I. First Consultation Responsibility System
(1) The physician or department that receives the patient for the first time shall be the first physician and the first department, and the first physician shall be responsible for the patient's examination, diagnosis, treatment, resuscitation, transfer to the hospital, and transfer to the department, etc. The first physician shall be responsible for the patient's examination, diagnosis, treatment, resuscitation, transfer to the hospital, and transfer to the department.
(2), the first physician must ask a detailed medical history, physical examination, necessary auxiliary examination and treatment, and carefully record the medical record. Patients with a clear diagnosis should be actively treated or proposed treatment; patients whose diagnosis is not yet clear should be treated symptomatically at the same time, they should promptly ask for consultation with higher-level physicians or physicians of the relevant departments.
(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 matters needing attention to be clear, and carefully do a good job of the shift record.
(4), the emergency, critical, serious patients, the first physician should take active measures to implement rescue. If the disease or multidisciplinary disease for non-affiliated professional diseases, should be organized by the relevant departments or report to the hospital authorities to organize a consultation. Critically ill patients in need of examination, hospitalization or transfer, the first physician should accompany or arrange for medical personnel to accompany the escort; such as the receiving hospital conditions, need to be transferred to the hospital, the first physician should be contacted with the transfer of hospitals to make arrangements for the transfer of hospitals.
(E), the first physician in dealing with patients, especially emergency, critical and serious patients, the organization of the relevant personnel to consult, decide to admit patients to the department and other medical acts of the right to decide, any department, any individual shall not be any reason to shirk or refuse.
Second, three-stage physician check-up system
(a), medical institutions should establish a three-stage physician treatment system, the implementation of the chief physician (or deputy chief physician), attending physicians and residents three-stage physician check-up system.
(2), the chief physician (deputy chief physician) or attending physician room visits, should be attended by residents and related personnel. Chief physician (deputy chief physician) room visits twice a week; attending physician room visits once a day. Residents are responsible for the patients under their care 24 hours a day, the implementation of morning and evening room checks.
(3) For patients in acute and critical condition, the resident should observe the change of condition at any time and deal with it in time, and if necessary, he/she can ask the attending physician and chief physician (deputy chief physician) to check the patient temporarily.
(d) For newly admitted patients, the resident shall check the patient within 8 hours of admission, the attending physician shall check the patient within 48 hours and give advice on treatment, and the chief physician (deputy chief physician) shall check the patient within 72 hours and give guidance on the patient's diagnosis, treatment, and handling.
(5), before the room visit should make adequate preparations, such as medical records, X-ray films, 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 laboratory tests and the need to solve the problem. The superior physician can do the necessary examination according to the situation, put forward the diagnosis and treatment of opinions, and make clear instructions.
(F), the contents of the room:
1, the resident room, required to focus on the rounds of acute and critical, difficult, to be diagnosed, newly admitted, post-surgery patients, while rounds of the general patient; check the laboratory report card, analyze the results of the examination, and put forward the views of further examination or treatment; verification of the day of the implementation of the medical advice; to give the necessary temporary medical advice, the next morning, the special examination of the medical advice; inquiry The patient's dietary situation; take the initiative to seek the patient's opinion on medical treatment and diet.
2, the attending physician room, required to the patients under the management of the system checkup. Especially for the newly admitted, acute and critical, the diagnosis is not clear and the treatment effect of the patient to focus on the examination and discussion; listen to the residents and nurses; listen to the patient's statement; check the medical record; understand the patient's condition and seek advice on medical care, nursing care, diet, etc.; check the implementation of medical advice and the effect of treatment.
3, the chief physician (deputy chief physician) room, to solve difficult cases and problems; review of new admissions, diagnosis of critically ill patients, diagnostic and treatment plans; to decide on major surgery and special tests and treatments; random inspection of medical prescriptions, medical records, medical care, quality of care; listening to physicians, nurses, diagnosis and treatment of care; the necessary teaching work; to decide the patients discharged, transferred to the hospital, and so on.
Three, difficult cases discussion system
(a), in all cases of difficult cases, admission within three days of the diagnosis is not clear, the treatment effect is not good, the seriousness of the disease should be organized to discuss the consultation.
(2), the consultation is chaired by the head of the department or the chief physician (deputy chief physician), convene the relevant personnel to participate in serious discussions, as soon as possible to clarify the diagnosis and propose treatment options.
(3), the physician-in-charge must be prepared in advance, the material will be organized, write a summary of the medical record, ready to speak.
(4), 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 the participants of the professional and technical positions, condition report and the purpose of the discussion, the participants of the speech, the discussion of opinions, etc., certainty or concluding observations recorded in the course of the record.
Four, consultation system
(1), medical consultation includes: emergency consultation, intra-departmental consultation, inter-departmental consultation, hospital-wide consultation, and out-of-hospital consultation.
(2), 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.
(3) In principle, intra-departmental consultation should be held once a week, with the participation of the whole department. Mainly for the Department of difficult cases, critical cases, surgical cases, cases of serious complications or cases with scientific 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.
(4), inter-departmental consultation: the patient's condition is beyond the scope of the specialty, need other specialties to assist in diagnosis and treatment, need to carry out inter-departmental consultation. Interdisciplinary consultation 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, introduce the condition and listen to the consultation opinions. After the consultation to fill in the consultation record.
(E), hospital-wide consultation: difficult and complex conditions and the need for multidisciplinary *** with collaborators, public *** health emergencies, major medical disputes or some special patients should be hospital-wide consultation. Hospital-wide consultation is proposed by the director of the department, reported to the Medical Affairs (Services) agreed or designated by the Medical Affairs (Services) and decide the date of the consultation. The consultation department shall report the summary of the condition of the consultation case, the purpose of the consultation, and the persons to be invited to the consultation to the Medical Affairs Section in advance, which will notify the relevant departments to attend. Consultation by the medical government (services) or apply for consultation department director presided over the convening of the vice president of business and medical government (services) should in principle participate in and summarize, should strive to unify and clarify the diagnosis and treatment of the views. The physician in charge of the consultation records, and will be summarized in the medical record.
Medical institutions should be selective hospital-wide deaths, disputes, etc., academic, retrospective, learning from the summary analysis and discussion, in principle, held ≥ 2 times a year, presided over by the medical administration (services), the participants are members of the hospital's medical quality control and management committee and the relevant departments.
(F), 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 Consultations" (Decree No. 42 of the Ministry of Health) the relevant provisions of the implementation.
V. Critical patient rescue system
(1), 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.
(2), 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 event should be the section chief, medical administration (business) section or hospital leadership to participate in the organization.
(3), the physician in charge should be based on the patient's condition and the patient's family (or entourage) to communicate with the patient's family in a timely manner, orally (rescue) or in writing to inform the danger of the disease and sign.
(4), 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 is required to be accurate, clear, the nurse must be repeated in the implementation of oral medical advice. 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.
(E), the rescue room should be systematic, well-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.
Six, 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, four types of surgery: the surgical process is simple, the surgical technology is low in the difficulty of the ordinary and common minor surgery.
2, three types of surgery: the surgical process is not complex, the surgical technical difficulty of a variety of moderate surgery;
3, two types of surgery: the surgical process is more complex, the surgical technology has a certain degree of difficulty in a variety of major surgery;
4, one type of surgery: the complexity of the process of surgery, the surgical technical difficulty of a variety of surgeries.
(2), the surgeon grading
All surgeons should be qualified to practice medicine according to law, and the place of practice in the hospital. According to their health qualifications and their corresponding positions, the grading of the surgeon.
1. Residents
2. Attending physicians
3. Associate physicians: (1) Low seniority associate physicians: within 3 years of serving as an associate physician. (2) Senior associate physician: more than 3 years as an associate physician.
4. Chief Physician
(3) Scope of Surgery for Physicians at All Levels
1. Residents: under the guidance of higher-level physicians, they will gradually carry out and become proficient in four types of surgery.
2, attending physicians: proficiency in three and four types of surgery, and under the guidance of the superior physician, gradually carry out the second type of surgery.
3, low seniority associate physician: proficiency in two, three, four types of surgery, and under the guidance of the participation of higher-level physicians, and gradually carry out a type of surgery.
4, senior associate chief physician: skilled in two, three, four types of surgery, under the guidance of the chief physician, to carry out a type of surgery. According to the actual situation, they can also complete part of a class of surgery alone, to carry out new surgeries.
5, chief physician: skilled completion of all types of surgery, especially to complete the development of new surgery or the introduction of new surgery, or major exploratory research project surgery.
(D), surgery approval authority
1, normal surgery: in principle, by the department pre-operative discussion, by the director or the director of the department authorized by the deputy director of the approval.
2, special surgery: any one of the following can be regarded as a special operation, subject to serious pre-operative discussion by the department, signed by the section chief, reported to the medical administration (business) for the record, if necessary, by the hospital consultation or reported to the competent hospital leadership for approval. However, in an emergency or emergency, in order to save the patient's life, the physician in charge should make the decision on the spot, scramble for time and seconds, and actively rescue, and promptly report to the superior physician and the general duty, shall not be delayed in the resuscitation of the time.
(1) Surgery that may lead to disfigurement or disability;
(2) The same patient needs to be operated again due to complications;
(3) High-risk surgery;
(4) Surgery that is new to the unit;
(5) Surgery for patients with no primary patient, surgery that may give rise to or be involved in judicial disputes;
(6) The person who is being operated on is a Foreign guests, overseas Chinese, Hong Kong, Macao, Taiwan compatriots, special persons, etc.;
(7) foreign physicians to participate in the operation, foreign medical practice must be in accordance with the "People's Republic of China *** and the State Practitioners Law" relevant provisions of the relevant procedures.
Seven, preoperative discussion system
(1), for major, difficult, disabling, vital organ removal and new surgery, must be preoperative discussion.
(2) The preoperative discussion shall be presided over by the chief of the department and attended by all physicians in the department, and the surgeon, head nurse and responsible nurse must attend.
(3), the discussion includes: diagnosis and its basis; surgical indications; surgical methods, points and precautions; possible dangers of surgery, accidents, complications and their preventive measures; whether to fulfill the surgical consent signing formalities (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.; checking the preoperative procedures, the patient's mind and requirements. etc.; check the completion of the preoperative preparations. The discussion was recorded in the medical record.
(4) For difficult, complex, major surgery, complex conditions require the cooperation of the relevant departments, should be 2-3 days in advance to invite the Department of Anesthesiology and the relevant departments for consultation, and make adequate preoperative preparations.
VIII. Checking System
I. Clinical Departments
1. When issuing medical orders, prescriptions or carrying out treatments, patients' names, genders, bed numbers, and hospitalization numbers (outpatient numbers) should be checked.
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, dose, time, usage, concentration.
3. When counting the medicines and before using the medicines, we should check the quality, labeling, expiration date and batch number, and if they do not meet the requirements, they should not be used.
4, before the administration of drugs, pay attention to ask whether there is a history of allergy; the use of drastic, poisonous, anesthesia, limited drugs should be repeatedly checked; intravenous administration of drugs should pay attention to whether there is no deterioration, the bottle mouth is loose, cracks; to a variety of drugs, pay attention to the contraindications.
5, blood transfusion should be strictly three check eight system (see nursing core system - six, check system) to ensure the safety of blood transfusion.
Two, 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 count all the dressings and the number of instruments before and after the preoperative and suture.
4, the specimen taken off by surgery, should be checked by the roving nurse and the operator, and then fill out the pathology test sent for examination.
Three, 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 prescription content is consistent; check the label (bag) and prescription content is consistent; check whether the drugs have no deterioration, whether more than the expiration date; check the name, age, and account for the use and precautions.
Four, blood bank
1, blood type identification and cross-matching test, two people work to "double check and double sign", one person work to redo a time.
2, when issuing blood, with the person who takes blood *** with the check section, ward, bed number, name, blood type, cross-matching test results, blood vial (bag) number, the date of blood collection, blood type and dosage, blood quality.
V. Laboratory
1. When taking specimens, check the department, bed number, name, and purpose of the test.
2. When collecting specimens, check the department, name, sex, union number, number and quality of specimens.
3. When testing, check the reagents, items, and the conformity of the lab sheet with the specimen.
4, after the test, check the purpose, results.
5. When sending the report, check the department and ward.
6, pathology
1, when collecting specimens, check the unit, name, gender, joint number, specimen, fixed solution.
2. When preparing specimens, check the number, type of specimen, number and quality of sections.
3. For diagnosis, check the number, specimen type, clinical diagnosis, and pathologic diagnosis.
4. When issuing the report, check the unit.
VII. Radiology
1. When examining, check the department, ward, name, age, film number, site, and purpose.
2. When treating, check the section, ward, name, site, condition, time, angle and dose.
3. When issuing reports, check the department and ward.
VIII. Physical Therapy Department and Acupuncture Room
1. When various treatments are given, check the department, ward, name, area, type, dose, time, and skin.
2, low-frequency treatment, and check the polarity, the flow of electricity, the number of times.
3. When high-frequency treatment, and check the body surface, the body for metal abnormalities.
4. Before acupuncture treatment, check the number and quality of needles, and when removing needles, check the number of needles and whether there is any broken needle.
9. (Electrocardiogram, electroencephalogram, ultrasound, basic metabolism, etc.)
1. When checking, check the department, bed number, name, gender, and the purpose of the test.
2. For diagnosis, check name, number, clinical diagnosis, and test result.
3. When issuing a report, check the department and ward.
Other departments should also be based on the above requirements to develop their own work checking system.
Nine, the doctor handover system
I, 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 or deputy chief physician, the third line of duty for the chief physician or deputy chief physician. Trainee physicians on duty should be under the direction of the hospital physician to carry out medical work.
II. 24-hour duty system is implemented in all wards. The physician on duty shall take over the shift on time, listen to the briefing of the physician on duty, and accept the medical work assigned by the physician on duty.
Three, for the emergency, critical and serious patients, must do a good job of bedside handover. The physician on duty should be 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.
Four, the duty physician is responsible for the ward of the temporary medical work and the patient's temporary situation, and make a good emergency, critical, serious patient condition observation and medical measures to record. First-line duty personnel in the diagnostic and treatment activities encountered difficulties or questions should be promptly referred to the second-line duty physician, the second-line duty physician should be timely guidance to deal with. If the second-line physicians cannot solve the difficulties, they should ask the third-line physicians to guide them. In case of special problems that need to be handled by the supervising physician, the supervising physician must actively cooperate. In the event of the need for administrative leadership to solve the problem, should be promptly reported to the hospital's general duty or medical administration (business) section.
Fifth, the first and second line of physicians on duty at night must stay in the duty room, may not leave their posts without authorization, and should immediately go to the clinic 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 third-line duty physician may live at home, but must leave contact information and should go immediately when receiving a request call.
Sixth, the duty physician can not be "double duty", such as duty and outpatient clinic, surgery, etc., except for emergency surgery, but in the hospital district has an emergency treatment matters, should be prepared for the shift in a timely manner.
Seven, daily morning meeting, the physician on duty should be the focus of the patient's situation to the 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.
Ten, new technology access system
I. New technology should be in accordance with the relevant provisions of the state for the relevant procedures before implementation.
Second, the implementer of a written application, fill out the "to carry out new business, new technology application form", provide the theoretical basis and specific implementation details, results and risk prediction and countermeasures, the director of the Department of the review and sign the consent to the medical administration (business) Section.
Third, the Medical Affairs (Services) Section 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 only be carried out.
Four, the implementation of new businesses, 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 in the process of medical administration (business) is responsible for organizing experts to carry out stage monitoring, timely organization of consultations 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.
Sixth, the new business, new technology to complete a certain number of cases, the department is responsible for timely summary, and submit a summary report to the Medical Affairs (Services) Section, the Medical Affairs (Services) Section to convene a meeting of the Academic Committee, to discuss and decide whether the new business, the new technology in the clinic is fully carried out.
VII, the director of the department 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 the 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.
Xi, medical records management system
I. Establishment of a sound hospital medical records quality management organization, improve the hospital's "four-level" medical records quality control system and work on a regular basis.
Four-level quality control system of medical records:
1, the first level of quality control team consists of the department director, case members (attending physician title or above), the head nurse. It is responsible for the quality check of medical records in the department or the ward.
2, the second quality control department consists of hospital administrative functions, responsible for outpatient medical records, running medical records, archived medical records, etc., monthly sampling assessment, and the quality of medical record writing into the medical staff comprehensive goal assessment content, quantitative management.
3, three-level quality control department by the hospital case room full-time quality management physicians, responsible for the inspection of archived medical records.
4, the fourth level of 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 in charge of the composition. Quarterly at least once a hospital-wide evaluation of the quality of the medical records of all departments, in particular, pay attention to the review of the quality of the force connotation.
Second, the implementation of the Ministry of Health, "the basic norms of medical record writing (for trial implementation)" (WeiMaFa [2002] No. 190), "medical institutions, medical records management regulations" (WeiMaFa [2002] No. 193) and the province of the "standardization and management of medical documents," the requirements, focusing on the newly assigned, the new transfer of physicians and physicians for further training in the relevant knowledge and skills training in the medical record writing.
Three, to strengthen the operation of medical records and archived cases of 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 physician-in-charge shall check the patients, inquire about the medical history, write the first record of the disease and deal with the medical advice within 8 hours. Emergency patients should be viewed within 5 minutes and deal with the patient, 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 personnel should be within 6 hours after the end of the rescue to make up the record according to the facts, and be noted.
3, newly admitted patients, within 48 hours there should be attending physician above the title of physician room records, general patients should be 2 times a week chief physician (or deputy chief physician) room records, and be noted.
4, at least 1 time a day for the record of the course of critically ill patients, when the condition changes, record at any time, the record time should be specific to the minute. For seriously ill patients, at least 2 days to record a medical record. For stabilized patients, at least once every 3 days. For patients with stable chronic diseases, at least 5 days to record the course of the record.
5, a variety of laboratory tests, reports, 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 outside hospitals, if needed as a basis for diagnosis or treatment, should be requested to the relevant departments of the hospital physicians to consult, write a written consultation opinion, stored in the hospital inpatient medical records.
Four, discharge records should generally be filed within three days, special medical records (such as death records, typical teaching medical records) filed no 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., copying medical records, should be escorted by medical staff or then the case room copying.
Fifth, according to the "provincial quality management of medical records evaluation of rewards and punishments," the requirements and provisions of the establishment of the department and individual quality evaluation of medical records writing notification system and rewards and penalties mechanism.
Twelve, medical record writing standards
1, unified with blue and black ink, the contents of the requirements of objective, true, accurate, timely and complete.
2, the use of standardized Chinese characters; numbers with Arabic numerals; drug names can be written in Chinese, Latin, English; units of measurement using the national legal units of measurement. 3, the medical record can not be deleted, cut and paste, digging and mending, individual typographical errors can be the same pen and ink double line in the misprints; the superior physician to modify the pen in red ink, signing the date of modification and the full name. More than three revisions per page need to be rewritten.
4, general patients within 24 hours to complete the admission medical records, critical patients within 6 hours to complete; the first record of the course of the shift to complete, emergency surgical patients to complete the preoperative. 5, the course of the record is generally 1 / 2 ~ 3 days, admission and postoperative 3 days at least 1 time a day, the critical patients 1 / day, there are changes in the condition of the record at any time, the chronic patients can be 1 / week, the stage of the section of the 1 / month.
6, 3 days before admission, there are three levels of physician checkup records: new admissions of general patients within 48 hours of the attending physician or more checkups and records, within 72 hours of the deputy chief physician or more checkups and records.
7. Before surgery, there is a record of the attending physician or above checking the room or record of discussion.
8, difficult and critical patients have a record of discussion, major surgery has a record of pre-operative discussion.
9, specialty patients should have transfer in and out records, and completed in a timely manner.
10, the implementation of the signature system: all need to perform surgery, blood transfusion and other special tests, special treatment, need to sign an informed consent.
11, all diagnostic and treatment operations, pre-operative and post-operative operator's records.
12, auxiliary examination report card within 24 hours to be posted back to the medical record, the lintel column of the posting sheet to be filled out.
Thirteen, clinical blood audit system
1, clinical blood audit system is the implementation of medical quality and medical safety of the core system, strict implementation of the clinical blood audit system to ensure that the patient's safe and standardized blood.
2, the blood bank must be designated in accordance with the local health administrative department of the blood collection and supply institutions to purchase blood, shall not be used without the name of the blood station (bank) and the license mark of the blood.
3. Blood used in each department must be in accordance with the principle of blood transfusion, and the abuse of blood supply is strictly prevented.
4, the booking of blood: patients need blood transfusion, should be clinically in charge of the physician to fill out the transfusion order, the nurse on duty according to the medical advice of the line "three pairs", to the patient's collection of cross blood, the test tube should be labeled, and indicate the section, name, bed, hospital number, the day before the transfusion of blood sent to the blood bank (with the exception of emergencies).
5. The staff of the blood bank should contact with the blood station in time according to the booking of blood volume of each clinical department to prepare all types of blood and ensure the clinical blood volume without any mistake.
6, the blood bank staff accepts the specimen, should be carefully checked one by one, after the specimen will be accepted for blood preparation after there is no error.
7, where the blood bank prepared by the various types of blood, there should be a clear sign, compartmentalized storage in the refrigerator at 4 degrees Celsius, and at any time to observe the temperature changes in the refrigerator.
8. The staff of the blood bank should strictly follow the operation regulations of blood cross-testing to carry out cross-testing, recheck the blood type when necessary, and observe the whole blood, which should be free of fat blood and hemolysis, and the blood bag should be sealed and absolutely free of error before it is issued.
9. When taking blood, the nurse should carefully check the name of the recipient, bed number, hospital number, blood type and cross results, blood storage number and the name of the blood supplier, time of blood collection, blood type and other items on the transfusion order, and the blood can be taken out of the blood bank only after there is no error.
10. If there is a reaction to the blood transfusion, the physician in charge of the clinic should explain the situation to the blood bank and find out the reason together with the blood station.
11. The staff of the blood bank must ensure that the amount of incoming and outgoing blood, the inventory of blood is clearly accounted for and carefully kept, and shall not be destroyed privately without the approval of the hospital leadership.