Introduction: In order to further implement the Ministry of Health, the State Administration of Traditional Chinese Medicine, the provincial health department on the implementation of the hospital management year activities of the requirements of the development of this provision. The following is my collection of Nanjing area between the hospital medical examination, test results of mutual recognition of the interim provisions, welcome to read.
First, the implementation of the purposeIn order to promote the in-depth development of hospital management activities, to further standardize medical behavior, to facilitate access to health care for the masses, to ensure medical quality, medical safety under the premise of avoiding unnecessary duplication of tests, and effectively reduce the burden on the patient, and gradually solve the problem of 'difficult to see a doctor, expensive to see a doctor', decided to pilot the work of mutual recognition of the results of medical examinations, tests between hospitals in the region of this city.
Second, the scope of applicationThe scope of application of the provisions of this provision is temporarily set for the city region engaged in the diagnosis of diseases, treatment activities above the second level (including second level) hospitals (including the corresponding size of the private hospitals).
Third, the principle of recognition
A hospital inspection, test results can be recognized without affecting the diagnosis and treatment of disease as a prerequisite to ensure the quality of care and medical safety.
Two of the recognized foreign hospital inspection, test results should be recorded in the medical record, the content of the record in addition to the inspection, test results should also include the name of the inspection agency, the date of inspection, file number. For hospitalized patients, the foreign hospital information to be retained should be retained.
Three hospitals of the same level, secondary hospitals to tertiary hospitals, the cyclical pattern of change in the time frame of the disease can provide a standardized and complete examination, test reports and the corresponding image data of the examination, test items in principle to be recognized each other, and no longer duplicate tests. Unless the diagnosis and treatment must be, the tertiary hospitals should also recognize the examination and test results of the secondary hospitals.
Four due to changes in condition, examination, test results are difficult to provide reference value (such as the diagnosis of the disease does not match, etc.); examination, test results in the development of the disease process changes in the magnitude of the large; examination, test items of great significance (eg, surgery and other major medical measures before) and other reasons need to be re-checked, it must be clear to the patient, and will be based on the review to be documented in the medical record. Among them, the use of Class A and B large-scale medical equipment inspection program (higher costs), must be signed by the patient or family members to agree before implementation. Emergency and first aid are not subject to the above restrictions.
Fourth, the recognition of projects and recognition methodsRecognition of projects including medical imaging results and clinical test results, divided into the following four categories.
The first category: medical imaging projects based on objective examination results (film, image) issued a diagnostic report. Including general radiography (including CR, DR), CT, MRI, nuclear medicine imaging (PET, SPECT).
The second category: medical imaging projects to be based on the dynamic observation of the inspection process to issue a diagnostic report, or diagnostic report is closely related to the inspection process `. Including radiography (including DSA), ultrasound, other imaging tests (electrocardiography, dynamic electrocardiography, electroencephalography, cerebral blood flow mapping, electromyography, etc.).
The third category: clinical test items, can only issue test reports, can not provide objective results. Including some of the better stability, higher cost of the test program. Specifically:
1, clinical biochemistry: total protein, albumin, glycated hemoglobin, total cholesterol, triglycerides, calcium determination, magnesium determination, iron determination;
2, clinical immunity: hepatitis B two half (except for abnormalities in liver function and preoperative), hepatitis C antibodies (except for abnormalities in liver function and preoperative), hepatitis A antibody IgM (except for abnormalities in liver function and preoperative), immunoglobulin, AFP (when used as a tumor marker), carcinoembryonic antigen, thyroid function (FT3, FT4, TSH);
3. Clinical microbiology: viral culture and identification, bacterial typing;
4. Clinical blood and body fluids: bone marrow smear cytology (the diagnosis is clear and uncontested clinically).
The fourth category: other less stable clinical test items. Such as routine blood, urine, stool routine, liver function, kidney function, blood glucose and so on.
For the first category of inspection items, as long as the patient can provide the inspection site is correct, comprehensive, good quality objective examination results (film, image), the hospitals should be mutually recognized. Recognized hospitals have doubts about the diagnostic report issued by the recognized hospitals, or if the patient cannot provide a diagnostic report, a consultation report can be issued by the imaging physician of the institution based on the objective examination results (films and images).
For the third category of test items, because the results are relatively stable, in the corresponding disease cycle change law time frame is generally not repeated.
For the second and fourth types of examination, testing programs, there are many factors that affect their results. The recognition of its results by the receiving clinician to determine, such as inspection, test results and clinical performance in line with the diagnostic and treatment needs, it is generally no longer reviewed.
V. Organization and management1, the hospitals should strengthen the organizational leadership of the work, the development of the corresponding inspection, supervision, assessment, evaluation system. On the one hand, to implement the corresponding external units of inspection, test results of the recognition of work, to avoid unnecessary duplication of inspection; on the other hand, to ensure that the unit's inspection, test quality, to eliminate the same inspection, test items in the same unit of different departments to complete as well as scientific research projects issued by the phenomenon of inspection, test reports, to provide patients with standardized and complete inspection, test reports and the corresponding imaging data.
2, the hospitals should strengthen the training of clinicians, so that clinicians continue to improve the basic clinical skills, to achieve a reasonable choice of examination, testing programs, to avoid over-reliance on instrumentation, to reduce unnecessary tests and repeat tests. At the same time, we must do a good job of publicizing the work of patients to reduce the duplication of tests due to the patient's own reasons, the patient's request for review of the project, should be recorded in the medical record, special projects (the use of large-scale medical equipment such as A, B higher cost projects) should be signed by the patient or family members to recognize.
3, the medical quality control committee to establish and improve the quality control system, strict quality inspection. In particular, the imaging, testing quality control committee should be regularly or irregularly inspected or sampling, to strengthen the quality control of inspection, testing, and regularly publish the results of the inspection, the inspection failed hospitals to be notified, and a deadline for rectification.
4, the hospitals above the second level should be based on the provisions of the implementation of the corresponding measures, and reported to the appropriate administrative department of health for the record to confirm; the district and county health bureaus will be subordinate to the implementation of hospitals reported to the Municipal Health Bureau for the record, and at the same time, to strengthen supervision and management of hospitals, to ensure that the smooth progress of the work.
5, the hospitals on the implementation of the 'mutual recognition' work to reduce the number of repeated examinations as well as for patients to save medical costs, according to the requirements of the Provincial Department of Health, please direct hospitals and other tertiary hospitals and municipal hospitals directly under the Office of the Ning Quarterly (the first quarter of the first month of each quarter, ten days before the report of the last quarter of the corresponding data) reported to the Municipal Health Bureau of Medical Affairs, the district and county health bureaus will be the hospitals belonging to the corresponding summary of data reported to the Municipal Health Bureau The medical affairs department.
These provisions since January 1, 2006 on a trial basis, by the Nanjing Municipal Bureau of Health is responsible for the interpretation.