3. Attending physician:
(1) Review the medical prescription issued by the subordinate physician in a timely manner, and provide necessary guidance to the operation of the subordinate physician.
(2) Newly admitted general patients are to be checked for the first time within 24 hours. In addition to the addition of history and physical examination, the content of the examination requires:
① Diagnosis and diagnostic basis; ② Necessary differential diagnosis; ③ Treatment principles; ④ Precautions in the diagnosis and treatment.
(3) Newly admitted emergency, critical and serious patients at any time to check, deal with, and report the condition to the superior physician.
(4) Timely inspection and revision of medical records written by subordinate physicians, to ensure the quality of discharged medical records, and sign the first page of the medical record.
(5) If the diagnosis is not confirmed within 3 days of admission, or if there is an inter-professional case, an intra- or inter-disciplinary consultation should be held in a timely manner.
(6) patients to be diagnosed within 1 week of admission is still not clear diagnosis, to the director of the request for case discussion or hospital consultation.
(7) Correctly graded use of antimicrobials and specialty medications according to regulations.
(8) Personally examine the patient before surgery and intervention, make preoperative preparations, draw up a rigorous surgical program and implement it according to surgical grading and management standards. Immediately after surgery, complete the postoperative record, 24 hours to complete the surgical record.
(9) Closely observe the patient's condition changes after surgery and do a good job in the postoperative period.
(10) Responsible for the approval procedures for discharge of cured patients and report to the superior physician.
4, the director (deputy director) of the physician:
(1) organization or participation in the development of the quality management program, rules and regulations, diagnosis and treatment and operation routine.
(2) guide junior doctors to do medical work, supervise and inspect junior doctors to implement the system and diagnostic and treatment routines.
(3) for the newly admitted general patients require 48 hours to carry out the first check-up; critically ill patients at least 1 daily check-up; patient condition changes should be checked at any time; weekly organization of the whole department check-up 2 times.
(4) in addition to the contents of the examination of the history and physical examination of the supplement, the general patient should be: ① diagnosis and its diagnostic basis; ② differential diagnosis; ③ principles of treatment; ④ new developments in this area.
Undiagnosed patients should be: ① differential diagnosis; ② clear diagnostic ideas and methods; ③ development of appropriate treatment measures.
Critically ill patients should be: ① the main problems of the current; ② methods to solve the main problems.
(5) difficult cases and cases not diagnosed within 1 week of admission, the organization of intra-departmental discussions or in-hospital consultation, if necessary, to the Medical Department to apply for out-of-hospital consultation or remote consultation.
(6) To guide and supervise subordinate physicians to correctly classify the use of antimicrobial drugs and specialty medications.
(7) Organize preoperative and important pre-treatment case discussions, and guide subordinate physicians to do a good job in intraoperative and postoperative medical work. Major surgeries and important treatments should be attended in person.
(8) Approve the discharge of untreated patients, and guide patients to continue treatment after discharge.
(9) Review and sign the attending physician review of the transfer, discharge medical records.
(2) Quality requirements for nursing staff:
1. Nurse manager of the department:
(1) Organize and coordinate the work of nursing staff in the department in accordance with the duties of the nurse manager.
(2) Must meet twice for newly admitted patients.
(3) Organize the department nurses must check the room twice a day.
(4) Check the health education and basic nursing care of the nurse in charge of the ward.
2, receiving nurse:
(1) According to the patient's condition and other conditions immediately arranged for beds, and do a good job of admission education.
(2) Establish the medical record book and notify the doctor in charge and the nurse in charge.
(3) Newly admitted patients within 24 hours to complete the cleaning and sanitation disposal work, the nurse in charge of the patient's first health education, while doing a good job of basic care.
3, treatment nurses:
(1) according to the doctor's orders in a timely manner to receive medication, dispensing, must be in place within one hour of the patient's drug use.
(2) Strict implementation of aseptic operating procedures, and carefully observe the treatment process of special reactions, timely feedback to the doctor in charge and the head nurse.
4, night shift nurses:
(1) must meet each patient in a timely manner, and record patients who leave the hospital without permission.
(2) For new patients to complete all the preparation and treatment.
(3) Record what you do and do what you write in a timely manner according to the content of the nursing documentation requirements.
(C) Pharmacy staff quality requirements:
1, the pharmacy pharmacist:
(1) conscientiously implement the prescription system in accordance with the prescription or ward medical advice printout in a timely manner to complete the correct allocation of drugs.
(2) unreasonable use of drugs or contraindications to timely contact with the doctor.
(3) Ensure that the stored medicines comply with the preservation conditions and that there are no expired medicines.
2, depot pharmacist:
(1) Timely completion of the completion of the drug program. (2) Timely completion of the quality acceptance of drugs. (3) Timely completion of drug delivery under.
3. Clinical pharmacist:
(1) Communicate with doctors and nurses in a timely manner on the rational use of medication for critically ill patients in the department. (2) The patient's medication must be observed twice a day. (3) The medication of special patients must establish a medication history.
(D) Laboratory staff quality requirements: according to the implementation of the Laboratory staff duties.
(e) Functional department staff quality requirements: according to the functional department staff duties.
(F) Radiology staff quality requirements: according to the radiology staff duties.
(vii) Quality requirements for staff in other examination and treatment departments: the quality of work requirements must be carried out in accordance with the work system of the department.
Fourth, the assessment content:
The whole process of medical quality control including outpatient medical, ward medical activities and other components. The assessment content by process is divided into:
(a) outpatient medical:
1, registration, consultation Consultation Office, registration room: according to the professional disease and the urgency of the condition to guide the patient registration.
2, the first physician:
(l) the first physician responsibility system:
a, inquiring about the history of the disease in detail, the physical examination seriously, the formulation of a preliminary diagnosis, to make the appropriate treatment, and at the same time in accordance with the requirements of the medical record written outpatient (emergency) medical records (monthly inspection focus on the quality of medical record writing).
b. Specialized outpatient consultation is recommended.
c. Admission to hospital.
(2) the second visit: ① the original receiving physician should: a, recommended specialist consultation; b, hospitalization. ② new physician should: a, hospitalization; b, outpatient treatment.
(3) the third visit: still not diagnosed, the receiving physician should: a, hospitalization b, the patient refused to hospitalization should be performed signature procedures.
(4) when the patient needs to be admitted to the hospital for treatment, should be issued by the admission notice of the physician in accordance with the needs of the condition, indicating the special mode of admission: car or escort.
(ii) ward medical treatment:
1. Completed within 24 hours:
(1) The patient should be given initial treatment within 30 minutes of admission.
(2) by the attending physician to make preliminary diagnostic and treatment opinions and complete the medical record (completed within 24 hours of hospitalization medical records).
(3) If necessary, the attending physician proposed and requested the superior physician to organize the departmental discussion, inter-departmental or hospital consultation.
(4) Emergency, critical and serious patients at any time to ask the supervising physician to view and complete the medical record within six hours.
2, within three days of admission:
(1) Diagnosis is made in accordance with the diagnosis and treatment routine.
(2) those who are not diagnosed, do further examination, and if necessary, organize intra-departmental discussions and inter-departmental consultations.
3, 1 week after the admission of those who are not diagnosed, must be discussed within the department or hospital consultation, diagnosed in accordance with the implementation of the diagnosis and treatment plan, 2 weeks still can not confirm the diagnosis of those who are required to carry out out out-of-hospital or teleconsultation. (Specialty according to the routine implementation of diagnosis and treatment).
4, therapeutic measures:
(1) drug therapy:
① drug selection: a, the development of specialized drug norms and strict implementation; b, to strengthen the rational use of antibiotics.
② After the use of drugs, pay attention to the observation of the efficacy.
③ According to the condition, the efficacy of timely change, adjust the drug program.
④ Pay attention to the observation of the adverse effects of drugs, pay attention to the interaction between drugs, pay attention to the effect of drugs on other organs and other diseases.
(2) surgical treatment:
①Pre-operative preparation according to the diagnosis and treatment routine, according to the approval of the surgical classification. ② Operate according to the surgical routine. ③ Postoperative treatment according to the diagnosis and treatment routine.
(3) special diagnosis and treatment according to the professional diagnosis and treatment routine.
5, transfer:
(1) cure - discharge, specialty clinic follow-up. (2) Improvement--Specialized outpatient follow-up. (3)Not cured--Patient request for discharge or transfer needs to fulfill the signature procedure. (4) death - death record within 24 hours, l weeks to complete the death case discussion and timely submission of the case.
6. Discharge:
(1) Cured patients can be discharged by the attending physician for approval and report to the superior physician.
(2) improved by the director of the department (or the main, deputy director of the physician) to the patient to explain to the specialty clinic to continue treatment or return to the hospital for treatment of precautions, and approval before discharge.
(3) not cured by the director of the department (or doctor, deputy director) to the patient to continue treatment guidance and approval before discharge.
(4) The bedside physician must write on the patient's outpatient medical record? Discharge summary?
Note:
1, according to the condition, without time constraints and timely organization of various forms of consultation, such as out-of-hospital consultation, remote consultation.
2, critical patients should be bedside handover, daily handover records.
3, the report: the critical patients must be sent to the medical department of the critical notification form; special, emergency rescue patients must be reported by phone to the section chief, the section chief reported to the medical department and the dean in charge; the death and admission to the hospital for two weeks without diagnosis of the case should be reported in writing to the medical department. Nursing assessment by the Nursing Department in accordance with the quality requirements. Other quality in accordance with the functional sections or assessment rules.
V. Assessment methods and reward and punishment system:
(a) by the Medical Quality Management Committee organized by the Medical Department, Nursing Department, Hospital Sensory Section, Information Technology Section, Pharmacy and other functional sections of the assessment of each medical department, and will be the results of the monthly assessment in the form of the "Circular" issued to each department. The process of diagnosis and treatment is running medical records, prescriptions, maternal health manuals, birth control services, surgical record forms, a variety of applications for reports and other medical documents according to the hospital "medical quality management supervision and evaluation evaluation standards" content item by item assessment, weekly random sampling and feedback; medical records are mainly by the Medical Department, Nursing Department, the Information Section (case room) is responsible for the monthly sampling and evaluation of feedback.
(2) analyze the degree of impact of various diagnostic and treatment activities on the overall quality of medical care and the implementation of medical quality management control measures in various departments.
1, according to the hospital "medical quality management supervision and evaluation standards" is divided into 100 points, such as the inspection of the total score of more than 80 for qualified, unqualified departments in accordance with the hospital "job target responsibility performance appraisal methods" for punishment.
2, major medical quality problems in accordance with the relevant provisions of the hospital depending on the circumstances to be punished, cancel the year's advanced department review qualifications and the responsible person for administrative punishment and other processing.
3, outpatient physicians need to be admitted to the hospital for treatment of patients who are not admitted to the hospital in a timely manner, must be educated, punished, resulting in serious adverse consequences, according to the hospital's "quality of medical care, business supervision and evaluation of the system of rewards and penalties," "medical errors and accidents, registration, reporting, processing system," "medical incident accountability system" and "complaint management approach" and other relevant provisions of the punishment.