名仕生殖醫(yī)院管理制度

學(xué)習(xí)好資料歡迎下載學(xué)習(xí)好資料歡迎下載學(xué)習(xí)好資料歡迎下載目錄第一部分醫(yī)療相關(guān)管理制度一、醫(yī)療機構(gòu)醫(yī)療核心制度1、首診負(fù)責(zé)制度..............................................................242、三級醫(yī)師查房制度..........................................................243、疑難病例討論制度..........................................................254、會診制度..................................................................255、危重患者搶救制度..........................................................266、手術(shù)分級管理制............................................................277、術(shù)前討論制度..............................................................288、抗生素分級管理制度.........................................................289、查對制度..................................................................2910、醫(yī)生交接班制度............................................................3011、新技術(shù)準(zhǔn)入制度............................................................3212、病歷管理制度..............................................................3213、執(zhí)業(yè)醫(yī)師管理辦法..........................................................33二、門診管理制度1、門診工作制度...............................................................352、門診首診負(fù)責(zé)制.............................................................353、門診處方制度...............................................................364、診前準(zhǔn)備制度...............................................................375、會診轉(zhuǎn)診制度...............................................................376、預(yù)約診療制度..............................................................377、醫(yī)師值班、交接制度........................................................388、醫(yī)師崗前培訓(xùn)制度..........................................................389、傳染病、性病報告制度......................................................39三、醫(yī)療管理工作制度1、門診部工作制度.............................................................402、病情告知、手術(shù)和創(chuàng)傷性檢查制度............................................403、醫(yī)師值班、交接制度........................................................414、保護(hù)病人隱私權(quán)制度........................................................415、轉(zhuǎn)科、轉(zhuǎn)院制度............................................................426、危重病人報告制度..........................................................427、外科工作制度..............................................................438、內(nèi)科工作制度..............................................................449、婦科工作制度..............................................................4410、中醫(yī)科工作制度...........................................................4411、皮膚科工作制度...........................................................4512、醫(yī)療美容科工作制度......................................................4513、醫(yī)學(xué)影像（X線）工作制度.................................................46四、醫(yī)務(wù)科工作制度1、醫(yī)務(wù)科工作制度............................................................462、醫(yī)療事故防范、處理預(yù)案....................................................473、手術(shù)審批制度..............................................................524、病歷書寫基本規(guī)范（試行）..................................................535、出具診斷證明制度..........................................................586、醫(yī)師崗前培訓(xùn)制度..........................................................597、住院醫(yī)師培養(yǎng)、管理制度....................................................598、病案室管理制度............................................................629、醫(yī)療意外和突發(fā)性事件報告制度..............................................62五、醫(yī)務(wù)管理制度1、醫(yī)療病案管理制度...........................................................642、醫(yī)療保密制度..............................................................723、差錯事故登記報告處理制度..................................................724、醫(yī)療安全管理制度...........................................................735、醫(yī)療登記、統(tǒng)計制度.........................................................74六、傳染病管理制度1、傳染病、性病報告制度.......................................................752、傳染病檢診制度............................................................75七、病房管理制度1、出入院工作制度.............................................................762、查房制度..................................................................773、醫(yī)囑制度..................................................................784、住院病歷書寫制度..........................................................785、會診制度..................................................................806、轉(zhuǎn)院、轉(zhuǎn)科制度.............................................................807、疑難病例及死亡病歷討論制度................................................818、術(shù)前討論、審批制度........................................................829、急、危、重病人搶救、報告制度..............................................8210、病房醫(yī)師值班、交接班制度..................................................8211、醫(yī)療差錯、事故等級、報告和處理制度........................................8312、晨會、科務(wù)會、工休會制度.................................................8413、病區(qū)管理制度.............................................................8614、住院醫(yī)師培養(yǎng)、管理制度...................................................8715、患者住院管理制度.........................................................88八、麻醉科管理制度1、麻醉科工作制度.............................................................892、麻醉工作制度...............................................................903、麻醉記錄單管理制度........................................................914、麻醉科值班與交接班制度.....................................................915、麻醉恢復(fù)室工作制度.........................................................92九、醫(yī)學(xué)影像科工作制度1、放射科工作制度.............................................................922、放射科工作人員防護(hù)制度.....................................................933、放射科查對制度.............................................................934、X線攝影室管理制度.........................................................945、超聲檢查工作制度...........................................................946、超聲醫(yī)療質(zhì)量管理制度.......................................................957、心電圖檢查工作制度.........................................................95十、藥房管理制度1、藥房工作制度..............................................................962、藥品質(zhì)量管理制度..........................................................963、藥品不良反應(yīng)報告制度.....................................................974、藥房查對制度...........................................................975、門診西藥房工作制度.......................................................976、門診中藥房工作制度.......................................................987、藥庫管理制度..............................................................998、中藥庫管理制度..........................................................1009、處方管理制度............................................................10110、特殊藥品管理制度......................................................10211、麻醉藥品管理制度......................................................10312、精神藥品管理制度......................................................10413、放射性藥品管理制度....................................................10514、醫(yī)療用毒性藥品管理制度................................................10615、藥品效期管理制度......................................................10616、醫(yī)院藥品采購管理制度..................................................10617、藥品統(tǒng)計工作制度......................................................10718、藥品入庫檢查驗收管理制度..............................................10819、藥品出入庫復(fù)核制度....................................................10920、藥品質(zhì)量問題報告制度...................................................10921、藥品不良反應(yīng)監(jiān)測和報告制度............................................10922、藥品調(diào)配和復(fù)核制度....................................................10923、藥品保管養(yǎng)護(hù)和有效期監(jiān)控制度...........................................110十一、檢驗科管理制度1、檢驗科工作制度...........................................................................1102、安全管理制度..............................................................................1113、檔案管理制度..............................................................................1124、檢驗科臨床檢驗危急值報告制度.........................................................1155、檢驗科質(zhì)量管理制度......................................................................1176、檢驗科儀器維護(hù)、檢查、維修制度......................................................1207、質(zhì)控品管理制度............................................................................1208、檢驗科醫(yī)院感染管理制度.................................................................1219、質(zhì)量管理小組工作制度...................................................................12110、檢驗科收標(biāo)本發(fā)送報告單制度..........................................................12111、檢驗科生化室工作制度..................................................................12212、檢驗科免疫室工作制度..................................................................12413、檢驗科查對制度.........................................................................12414、血液發(fā)放查對制度.......................................................................12515、檢驗科疫情報告管理制度................................................................12516、檢驗科消毒隔離管理制度...............................................................12517、檢驗科醫(yī)療廢棄物處理制度............................................................12618、檢驗科標(biāo)本接收管理制度...............................................................12719、醫(yī)院檢驗科標(biāo)本拒收拒檢制度..........................................................12820、檢驗科安全制度..........................................................................12821、檢驗科儀器管理制度.....................................................................13022、檢驗科急診檢驗管理制度...............................................................13023、檢驗科差錯事故登記報告制度..........................................................13224、檢驗科信息管理制度....................................................................13225、檢驗科行為道德規(guī)范....................................................................13326、檢驗科投訴處理制度.....................................................................13327、檢驗科環(huán)境衛(wèi)生責(zé)任制度...............................................................13428、檢驗質(zhì)量保證措施.......................................................................13429、試劑管理制度.............................................................................13630、標(biāo)本管理制度.............................................................................13631、檢驗中心試劑請購、審批、驗收、貯存、入賬程序...................................13732、關(guān)于加強室內(nèi)質(zhì)控的若干規(guī)定...........................................................13833、血型安全鑒定規(guī)定........................................................................13834、檢驗科儀器室管理制度..................................................................13935、檢驗科感染管理制度.....................................................................13936、關(guān)于臨床檢驗中應(yīng)急措施的制度........................................................14037、檢驗科技術(shù)質(zhì)量管理制度................................................................14038、試劑、天平室制度........................................................................14139、技術(shù)管理制度.............................................................................14140、檢驗科報告發(fā)放制度.....................................................................14241、差錯等級制度............................................................................14242、醫(yī)院缺陷等級報告制度..................................................................14243、檢驗核對內(nèi)容.............................................................................14244、臨檢室制度................................................................................14345、檢驗科細(xì)菌室管理制度...................................................................14346、檢驗科醫(yī)院感染控制管理制度..........................................................144十二、醫(yī)療投訴管理制度1、投訴處理管理度.............................................................................1452、醫(yī)療收費投訴管理制度.....................................................................1453、醫(yī)療差錯（事故）登記報告制度..........................................................1454、醫(yī)療投訴管理程序..........................................................................1465、醫(yī)療投訴登記處理程序.....................................................................1466、醫(yī)療糾紛及投訴接待處職責(zé)...............................................................1477、接待醫(yī)療糾紛投訴的規(guī)定及處理程序.....................................................1488、醫(yī)院醫(yī)療糾紛投訴處理制度................................................................1489、重大醫(yī)療過失行為和醫(yī)療事故報告制度的規(guī)定...........................................14910、醫(yī)療事故防范處理預(yù)案...................................................................15111、醫(yī)療糾紛處理程序圖解....................................................................15412、病歷封存流程..............................................................................155十三、傳染病管理制度與崗位職責(zé)1、醫(yī)院傳染病管理委員會職責(zé)與制度.........................................................1562、傳染病登記、報告制度......................................................................1563、法定傳染病分類..............................................................................1584、預(yù)檢分診流程圖..............................................................................1595、傳染病疫情管理制度.........................................................................1606、傳染病疫情報告制度.........................................................................1627、傳染病疫情報告流程........................................................................1638、醫(yī)院傳染病預(yù)檢分診制度...................................................................1639、醫(yī)院傳染病病例登記和轉(zhuǎn)診制度............................................................16410、違反傳染病防治法責(zé)任追究制度.........................................................16411、感染管理制度..............................................................................16512、傳染病報告培訓(xùn)制度.......................................................................16513、消毒隔離制度...............................................................................16614、傳染病登記、報告流程....................................................................16715、傳染病報告卡上報流程.....................................................................16816、傳染病疫情網(wǎng)絡(luò)直報員工作職責(zé)..........................................................17017、疫情報告管理工作職責(zé).....................................................................170十四、醫(yī)院感染管理1、醫(yī)院感染管理委員會制度....................................................................1712、醫(yī)院感染管理委員會會議制度..............................................................1723、醫(yī)院感染管理科（醫(yī)務(wù)科）工作制度.......................................................1724、醫(yī)院感染年度培訓(xùn)計劃......................................................................1745、醫(yī)院感染管理制度............................................................................1756、醫(yī)院感染報告制度............................................................................1767、醫(yī)院感染發(fā)病率監(jiān)測制度...................................................................1778、醫(yī)院環(huán)境衛(wèi)生學(xué)監(jiān)測制度...................................................................1789、醫(yī)院消毒滅菌效果監(jiān)測制度.................................................................17810、消毒隔離制度...............................................................................18011、病房醫(yī)院感染管理制度.....................................................................18112、病房消毒隔離制度..........................................................................18113、門診手術(shù)室醫(yī)院感染管理制度.............................................................18214、手術(shù)室醫(yī)院感染管理制度..................................................................18315、手術(shù)室消毒隔離制度........................................................................18416、治療室、換藥室、注射室醫(yī)院感染管理制度.............................................18517、治療室、換藥室、注射室消毒隔離制度..................................................18618、門診部醫(yī)院感染控制制度..................................................................18719、檢驗科及實驗室醫(yī)院感染管理制度.......................................................18820、超聲科醫(yī)院感染管理制度及消毒隔離制度................................................18821、醫(yī)務(wù)人員手衛(wèi)生制度........................................................................18922、消毒藥械、一次性使用無菌醫(yī)療用品的管理制度........................................19123、抗感染藥物應(yīng)用的管理制度................................................................19224、抗感染藥物應(yīng)用原則........................................................................19225、醫(yī)院污水管理制度..........................................................................19326、艾滋病疫情監(jiān)測管理制度...................................................................19327、醫(yī)務(wù)人員職業(yè)暴露管理防護(hù)制度..........................................................19428、醫(yī)療廢物管理制度..........................................................................19529、醫(yī)療廢物分類目錄..........................................................................19630、醫(yī)療廢物分類收集、交接登記、運送、暫時貯存、安全防護(hù)、培訓(xùn)工作制度........19831、傳染病病歷登記和轉(zhuǎn)診制度................................................................19932、傳染病疫情管理制度........................................................................20033、傳染病報告制度.............................................................................20034、傳染病信息網(wǎng)絡(luò)直報制度..................................................................20635、傳染病疫情自查制度........................................................................20736、傳染病預(yù)檢分診制度.......................................................................20837、拖布管理制度................................................................................20838、消毒技術(shù)指引...............................................................................209十五、醫(yī)療質(zhì)量管理制度1、醫(yī)院質(zhì)量保證制度..........................................................2142、院長質(zhì)量查房制度..........................................................2153、門診醫(yī)療質(zhì)量管理和檢控制度...............................................217十六、醫(yī)療廢物管理制度1、醫(yī)療廢物管理制度.........................................................2182、重慶名仕生殖醫(yī)院醫(yī)院醫(yī)療廢物管理制度.................................2193、醫(yī)療廢物發(fā)生意外事故的應(yīng)急預(yù)案............................................220醫(yī)療廢物流失、泄漏、擴散意外事故處理流程.................................2205、醫(yī)療廢物流失、泄露、擴散事故處理流程圖...................................2226、醫(yī)療廢物流失、泄漏、擴散事故時緊急處理措施...............................2237、醫(yī)療廢物運送流程及管理要求...............................................2238、醫(yī)療廢物內(nèi)部運送工作制度.................................................2239、醫(yī)療廢物的管理要求.......................................................22310、重慶名仕生殖醫(yī)院醫(yī)療廢物處理工作流程................................22411、操作流程...........................................................22412、醫(yī)療廢物分類收集方法及工作要求...........................................22513、醫(yī)療廢物運送的工作要求...................................................22514、醫(yī)療廢物的交接登記要求...................................................22615、醫(yī)療廢物管理人員培訓(xùn)制度.................................................22616、醫(yī)療廢物職業(yè)安全防護(hù)工作制度.............................................22717、醫(yī)療廢物的管理措施......................................................22718、醫(yī)療廢物暫存處管理制度..................................................22819、醫(yī)院感染管理知識教育及培訓(xùn)制度...........................................22920、醫(yī)院環(huán)境衛(wèi)生學(xué)和消毒滅菌效果監(jiān)測制度....................................22921、污水消毒處理工作規(guī)程....................................................22922、醫(yī)療廢物處理流程.........................................................231第二部分臨床崗位職責(zé)一、醫(yī)務(wù)管理崗位職責(zé)1、業(yè)務(wù)院長崗位職責(zé).........................................................2322、醫(yī)務(wù)科主任崗位職責(zé)......................................................232二、門診醫(yī)師崗位職責(zé)1、門診部主任崗位職責(zé)........................................................2332、門診部主任（副主任）醫(yī)師崗位職責(zé)..........................................2333、門診部主治醫(yī)師崗位職責(zé)....................................................2344、外科醫(yī)師崗位職責(zé)..........................................................2345、內(nèi)科醫(yī)師崗位職責(zé)..........................................................2346、婦科醫(yī)師崗位職責(zé).........................................................2357、中醫(yī)科醫(yī)師崗位職責(zé).......................................................2358、皮膚科醫(yī)師崗位職責(zé)........................................................235三、住院部醫(yī)師崗位職責(zé)1、住院部主任崗位職責(zé)........................................................2362、臨床主任（副主任）醫(yī)師崗位職責(zé)...........................................2363、臨床主治醫(yī)師崗位職責(zé)......................................................2374、臨床住院醫(yī)師崗位職責(zé)......................................................237四、麻醉科崗位職責(zé)1、麻醉科主任崗位職責(zé)........................................................2382、麻醉科主任醫(yī)師崗位職責(zé)....................................................2383、麻醉科主治醫(yī)師崗位職責(zé)...................................................2394、麻醉科醫(yī)師崗位職責(zé).......................................................239五、醫(yī)學(xué)影像科崗位職責(zé)1、放射科主任職責(zé)............................................................2402、放射科醫(yī)師職責(zé)............................................................2403、超聲診斷醫(yī)師職責(zé)..........................................................2404、心電圖診斷醫(yī)師職責(zé)........................................................241六、藥房崗位職責(zé)1、藥房主任崗位職責(zé)..........................................................2412、（中、西）主任藥師崗位職責(zé)................................................2423、（中、西）主管藥師崗位職責(zé)................................................2424、藥劑師（中藥師）崗位職責(zé)..................................................2425、藥劑士（中藥士）崗位職責(zé)..................................................2436、藥劑員（中藥員）崗位職責(zé)..................................................2437、藥庫管理員崗位職責(zé)........................................................2438、門診西藥房崗位職責(zé)........................................................2439、門診中藥房崗位職責(zé)........................................................24410、門診中藥師（士）崗位職責(zé).................................................244七、檢驗科崗位職責(zé)1、檢驗技師職責(zé).................................................................................2452、檢驗技師工作要求...........................................................................2453、檢驗士職責(zé)....................................................................................2484、檢驗師職責(zé)...................................................................................2485、主管檢驗師職責(zé)..............................................................................2486、主任（副主任）檢驗師職責(zé)..................................................................2497、檢驗科主任職責(zé)..............................................................................2498、檢驗員職責(zé)...................................................................................2509、門診采樣室工作人員職責(zé)....................................................................250八、醫(yī)院感染管理崗位證職責(zé)1、醫(yī)院感染管理委員會及職責(zé).................................................................2512、醫(yī)院感染科（專兼職人員）職責(zé)...........................................................2513、醫(yī)務(wù)人員醫(yī)院感染管理職責(zé).................................................................2514、護(hù)理部在醫(yī)院感染管理工作中的職責(zé).......................................................2525、藥房在醫(yī)院感染管理工作中的職責(zé).........................................................2526、檢驗科在醫(yī)院感染管理工作中的職責(zé).......................................................252九、各類醫(yī)療質(zhì)量管理委員會職責(zé)與制度1、醫(yī)療質(zhì)量管理委員會職責(zé)與制度.............................................2532、病案管理委員會職責(zé)與制度................................................2543、醫(yī)院傳染病管理委員會職責(zé)與制度...........................................2554、院內(nèi)感染管理委員會職責(zé)與制度.............................................2555、藥事管理委員會職責(zé)與制度................................................2566、醫(yī)療安全管理委員會職責(zé)與制度.............................................2567、臨床用血管理委員會職責(zé)與制度.............................................2578、醫(yī)院、麻醉藥品、第一類精神藥品管理領(lǐng)導(dǎo)小組職責(zé)與制度.....................2589、急診急救搶救領(lǐng)導(dǎo)小組職責(zé)及搶救制度.......................................25810、護(hù)理質(zhì)量管理委員會職責(zé)與制度............................................259第三部分臨床相關(guān)工作流程一、醫(yī)務(wù)科相關(guān)工作流程1、會診制度工作流程.........................................................2602、全面質(zhì)量管理工作流程....................................................2613、醫(yī)務(wù)不合格醫(yī)療服務(wù)控制流程..............................................2624、醫(yī)院患者醫(yī)療投訴處理流程.................................................2635、醫(yī)療質(zhì)量三級質(zhì)量流程....................................................2646、醫(yī)院臨床科室質(zhì)量管理流程................................................265醫(yī)院門診醫(yī)生工作相關(guān)流程1、醫(yī)院門診醫(yī)生工作流程.....................................................2662、門診首診負(fù)責(zé)制度流程.....................................................267三、病房管理相關(guān)流程1、住院醫(yī)師交接班、值班制度流程..............................................2682、搶救工作流程..............................................................2693、休克搶救流程..............................................................270四、麻醉科相關(guān)工作流程1、麻醉科工作流程............................................................2712、麻醉病歷的書寫流程.......................................................272五、醫(yī)學(xué)影像科工作流程1、X線造影檢查工作流程......................................................2732、X線透視檢查工作流程......................................................2743、醫(yī)院門診心電圖室檢查服務(wù)流程.............................................2754、B超、彩色超聲診斷流程....................................................276六、藥房工作流程1、醫(yī)院門診藥房工作流程.......................................................................2772、醫(yī)院急救物品和藥品管理流程..............................................................278第四部分各科醫(yī)療質(zhì)量考核標(biāo)準(zhǔn)1、門診醫(yī)療質(zhì)量考核標(biāo)準(zhǔn)......................................................2792、臨床科醫(yī)療質(zhì)量考核標(biāo)準(zhǔn)....................................................2803、病房醫(yī)療質(zhì)量考核標(biāo)準(zhǔn)......................................................2824、麻醉科醫(yī)療質(zhì)量考核標(biāo)準(zhǔn)....................................................2835、超聲、心電室醫(yī)療質(zhì)量考核質(zhì)量..............................................2846、放射科醫(yī)療質(zhì)量考核標(biāo)準(zhǔn)...................................................2857、藥房醫(yī)療質(zhì)量考核標(biāo)準(zhǔn)......................................................2868、病區(qū)護(hù)理管理質(zhì)量考核標(biāo)準(zhǔn)..................................................2879、手術(shù)室質(zhì)量管理考核標(biāo)準(zhǔn)...................................................288第五部分護(hù)理管理制度一、護(hù)理核心制度1、護(hù)理質(zhì)量管理制度..........................................................2892、病房管理制度..............................................................2893、搶救工作制度..............................................................2904、分級護(hù)理制度..............................................................2915、護(hù)理交接班制度............................................................2926、查對制度..................................................................2937、給藥制度..................................................................2948、護(hù)理查房制度..............................................................2959、患者健康教育制度..........................................................29610、護(hù)理會診制度.............................................................29611、病房一般消毒隔離管理制度.................................................29712、護(hù)理安全管理制度.........................................................29713、護(hù)理差錯、事故報告制度...................................................29814、術(shù)前患者訪視制度.........................................................298二、護(hù)理工作制度1、護(hù)理部工作制度............................................................2992、護(hù)理部會議制度............................................................3003、護(hù)理人員工作守則..........................................................3004、病房管理的質(zhì)量標(biāo)準(zhǔn)........................................................3015、護(hù)理業(yè)務(wù)查房制度..........................................................3026、護(hù)理人員繼續(xù)教育及考核制度................................................3037、差錯事故管理制度..........................................................3038、護(hù)士獨立從事臨床護(hù)理工作的管理規(guī)定........................................3059、護(hù)士三基三嚴(yán)訓(xùn)練培訓(xùn)制度..................................................30610、新護(hù)士上崗前培訓(xùn)制度.....................................................30711、護(hù)理安全管理制度.........................................................30712、護(hù)理質(zhì)量管理制度.........................................................30813、搶救及特殊事件報告處理制度...............................................30814、搶救工作制度.............................................................30915、護(hù)理文件書寫制度........................................................30916、護(hù)理文件管理制度.........................................................31017、物品、藥品器材管理制度...................................................31018、護(hù)理投訴管理制度.........................................................31119、護(hù)理突發(fā)事件報告制度.