve the difficulties, the third-line on-duty physician should be instructed to deal with them. In case of special problems that need to be handled by the attending physician, the attending physician must actively cooperate. In case of problems that need to be solved by the administrative leadership, it should be reported to the hospital's general duty or medical service department in a timely manner.
Fifth, the first-line physicians on duty at night must stay in the duty room, do 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 an emergency rescue, consultation, etc. need to leave the ward, you must explain to the nurse on duty to go and contact methods. The second and third line physicians on duty can live at home, but must keep communication open, and should go immediately when receiving the request call.
Sixth, the duty physician can not "a post double responsibility", such as duty and clinic, surgery, etc., except for emergency surgery, but in the ward with emergency treatment matters, should be prepared by the class for timely processing.
Seven, the daily morning meeting, the physician on duty should be key patients to the ward medical staff report, and to the physician-in-charge of the situation of critically ill patients and the problems that remain to be dealt with.
XII, 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 section chief review and sign the consent to report to the Department of Medical Services.
Third, the Department of Medical Services Organization 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 implementation of new services, new technologies by the Department of Medical Services is responsible for organizing experts to stage monitoring, timely organization of consultations and academic discussions, to solve 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 Department of Medical Services, the Department of Medical Services to convene a meeting of the Academic Committee, to discuss the decision of the new business, the new technology whether the full implementation of clinical.
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 deal with the proper, good records.
Thirteen, medical records management system
First, the establishment of a sound hospital medical records quality management organization, improve the hospital's "three-tier" medical records quality control system and work on a regular basis.
Three-level quality control system of medical records:
1, the first level of quality control team by the department director, case members (attending physician title or above), the head nurse. Responsible for the quality check of medical records in the department or the ward.
2, the second quality control department for the medical administration of the quality control office, is responsible for outpatient medical records, running medical records, archived medical records monthly sampling assessment, and the quality of medical record writing into the medical staff comprehensive goal assessment content, quantitative management.
3, the three-tier quality control organization by the president or vice president of business and experienced, responsible senior title of the medical, nursing, technical staff and the main business management department responsible for the composition. Monthly evaluation of the quality of the hospital's medical records of all departments, in particular, pay attention to 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 [2002] No. 190), "medical institutions, medical records management regulations" (Wei medical hair [2002] No. 193) and the province of the "standardization and management of medical instruments," the requirements, pay attention to the new allocation, the new transfer to the physician and the doctor's training of the relevant medical record writing knowledge and skills training.
Third, to strengthen the operation of the medical record and archived case management and quality control.
1, the medical record of the first session of the record, preoperative conversation, preoperative summary, surgical records, postoperative (postpartum) records, important rescue records, special invasive examination, pre-anesthesia conversation, pre-transfusion conversation, discharge diagnostic certificates and other important records should be written by the hospital physician in charge of the signature or review. Surgical records should be written by the operator or the first assistant, such as the first assistant for training physicians, must be reviewed and signed by the hospital physician.
2. After the admission of the patients, the attending physician should check the patients, ask for medical history, write the first record of the course of the disease and deal with the medical advice. Emergency patients should be viewed within 5 minutes and deal with patients, hospitalized medical records and the first record should be completed within 2 hours in principle, due to the rescue of the patient failed to complete in time, the relevant medical staff should be in the end of the rescue within 6 hours according to the fact that the record, and be noted.
3, newly admitted patients, within 48 hours there should be attending physician above the title of physician room record, general patients should be 1-2 times a week chief physician (or deputy chief physician) room record, and be noted.
4, the critical patient's course of record at least 1 time a day, when the condition changes, record at any time, record time should be specific to the minute. For seriously ill patients, at least 2 days to record a medical record. For stabilized patients, the patient history should be recorded at least once every 3 days. For stable patients with chronic diseases, at least 5 days to record the course of the record.
5, a variety of laboratory tests, report cards, blood orders should be posted in a timely manner, is strictly prohibited from loss. 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 are attached to the hospital's medical record. Imaging data or pathology data from other hospitals, if needed as a basis for diagnosis or treatment, should be requested to the relevant departments of the hospital physician consultation, written consultation opinions, stored in the hospital inpatient medical records.
Fourth, the discharge medical records should generally be filed within three days, special medical records (such as the death of the medical records, typical teaching medical records) filing time is not more than one week, and timely report to the case room for the record.
V. Strengthen the safety of medical records to prevent damage, loss, theft, etc., when copying medical records, should be escorted by medical staff or then the case room copying.
Sixth, the establishment of the department and individual medical records writing quality evaluation notification system and reward and punishment mechanism.
Fourteen, graded care system
1. special care
1.1, adapt to the object
Critical condition, need to be observed at any time, in order to carry out the rescue of the patient, such as severe trauma, a variety of complex and difficult after major surgery, organ transplantation, large-area burns and the "five failures" and so on.
1.2, nursing content
1.2.1, the establishment of specialized 24-hour nursing, close observation of the condition and vital signs.
1.2.2, the development of nursing plans, strict implementation of the diagnosis and treatment and nursing measures, timely and accurate fill in the special care record sheet.
1.2.3 Prepare first-aid medicines and equipments for emergency use at any time.
1.2.4, conscientiously and carefully do all the basic care, strictly prevent complications, to ensure patient safety.
2. First-class nursing
2.1, adapt to the object
Critical condition requires absolute bed rest patients, such as a variety of major surgery, shock, paralysis, coma, fever, hemorrhage, liver and renal failure, and preterm infants and so on.
2.2, nursing content
2.2.1, every 15 ~ 30 minutes to visit the patient, observe the condition and vital signs.
2.2.2, formulate nursing plan, strictly implement the diagnosis and treatment and nursing measures, fill out the special nursing record sheet in time.
2.2.3 Prepare resuscitation medicines and equipment as needed.
2.2.4, conscientiously and carefully do the basic care, prevent complications, to meet the patient's physical and mental needs.
3. Secondary care
2.1, adapt to the object
Severe condition, life can not take care of the patient, such as major surgery after the stabilization of the condition of the person, as well as the old and frail, young children, chronic diseases should not be more active.
3.2, nursing content
3.2.1, every l two hours to visit the patient, observe the condition.
3.2.2, according to nursing routine care.
3.2.3, life to give the necessary assistance, to understand the patient's condition and state of mind, to meet the physical and mental needs.
4. tertiary care
4.1, adapt to the object
Mildly ill patients, life can basically take care of themselves, such as general chronic diseases, disease recovery and pre-surgical preparation stage.
4.2, nursing content
4.2.1, twice daily rounds of the patient, observe the condition.
4.2.2, according to nursing routine care.
4.2.3, give health care guidance, urge the patient to comply with hospital regulations, understand the patient's condition dynamics and mentality, to meet the needs of the two aspects of the heart.
4.2.3.