(修改)海南省农垦那大医院全面质量管理和持续改进实施方案(新)
海南省农垦那大医院
全面质量管理和持续改进实施方案
,试行,
通过科学的质量管理～建立正常、严谨的医疗工作秩序～确保医疗质量与安全～杜绝医疗事故的发生～促进医院医疗技术水平和管理水平持续改进～不断发展。特此制定全面质量管理和持续改进实施方案～以求正确有效地实施
标准
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化医疗质量管理。
一、指导思想
,一,实行全面质量管理和全程质量控制。建立从患者就医到离院～包括门诊医疗、病房医疗和部分院外医疗活动的全程质量控制流程和全程质量管理体系。明确管控内容并将其纳入医疗管理部门的日常工作～实施动态监控并与科室目标责任制结合～保证质控措施的落实。
,二,以规章制度和医疗常规为依据～并不断修订完善。
,三,强化各种医疗技术把关制度～如三级医师查房制度、会诊制度和疑难病例讨论制度等～将医务人员个人医疗行为最大限度地引导到正确的诊疗方案中。
,四,质量控制部门有计划、有针对性地进行干预～对多因素影响或多项诊疗活动协同作用的质量问
题
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～进行专门调研～并制定全面的干预措施。
二、管理体系
全程医疗质量控制系统的人员组成可分为医院医疗质量管理委员会、科室医疗质量控制小组和各级医务人员自我管理三级管理体系。
,一,医院医疗质量管理委员会
医院医疗质量管理委员会由院领导和相关职能部门主任及各科科主任组成～院长任主任～院长是医疗质量管理工作的第一责任者。医务科、护理部、质控科、医院感染管理科等为医院质量管理职能部门～其职责分述如下:
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
1、医疗质量管理委员会职责
,1,教育各级医务人员树立全心全意为患者服务的思想～改进医疗作风～改善服务态度～增强质量意识。保证医疗安全～严防差错事故。
,2,审校医院内医疗、护理方面的规章制度～并制定各项质量评审要求和奖惩制度。
,3,掌握各科室诊断、治疗、护理等医疗质量情况(及时制定措施～不断提高医疗护理质量。
,4,对重大医疗、护理质量问题进行鉴定～对医疗护理质量中存在的问题～提出整改要求。
,5,定期向全院通报重大医疗、护理质量情况和处理决定。
,6,对院内有关医疗管理的体制变动～质量标准的修订进行讨论～提出建议～提交院长办公会审议。
2、医务科等职能部门职责
,1,医务科等质量控制部门接受主管业务院长和医疗质量管理委员会的领导～对医院全程医疗质量进行监控。
,2,定期组织会议收集科室主任和质控小组反映的医疗质量问题～协调各科室质量控制过程中存在的问题和矛盾。
,3,抽查各科室住院环节质量～提出干预措施并向主管业务院长或医院医疗质量管理委员会汇报。
,4,收集门诊和病案质控组反馈的各科室终未医疗质量统计结果～分析、确认后～通报相应科室人员并提出整改
意见
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。
,5,定期,每季度,向医院提出全程医疗质量量化考核结果～以便与绩效挂钩。
,二,科室医疗质量控制小组职责
科室是医疗质量管理体系的重要组成部分～科主任是科室医疗质量的第一责任者。科5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
室质控小组职责如下:
,1,各科室医疗质量控制小组由科主任、护士长和其他中级以上职称相关人员3-5人组成。
,2,结合本专业特点及发展趋势～制定及修订本科室疾病诊疗常规、药物使用规范、医疗质量目标控制并组织实施～责任落实到个人～与绩效工资挂钩。
,3,定期组织各级人员学习医疗、护理常规～强化质量意识。
,4,参加院医疗质控会议～反映问题。收集与本科室有关的问题～提出整改措施。
,三,医务人员自我管理
在医疗活动过程中～医务人员的个人行为具有较大的独立性～其个人素质、医疗技术水平对医疗质量影响较大～是质量不稳定的主要因素～是质量控制的基本点。在质控过程中～特别要强调首诊负责制、三级医师查房制度、会诊制度、查对制度、医嘱制度和疑难病例、术前、死亡讨论等核心制度～确保医疗质量控制的正确实施。对各级医务人员的要求分述如下:
1、门诊医师
,1,严格执行首诊医师负责制。
,2,询问病史详细、物理检查认真～要有初步诊断。
,3,门诊病历书写完整、规范、准确。
4,合理检查～申请单书写规范。 ,
,5,具体用药在病历中记载。
,6,药物用法、用量、疗程和配伍合理。
,7,处方书写合格。
,8,第二次就诊诊断未明确者～接诊医师应:a. 建议专科就诊,b.请上级医师诊视,c. 收住院。
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
,9,第三次就诊诊断仍未明确者～接诊医师应:a. 收住院,b. 患者拒绝住院需履行签字手续。
,10,按专科收治病人。
,11,按病情需要～注明特殊入院方式:车送或陪护。
2、病房住院医师
,1,病人入院30分钟内进行检查并作出初步处理。
,2,急、危、重病人应即刻处理并向上级医师报告。
,3,按规定时间完成病历书写,入院记录应当于患者入院后24小时内完成,首次病程记录应当在患者入院8小时内完成,。
,4,病历书写完整、规范～不得缺项。
,5,24小时内完成血、尿、便化验～并根据病情尽快完成肝、肾功能、血电解、胸片和其它所需的专科检查。
,按专科诊疗常规制定初步诊疗方案。 ,6
,7,对所管病人～每天至少上、下午各巡诊一次。
,8,按规定时间及要求完成病程记录,会诊、术前讨论、术前小结、转出和转入、特殊治疗、病人家属谈话和签字、出院小结和死亡讨论等一切医疗活动均应有详细的记录,。
,9,对所管病人的病情变化应及时向上级医师汇报。
,诊疗过程应遵守消毒隔离规定～严格无菌操作～防止医院感染病例发生。若有医 ,10
院感染病例～及时填表报告。
,11,病人出院时须经上级医师批准～应注明出院医嘱并交代注意事项。
3、病房主治医师
,1,及时对下级医师开出的医嘱进行审核～对下级医师的操作进行必要的指导。
,2,新入院的普通病人要在48小时内进行首次查房。除对病史和查体的补充外～查5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
房内容要求有:?诊断及诊断依据,?必要的鉴别诊断,?治疗原则,?诊治中的注意事项。
,3,新入院的急、危、重病人随时检查、处理～并向上级医师汇报病情。
,4,及时检查、修改下级医师书写的病历～把好出院病历质量关～并在病历首页签名。
,5,入院3天未能确诊或有跨专业病种的病例时应及时举行科内或科间会诊。
,6,待诊病人在入院1周内仍诊断不明时～向主任请示病例讨论或院内会诊。
,7,按医院规定正确分级使用抗生素和专科用药。
,8,手术前亲自检查病人～做好术前准备～包括术前手术部位标识～按手术分级管理标准拟订严密的手术方案并实施。术后即刻完成术后记录～24小时完成手术记录。
,9,术后严密观察患者病情变化～并做好术后工作。
,10,负责治愈患者出院的审批手续～并向上级医师汇报。
4、病房主任,副主任,医师
,1,组织或参与制定本科质量管理方案、各项规章制度、诊疗和操作常规。
,2,指导下级医师做好医疗工作～督促检查下级医师执行各项制度和诊疗常规。
,3,对新入院的普通病人要求72小时内进行首次查房,危重病人至少每日查房1次,病人病情变化应随时查房,每周组织全科查房1—2次。
,4,查房内容除对病史和查体的补充外～普通病人应有:?诊断及其诊断依据,?鉴别诊断,?治疗原则,?有关方面的新进展。未确诊病人应有:?鉴别诊断,?明确的诊断思路和方法,?拟定相应的治疗措施。危重病人应有:?当前的主要问题,?解决主要问题的方法。
,5,疑难病例及入院1周未确诊病例～组织科内讨论或院内会诊～必要时向医务科申请院外会诊。
,6,指导和监督下级医师正确分级使用抗生素和专科用药。
,7,组织术前和重要治疗前病例讨论～指导下级医师做好术中、术后医疗工作。重大5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
手术和重要治疗要亲自参加。
,8,审批未愈患者出院～并指导病人出院后的继续治疗。
,9,审签主治医师审查的转科、出院病历。
三、医疗质量管理内容
,一,基础医疗质量管理
基础医疗质量管理是指医院人力资源、财务管理、医院的
管理制度
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、医院环境、设施、医疗设备、业务技术、药品供应、后勤保障、信息方面的管理～是医疗质量管理中最基本的一环。
1、制度建设:建立健全,1,工作制度、岗位职责,,2,诊疗常规或规范、操作技术常规,,3,医疗流程,,4,医疗质量考核标准。
2、人力资源管理:按照二级甲等医院要求和规模～合理设臵科室～合理安排人员～做到合理、高效、优质服务～充分调动人员的积极性。
、服务临床一线:医务科、护理部、总务科、设备科等科室要经常性地深入到一线～3
服务到临床一线～坚持下送下收。
4、改善服务流程～为病人提高快捷安全服务。未检查完或门诊病人未看完～抢救病人未脱离危险不下班～设立院长接待日、意见箱～为病员煎药～有水服药～为病人导医～诊费公开～提供查询～保持清洁安静的舒适环境等。
,二,环节质量管理:
医疗质量是医务人员利用医疗技术为患者诊断和治疗过程中体现出来的～医疗服务的提供过程与实现同时进行～很难对医疗服务进行检查～即合格后校对～因此环节质量直接影响到医疗质量～且医疗服务对象是人～服务过程中出现不合格可能产生严重后果～且难以纠正～可见～环节质量管理十分重要。
1、职工自觉履行好岗位职责。全院各岗位人员都有自己的岗位职责～必须严格自觉履5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
行好～否则为岗位不作为或不能胜任岗位工作。每个岗位人员履行好职责是环节质量管理重要一环～自觉履职～自觉接受院、科两级检查～院科要经常开展履职教育。
2、抓好科室质量管理:科室质量管理是环节管理的中间环节、关键环节～能及时发现及纠正医疗过程中的质量问题。科主任、护士长是科室质量管理负责人～要狠抓落实。
3、抓好环节中的重点环节和薄弱环节。
?抓好院长查房、会诊、病例讨论、手术审批、转诊转院、分科收治等制度的贯彻落实。
?抓好诊疗活动的查对工作。
?做好危重病人、围手术期病人和特殊病人的管理。
?抓好手术安全核查、风险评估管理～确保手术安全。
?抓好抗菌药物使用管理～确保用药安全
?抓好临床输血管理～确保用血安全。
?抓好急诊急救工作～对急诊科应急反应、人员、设备、急救药品等情况随时抽查。
?抓好值班制度～节假日值班技术力量要保证～做好交接班及报告书写～经常随机抽查,特别是节假日夜班间抽查,在岗情况。
?做好病历书写和管理～及时客观准确书写～上级医师及时修改签名～按时归档～妥善保存～归档病例不得修改、返回～原则上不借阅。
?做好沟通工作:一方面做好医患沟通工作并做好谈话记录～另一方面做好院内上下、科室之间、同事之间工作的沟通～确保质量管理的决定及时执行～工作上能互相协作～确保工作正常运转。
?实施零缺陷管理～防止差错事故发生。
?持证上岗～严格执业准入。
?抓好重点科室质量管理～提高诊断、治疗质量。
?在医疗进程中～下一个工作环节有责任监督上一个工作环节～如发生划价、发药错误、5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
处方差错～只能由医务人员核对后纠正～严禁由病人跑路。
?病人出院结帐时～帐目核对由科室内部核对～禁止病人参与核对工作～杜绝病人往返跑路。
(三)终末医疗质量管理:
1、单病种管理:
,1,确定单病种:能反映医院、科室医疗工作重心～选常见多发病疾病顺位排列前5种疾病作为单病种～如阑尾炎、剖宫产。
,2,规范诊疗方案。
,3,制定治愈好转率、死亡率、平均住院日、平均医疗费用。
,4,分析与评价:是否为纳入标准～是否符合诊疗规范～治愈好转率、平均住院日、平均医疗费用是否达到目标～找出问题～进行分析、评价～每季度1次～并督促整改。
2、质量指标管理:医疗质量总指标年初分解下达各科室～年终总结时～医院质量指标院科分别统计～实行月报、季报、半年报、年报～主要是月报进行管理～定期分析评价～特别是指标中“三日确诊率”、“入出院诊断符合率”、“术前术后诊断符合率”、“危重病人抢救成功率”、“治愈好转率”、“无菌手术切口感染率”、“医院感染发生率”、“传染病报告率”等重点考核内容。
四、医疗质量管理控制目标
,一,临床医疗
1. 病床使用率?90,
2. 病床周转次数?19次/年
3. 平均住院日?15天
4. 入院病人三日确诊率?90%
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
5. 择期手术患者术前平均住院日?3天
6. 入出院诊断符合率?95,
7. 手术前后诊断符合率?95,
8. 临床主要诊断、病理诊断符合率?60,
9. 急危重症抢救成功率?85,
10.治愈好转率?92,
11.清洁手术切口甲级愈合率?97,
12.麻醉死亡率?0.02,
13.合格病历?92,
14.院内急会诊到位时间?10分钟
15.住院患者抗菌药物使用率不超过60%
16.I类切口手术患者预防使用抗菌药物比例不超过30%。 17.住院患者外科手术预防使用抗菌药物时间控制在术前30分钟至2小时 18.I类切口手术患者预防使用抗菌药物时间不超过24小时。 19.接受抗菌药物治疗住院患者微生物检验样本送检率不低于30%。 20.法定传染病报告率100,
21. 医疗质量安全事件报告率?90,
22.手术安全核查率100%。
23. 药品和医疗器械临床试验、手术、麻醉、特殊检查、特殊治疗履行患者告知率100,
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
24. 术前讨论、死亡病例讨论、疑难病例讨论率100% 25.定性为完全或主要责任的一级医疗事故、二级医疗事故率 0 26. 三级、四级医疗事故发生率?0.1‰
27. 医疗事故争议协商解决～进行补赔偿,含减免、法院判决,～每年不超过业务收入的3‰,
28.已出院患者对医疗服务满意度?90,
,二,急诊
29. 急救物品完好率100,
30. 器械、仪器完好率90%
31. 急诊留观时间?48小时
,三,门诊
32. 处方合格率?95,
33. 门诊病历书写格式合格率?90,
34. 门诊与出院诊断符合率?90,
35. 普通门诊具有主治医师以上专业技术职务任职资格的本院医师比例?60, 36. 挂号、划价、收费、取药等服务窗口等候时间?10分钟 37.门诊患者抗菌药物处方比例不超过20%
,四,护理
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
38. 静脉输液、吸氧、无菌技术、吸痰、引流管护理、背部护理、心肺复苏等护理技术操作合格率,合格标准为理论80分,操作85分,?98,,基础护理合格率?90,
39. 危重患者,特护、一级护理,护理合格率?90,
40. 健康教育覆盖率100%,陪护率?5%
41. 护理表格书写合格率,合格标准为90分,?90,
42. 一人一针一管执行率应100,
43. 无护理并发症,烫伤、褥疮、坠床,,难免褥疮例外,
44. 每百张床年护理严重差错发生次数?0.5
45. 年护理事故发生次数为零
46. 新护士上岗前培训率100%,护士、护师规范化培训率70%,主管护师以上继教覆盖率?80%
47. 技术操作考核～护师以下职称每年一次、主管护师每3年一次～参与率?95%,护理人员理论考试,分科别,每年一次～参与率?95%
48. 病房床位与病房护士比例1:0.4
49. 患者对护理工作和服务态度满意度?90,
,五,医院感染
50. 医院感染现患率?10,
51. 医院感染现患调查实查率?96,
52. 医院感染漏报率?20,
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
53. 清洁手术切口感染率?1.5,
54. 医疗器械消毒灭菌合格率100,
,六,输血
55. 开展成分输血比例?85,。
56.输血适应证合格率?90,
,七,医技
共性质量目标,包括其他辅助科室,:
57. 医技科室检查报告科学性和准确率?95%
58. 检查报告误诊率?3,
59. 报告及时性?95%
60.超声自检查开始到出具结果时间?30分钟。
61.大型设备检查项目自开具检查报告申请单到出具检查结果时间?48小时。 62.血、尿、便常规检验、心电图、影像常规检查项目自检查开始到出具结果时间?30
分钟～生化、凝血、免疫等检验项目自检查开始到出具结果时间?6小时～细菌学等检验项
目自检查开始到出具结果时间?4天。
63.术中冰冻病理自送检到出具结果时间?30分钟。
64. 内窥镜检查完毕即发报告
65. 万元以上医疗设备、仪器完好率?95,
66. 万元以上医疗设备、仪器使用时间?30小时/周
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
放射科:
67. CT检查阳性率?70,
68. MRI检查阳性率?70,
69.大型,光机检查阳性率?70,
70.患者、医师与护理人员对医学影像部门服务满意度?90, 检验科:
71. 临床化学室间质评全年平均及格,,，,?120, 72. 临床化学室内质控各项CV值～在允许误差范围内达到规定标准 73. 血液学室间质评全年平均及格,改良偏离指数,，?,, 74. 细菌室间质评全年鉴定正确率?80,
75. 报告单审核率100%
76.患者、医师与护理人员对检验科服务满意度?90,
药剂科:
77. 处方复核率100,
78. 调配处方出门差错率?1/10000
79. 中药处方饮片误差??5%
80. 制剂检验合格率达100%
81. 麻醉药品帐、物符合率100%
82. 无假冒伪劣药品
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
83. 药品供应满足率?95%
84. 药品收入占医疗总收入比例?45,
85.抗菌药物品种原则上不超过50种
86.患者与医师、护理人员对药剂科门服务满意度?90,
注:本医疗质量管理控制目标为全院共用
五、科室质量考核标准
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
1、内/外科系统质量安全管理与持续改进评价标准
分扣分得项目 基本要求 缺陷内容
值 标准 分
1.科主任负责质量管理与持续改进?科主任不了解全面质量管理内容或1
工作～落实“医疗质量管理与持续改不清楚科室质量管理重点～对质量存在
进方案”内容要求～建立科室质量管问题的改进缺乏计划性
理小组及工作制度～体现全面质量管?缺科室质量管理小组及制度
3 理与持续改进 ?科室质量管理小组未按PDCA循环开0.5
展有效质量管理活动 0.5
?科室质量存在问题改进力度不够～相
同质量问题重复出现无改进 1
2.每月召开1次科室质量与安全工作?未按规定召开科室质量与安全工作1
会议～内容要体现全面、全过程质量会议 一、 3 管理～有记录 ?缺改进工作措施及督办记录 1 质 ?未体现全面、全过程质量管理 1 量 3.科室落实“住院医师规范化培训方?缺培训记录 1 管 2 案”～有记录。医院每半年进行抽查?抽查考核不合格～每人次扣0.5分 1 理 考核1次
4.制定全员培训计划和主治医师以?缺全员培训计划 1 ,12,
上人员的培训规划～做到知识不断更?科室人员对质量管理要求不熟悉 1
新。积极引进新技术新业务～有相关?无主治医师及以上人员的知识更新
培训内容、讨论记录和操作规程～有培训内容 0.5
代表科室特色及水平的技术项目。全?无开展新技术新业务工作培训?无
4 员参与质量管理与持续改进的全过开展新技术、新业务的讨论记录和操作0.5
程 规程 0.5
?缺乏代表科室特色及水平的技术项
目 0.5
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
1.有常见多发病“临床诊疗指南或常?缺“临床诊疗指南或常见疾病诊疗常1
见疾病诊疗常规”及“医疗护理操作规”
常规”～能熟练运用“诊疗指南”和?未落实“临床诊疗指南或常见疾病诊1
“操作常规”指导临床工作。患者收疗常规”
入住院治疗应有标准或规范 ?缺“医疗护理操作常规” 1
?未落实“医疗护理操作常规” 1
5 ?缺少“临床诊疗指南”和“医疗护理0.5
操作常规”内容培训记录
?缺门诊患者收入住院标准或规范 0.5
二、 2.有合理使用抗生素的规范～有合理?缺合理使用抗生素的规范或医师对0.5
使用抗生素的督查记录及处理措施 规范内容不了解 医 ?无合理使用抗生素的督查记录及处0.5 疗 理措施
1 规 范 ,8,
3.有合理使用血液与血液制品的规?缺合理使用血液与血液制品规范或0.5
范～有合理使用血液与血液制品的督医师对规范内容不了解
查记录及处理措施 ?无合理使用血液与血液制品的督查0.5
记录及处理措施
?血液与血液制品的应用不合理或存1
在无明确适应证应用 2
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
分扣分得
项目 基本要求 缺陷内容
值 标准 分
1.医护人员熟悉《医疗事故处理条?科室人员对《条例》内容不了解 1
例》内容要求～落实“科室防范医疗?缺科室组织学习《条例》记录 0.5
纠纷及事故发生的重点措施”～制定?医护人员不掌握紧急封存病历及反1
科室“医疗差错及事故报告处理制应标本的程度
度”～建立医疗差错及事故登记本～?未制定“医疗差错及事故报告处理制1
对发生的医疗差错及事故立即报告度” 8 医务科～并登记、讨论 ?医护人员不了解发生医疗差错及事1
故后的报告处理程序
?未建立医疗差错及事故登记本?医0.5
疗差错或事故未及时报告医务科～每漏2
报一次扣1分
?未登记、讨论发生的差错事故 1 三、
2.有“普通、疑难患者诊疗方案确认?未按流程要求确认诊疗方案 2 医 流程”～患者病情发生变化需临时改?各级医师处臵时间超出流程规定时1
变诊疗方案时需按照“住院诊疗方案限～每人次扣0.5分 疗 4
临时改变时的决定程序”进行 ?临时改变诊疗方案时未按程序要求1
安 进行
3.对医疗活动中发生的异常医疗信?科室人员对“异常医疗信息请示报告全 1
息要及时请示报告～增加工作的危机制度”不了解
,20, 2 1 感和机敏性 ?异常医疗信息发生后科室难以处臵
未及时上报～每漏报1次扣0.5分
4.建立“危重患者管理制度”～科室?缺“危重患者管理制度 0.5
应加强对危重患者的管理及观察～进?危重患者抢救未进行全科讨论 0.5
行全科讨论～对科室难以处臵的危重?科室对危重患者难以处臵时未及时1 2
患者应及时填写“危重患者报告书”上报医务科～每漏报一次扣0.5分
上报医务科
5.建立“新技术新业务准入管理制?缺“新技术新业务准入管理制度” 1
度”及“新开展有创操作报批制度” ?缺“新开展有创操作报批制度” 0.5 2 ?科室人员对制度内容不了解或未执0.5
行～每人次扣0.5分
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
6.履行各项告知程序～落实诊断、治?对告知内容不了解～每人次扣0.50.5
疗、操作告知义务～充分尊重患者权分 0.5
益～需患者知情同意的诊断、治疗和?未落实告知程序～每例次扣0.5分 0.5 2 操作项目～科室要列出目录～各级医?科室未列出告知项目目录 0.5
师应熟悉目录内容 ?未维护和尊重患者的权益
考核卫生行政部门规定的单病种病?入院诊断与出院诊断不符～每例次扣1
例和临床专科前5位住院病种～重点0.5分
考核:1.诊断与鉴别诊断。入院诊断?缺鉴别诊断内容～每例次扣0.5分 1 3 与出院诊断相符合～有鉴别诊断内?确定诊断者为非主治医师及以下人1
容～确定诊断者为主治医师及以上人员～每例次扣0.5分
员
2.治疗方案的正确性。诊疗方案的确?诊疗方案的确定应由具备本专业资1 四、
定应由具备本专业资格的主治医师格的主治医师负责～违背1次扣0.5
病 负责,疑难危重患者的诊疗方案由科分 1
主任或副主任医师及以上人员制定,?疑难危重患者的诊疗方案由科主任 种
诊疗方案中有避免并发症的内容,病或副主任医师以及以上人员制定～违背
质 程记录中有诊疗方案及实施的内容。1次扣0.5分 1 5
对执行诊疗计划中出现的问题要有?诊疗方案中缺避免并发症的内容 1 量
明确的变更或调整程序 ?病程记录中缺诊疗方案及实施的内1
控 容
?对诊疗计划变更或调整的原因与背制
景未进行讨论及记录
,30, 3.检查与处理的适宜性,适应证、检?医技科室检查项目,CT～MRI～彩超2
查时机、适宜的间隔、是否有针对性等,与诊治工作不相关
等, ?有创操作,介入治疗、内镜、血管造2
医技科室检查项目,CT～MRI～彩影等,项目与疾病诊治缺乏适宜性 6
超等,与诊治工作要相关。有创操作?对检查、治疗结果的评价意见未记在2
,介入治疗、内镜、血管造影等,项病程记录中或未根据检查诊断结果对
目与疾病诊治要适宜 诊疗方案进行变更与调整
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
4.用药的合理性与安全性～处方、医?抗生素应用缺乏适应证或长期用药1 嘱要以本院“用药指南”或规范为基者无细菌培养与药敏检查结果的支持 础～医师、护士应知晓本科常用药物?药物过敏无记载 1 的信息,适应证、禁忌证、配伍禁忌?对药物不良反应和安全评估无处臵0.5 等,～重点是感染患者抗生素使用的意见 适宜性,剂量、途径、疗程、抗生素?发生药物不良反应未按“药物不良反0.5 选用档次、联合应用的适应证等,～应监察报告制度”填表上报或病历中无 抗生素应用要有细菌培养与药敏检记录 6
查结果的支持。细胞毒性药、特殊药?同类药物重复应用 1 物的使用要注意使用依据与给药方?应用与本病诊治无关的药物 1 法～避免同种重复用药～对易发生不?对可能发生的药物不良反应与注意1 良反应的药物～在使用前要向患者进事项未向患者交待
行交待～并将相关内容记录在病历
中。如发生不良反应要按制度规定及
时上报
5.处理急危重症患者的应急反应能?缺科室处理急危重症患者应急预案 1 力。制定“科室处理急危重症患者的?科室人中对处理急危重症患者应急 应急预案”～对预案内容进行模拟训预案不熟悉 1.5 练～要求熟练掌握、反应迅速。有明?未进行模拟训练～出现应急情况忙乱1 确的“人员紧急替代制度”并保证联无章 0.5 系通讯工具畅通～以使出现各种突发?缺抢救设备操作规程 1
8 事件时相关人中能确保按时到位 ?科室人员不能熟练操作相关抢救设
备 2
?对急危重症患者未按制度要求按时、
按规定程序处理 1
?缺人员紧急替代制度或替代人员不
明确或联系通讯工具不畅通
6.疗效与转归。有本科常见多发病的?缺少本科常见多发病的疗效与转归1 疗效与转归的数据资料,好转率、治的数据资料,好转率、治愈率、死亡率, 愈率、病死率,。有与院外先进水平?无与院外先进水平比较的诊治项目 2
比较的诊治项目 1
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
1.三级查房制度:严格落实查房制?查房次数不足 1.5
度～保证查房次数～查房前做好各项?查房准备工作不充分 1 五、 准备～查房时按查房规范进行～结合?查房形式不规范 1
国内外进展～重点解决诊疗中的疑难?病历中缺三级医师查房记录或记录1.5 医
问题～做到解决实际问题与提高诊疗内容不规范
8 疗 水平相结合。注意查房礼仪～不在患?查房内容未能结合本学科当前进展 1
者面前随意谈论其病情～以保护医密 ?查房内容对疾病的诊断治疗缺乏指1 核
导作用 心 ?查房过程中泄露医密～加重了患者思1
想负担及精神压力 制
2.首诊负责制度:落实“首诊医师负?未执行“首诊医师负责制” 2 度 责制”及“专病专治”原则～按“科?首诊医师拒绝诊治患者或出现推诱1
室流程规范”要求接诊并做到合理分患者现象 ,30,
流患者。首诊医师不得以任何理由推?如属他科疾病～首诊医师未安排患者2
诱或拒绝诊治患者～如患者病情属他转诊～或收治非本专业患者～每人次扣
7 科疾患～应介绍患者到他科就诊～在1分
未确定接受科室前～首诊医师要对患?对疑难病例～首诊医师未请示上级医1
者全面负责 师
?对病情涉及多科的患者～首诊医师未1
按患者的主要病情收住相应科室
3.死亡病例讨论制度:应在患者死亡?死亡病例未讨论 2
1周内讨论～由科主任或副主任医师?讨论时间超过规定期限 1 4
及以上人员主持～并记录于病历中 ?病历中缺讨论记录 1
4.疑难危重病例会诊讨论制度:由科?未进行科内会诊或科间会诊或邀请2
主任或副主任医师以上人员主持～按院外专家会诊
规定时间进行讨论并记录于病历中。?会诊、讨论不及时 1
6 会诊医师应为主治医师及以上人员?病历中缺会诊讨论记录 1
,急会诊除外,～在24h内完成 ?会诊医师不具备会诊资格～每发现12
人次扣1分
5.晨会与值班交接班制度:医师要严?危重患者未进行书面及床头双交接2
守工作岗位～有事外出要告知值班人班
员去向～科室要建立医师交接班记录?未坚守工作岗位～出现脱岗 1 5 本～每班有记录～危重患者要书面及?有事外出未告知值班人员去向 1
床头双交接班 ?交接班本存在漏交或漏接情况 1
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
科室应制定常规手术治疗目录～以规? 大中型手术未进行术前讨论 1 范医师的诊疗行为～落实“手术审查?病历中缺讨论记录 1 与批准制度”、“外科患者围手术期管?手术治疗方案讨论不全面～未能充分1 理制度及流程规范”～加强围手术期预见手术中可能发生的意外情况 关键环节的管理。每个患者的外科治?重大、疑难、致残手术及新开展手术、1
5 疗,手术、麻醉,都必须有方案 外宾和有关领导手术未填写《重大手术 1.术前讨论制度:甲、乙类手术要进申请报告书》报告医务科 行术前讨论～重大、疑难、致残手术?患者手术前准备不充分或必查项目0.5 及新开展手术、有关领导手术要填写未做 《手术审批报告单》报告医务科 ?预防性应用抗生素超出规格及时限0.5
要求 六、
2.手术签字知情同意制度:患者知情?非规定人员与患方进行术前谈话及1 围 同意书由术者或主管医师负责谈话及签字～每人次扣0.5分 手
签字～医患双方应各有二人参加。新?未履行告知义务～在未征得患者、1 术
开展手术、大型手术、特定范围的手家属或委托人同意情况下进行手术或 期
术由具备资格的上级医师、科主任负改变术式,特殊情况除外, 管
责谈话及签字～术中意外处理及术中?未签订手术麻醉同意书 理 3 改变术式由具备资格的医师负责谈话1 制
及签字。签订手术麻醉同意书。对手度
术目的、必要性、危险性、合并症等,20,
应进行充分说明～应使用能够理解的
语言～对患者及家属提出的问题要予
以解答
3.手术医师分级管理制度:科室根据?科室未制定手术医师分级管理办法1 科内具体情况确定本科大中型手术范及各级医师手术权限范围 围～明确各级医师手术权限～特殊情?未明确科内大中型手术范围 况下如需实施超权限手术要经科主任?未经科主任批准～医师实施超权限1 4
批准～中等手术由主治医师批准签发范围手术 1 手术通知单～新开展与大型手术由科?医师越权限签发手术通知单 主任批准签发手术通知单 1
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
4.术中管理制度:科室要制定常规手?科室未制定常规手术操作规范 1 术操作规范～术中发生意外情况及改?术中出现意外情况或改变术式未按 变术式要按规定流程进行～落实术中规定要求进行操作 1 查对制度～遇事要沉着、冷静。凡手?未落实术中查对制度 4
术标本都应实施病理诊断～对于肿瘤?手术标本未进行常规病理检查或肿1 或怀疑肿瘤手术应进行术中快速病理瘤标本未进行快速病理诊断 1 诊断。
5.术后管理制度:术后要加强患者全?术后未及时随访 0.5 身情况观察～对并发症要进行早期预?未进行并发症的预防控制 0.5 2
防～做到早期发现、及时处理 ?出现不应该发生的并发症 1 6.手术室出入基本标准与程序～落实?运送患者时未进行确认 0.5 病房与手术室之间检查与交接制度 ?无识别标志带牌 0.5 2
?患者交接时无记录及签字 1 7.手术安全核查、风险评估制度:手?手术安全核查、风险评估表 3 术安全核查由术者、麻醉师、护士在?手术部位未标识 1 手术实施前、手术开始前、患者离开?手术部位标识不正确 1 手术室前共同核对～科室应认真填写?科室未认真执行手术安全核查、风 10 手术安全核查、手术风险评估表。手险评估 2 术部位标识正确、三方核查、评估、?安全核查流程不正确 1 确认后应分别签名。 ?缺三方人员签名 1
?科室人员对手术安全核查、风险评
估制度不知晓 1
备注:内科系统满分为100分～评价项目为第一项至第五项,外科系统满分为130分～评价
项目为第一项至第七项。
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
2、急诊科质量安全管理与持续改进评价标准
扣分
项目 分值 基本要求 缺陷内容 得分
标准
科主任负责质量管理与持续改?科主任不了解全面质量管理内容或不清
进工作～落实“医疗质量管理持楚科室质量管理重点～对质量存在问题的改1. 5
续改进方案”内容要求～建立科进缺乏计划性
室质量管理小组及制度～体现全?缺科室质量管理小组及制度
面质量管理与持续改进 ?科室质量管理小组未按PDCA循环开展有0.5
建立与完善急诊管理信息系统效质量管理活动 0.5
6 一、
动态监测影响医疗质量和安全?科室质量存在问题改进力度不够～相同质 质
的各种因素～保持持续改进～以量问题重复出现无改进 1 量
提高工作效率 ?未建立完善的管理信息系统 1 管
要求传染病漏报率?10%～急诊?传染病漏报率、急诊抢救成功率、急诊病1 理
抢救成项率?85%～急诊病历甲历甲级率达不到规定要求～每项扣0.5分 1.5 ,26,
级率?90%
2(每月召开1次科室质量与安?未按规定召开科室质量与安全工作会议 1.5
全工作会议～内容要体现全面、?缺改进工作措施及督办记录 2
5 全员、全过程质量管理～有记录。?未体现全面、全过程质量管理 1
每半年征求1次临床、医技科室?未按规定征求临床、医技科室的意见 0.5
对急诊工作的意见
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
3(对员工进行心肺复苏等急救?缺人员培训计划 2 知识及操作培训～落实“住院医?缺培训记录 2
5 师规范化培训方案”～有计划～?抽查考核不合格～每人次扣0.5分 1 有记录。医院每半年抽查考核1
次
4(制定全员质量培训计划和业?缺全员质量培训计划和员工业务培训规1 务培训规划～做到知识不断更划或无知识更新内容 新。积极引进新技术新业务～有?员工对质量要求不熟悉 1 相关培训内容、讨论记录和操作?值班医师不具备值班资格或对急诊危重1 规程～有代表科室特色及水平的患者救治流程不熟悉 技术项目～有临床工作统计资?护师、主治医师及以上人员心肺复苏技能2 料。全员参与质量管理与持续改达不到规定要求～每人次扣0.5分 进的全过程。急诊科医师应是急?无开展新技术新业务工作培训 1
10 诊专科培训合格、担任住院医师?无开展新技术、新业务的讨论记录和操作2 2年以上的医师。护师、主治医规程 师及以上人员心肺复苏技能达?缺乏代表科室特色及水平的技术项目 1 到高级水平 ?缺临床工作统计数据资料 1
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
扣分
项目 分值 基本要求 缺陷内容 得分
标准
1 1(有医务科,设专人,对急诊?缺医务科对急诊科的质量监控制度 1.5
科的质量监控制度～有临床、医?缺临床、医技科室支持制度 1.5
技科室支持制度～使重症患者能?未落实临床、技科室支持制度 2
得到医院提供的优先诊疗检查?急会诊门诊楼或病区医师未按规定时限1
等服务。急会诊要求门诊楼医师到达
5min、病区医师10min内到达。1 8 ?病历书写与抢救记录～不符合规范要求
应有急诊抢救记录与留观病历1 ?无24h上级医师查房记录
书写的规范～留院观察病程记录
每24h不得少于2次～急、危、二、
重症患者随时记录～24h内应有
医 上级医师查房意见
2(有急诊工作流程～保持“绿?缺急诊工作流程 1 疗
色通道”畅通。从患者到分诊台?未落实急诊工作流程 3
规 到开始抢救处臵的时间应在?绿色通道不畅通～抢救延时 2 8 5min内,10min内完成危重病人?未在规定时间内完成处臵流程 2 范
的诊疗处臵,气道、静脉穿刺、
,24, 呼吸机等,
3(有主要抢救设备与设施目录～?缺抢救设备与设施配臵目录 1
保持抢救设备完好齐备～有专人?无专人管理抢救设施与设备 1
管理设备～每日交接班。有抢救?缺交接班记录及保养记录 1
设备操作规程及保养记录～并且?抢救设备不齐全或存在故障 1 8 员工能够熟练操作设备。有设备?缺抢救设备操作规程 1
不足时的应急调用方案～保证?员工不能熟练操作设备 1
5min到位 ?缺设备不足时的应急方案 1
?应急方案落实不到位 1 5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
1(医护人员熟悉《医疗事故处?员工对《条例》内容不了解 1
理条例》内容要求～落实“科室?缺科室组织学习《条例》计划及记录 0.5
防范医疗纠纷及事故发生的重?医护人员不掌握紧急封存急诊病历及反1
点措施”～制定科室“医疗差错应标本的程序
及事故报告处理制度”～对发生?未制定“医疗差错及事故报告处理制度” 0.5
医疗差错及事故要立即报告医?医护人员不了解发生医疗差错及事故后1
务科～并登记、讨论 报告处理程序 1 9
建立急危重症病人“危重程度评?缺医疗差错及事故登记本 1
分”制度～救治急危重症病人的?医疗差错或事故后未及时报告医务科～每1
病历中有“危重程度评分”的记漏报1次扣0.5分
载 ?未登记、讨论发生的差错事故 1
?缺“危重程度评分”制度 1
三、 ?未落实“危重程度评分”制度 1 2 2 (对医疗活动中发生的异常?员工对“异常医疗信息请示报告制度”不了医 0.5
医疗信息要按规定及时请示报解 1 疗 告～增加工作的危机感和机敏?异常医疗信息发生后科室难以处臵时未2 性。有安全保卫制度 及时上报～每漏报一次扣0.5分 安 0.5
?缺安全保卫制度
全 3(落实“危重患者管理制度”～?未落实“危重患者管理制度”内容要求 1
科室要加强对危重患者的抢救?值班人员对“三无”或危重患者处理程序2 ,30,
及观察～对“三无”或危重患者不了解～存在处臵过失～每发现1次扣0.5 3 情况复杂而难以处臵时～应按规分
定采取相应措施并及时报告医
务科或总值班
4(履行各项告知程序～落实诊? 对告知内容不了解～每人次扣0.5分 1
断、治疗、操作告知义务～紧急?未落实告知程序～每例次扣0.5分 1
情况下经治医师可委托本院医?科室未到出告知项目目录 0.5
务人员履行告知义务。充分尊重?未维护和尊重患者的权益 0.5 3 患者权益～需患者知情同意的诊
断、治疗和操作项目～科室要列
出目录～各级医师应熟悉目录内
容
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
5(有处理急危重症患者的应急?缺“急危重症患者处理应急预案” 1 反应能力。制定科室“急危重症?员工对处理急危重症患者应急预不熟悉 1.5 患者处理应急预案”～和中毒、?缺中毒、外伤等“突发意外伤害事件抢救1 外伤等“突发意外伤害事件抢救预案” 预案”～并定期进行模拟演练～?员工对中毒、外伤等“突发意外伤害事件1.5 提高对重大、紧急、意外事件的抢救预案”不熟悉 9
应急应变能力～要求熟练掌握、?缺应急预案演练记录或未进行模拟演练 1.5 反应迅速～并有演练记录。制定?缺针对各种急危重症患者的“诊疗常规” 1 科室针对各种急危重症患者的?员工处臵急危重症患者时不熟悉“诊疗常1.5 “诊疗常规”～并熟练掌握和应规”内容～治疗方案混乱
用
6.有科室“人员紧急替代制度”～?缺科室“人员紧急替代制度” 1 科内有各级各类人员空缺替代?替代人员不明确或联系通讯工具不畅通2 程序与有效的联络途径,值班表或不能及时到位 备查,～有对替代人员进行急救1 4 ?缺替代人员急救培训记录
培训的记录～并保证联系通讯工
具畅通～出现各种突发事件时相
关人员能按时到位
1(急诊首诊负责制度:落实“急?未执行“首诊医师负责制” 1 诊首诊负责制”～按“科室流程?首诊医师拒绝诊治患者或出现推诱患者1.5
四、 规范”的要求接诊并做到合理分现象 流患者。首诊医师不得以任何理1.5 ?首诊医师将患者收住非相应专业病区～每核
由推诱或拒绝诊治患者。如患者 发现1人次扣0.5分 6 心 病情属他科疾患～应予收住相应1 ?对疑难、危重病例～首诊医师未按有关规病区。对危重患者应就地组织抢 定诊治或进行会诊 医
救～待病情稳定后再转入病区。1 ?对病情涉及多科的患者～首诊医师未按患
疗 在未确定接受科室前～首诊医师者的主要病情收住相应科室
要对患者全面负责 制
2.晨会与值班交接制度:科室要?医师交接班本存在漏交或漏接情况 1 度 建立医师交接班记录本～每班有?危重患者未进行书面及床头双交接班 1 记录～危重患者要书面及床头双?有事外出未告知值班人员去向 1 4 ,20,
交接班。医师要严守工作岗位～?未坚守工作岗位～出现脱岗 1 有事外出要告知值班人员去向
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
3.抢救工作制度:科室有抢救工?缺抢救工作制度 1
作制度～并严格落实～保证接诊?未落实抢救工作制度 2 5
工作的及时、迅速 ?因抢救不及时～导致不良后果 2
4.优先诊疗程序:科室有“根据?缺“根据病情优先获得诊疗的程序” 1
病情优先获得诊疗的程序”～值? 医师未对急危重症患者进行优先诊治 2
班医师对急危重症患者或有纠? 医师未对有纠纷征兆的患者进行优先1
纷征兆的患者等应采取优先诊诊治
疗程序～进行优先诊治。重点观?急性心肌梗死或各种外伤患者救治延时 1 5
察核实急性心肌梗死和各种外
伤患者从进入急诊室到进行处
臵的时间,min,～含必要检查及
治疗项目实施时间
3、麻醉科质量安全管理与持续改进评价标准
扣分
项目 分值 基本要求 缺陷内容 得分
标准
1.科主任负责质量管理与持续改进工?科主任不了解全面质量管理内容 1
作～落实“医疗质量管理与持续改进或不清楚科室质量管理重点～对质
一、 方案”内容要求～建立科室质量管理量存在问题的改进缺乏计划性
小组及制度～体现全面质量管理与持?缺科室质量管理小组及制度 1 质 4 续改进 ?科室质量管理小组未按PDCA循 1
量 环开展有效质量管理活动
?科室质量存在问题改进力度不 1 管
够～相同质量问题重复出现无改进
理 2 1 .每月召开1次科室质量与安全?未按规定召开科室质量与安全工1
工作会议～内容要体现全面、全过程作会议 ,20, 3 质量管理～有记录 ?缺改进工作措施及督办记录 1
?未体现全面、全过程质量管理 1 5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
3 3..建立麻醉医师资质管理及评价?缺麻醉医师资质管理评价制度 1
制度及组织～按照评价方法及程序对?未建立麻醉医师资质管理评价组1
麻醉医师的资质和能力进行评价。落织织 1 5 实“住院医师规范化培训方案”～有记?缺麻醉医师资质管理评价记录 1
录。医院每半年进行抽查考核1次 ?缺住院医规范化培训记录 1
?抽查不合格～每人次扣0.5分 1
4.制定全员培训计划和员工的培训规?缺全员培训计划、员工的培训规2
划～做到知识不断更新。积极引进新划或无知识更新内容
技术新业务～有相关培训内容、讨论?员工对质量管理要求不熟悉 1
记录和操作规程～有代表科室技术水?未开展新技术新业务工作培训 1
平和能力的项目。有临床工作统计资?无开展新技术、新业务的讨论记 8
料。全员参与质量管理与持续改进的录和操作规程 2
全过程 ?缺乏代表科室技术水平和能力的
项目 1
?无科室工作统计资料 1
1.有麻醉诊疗常规和操作规范～能熟?缺诊疗常规和操作规范 3
练运用诊疗常规和操作规范指导临床?未落实诊疗常规和操作规范 3 7 工作 ?缺诊疗常规和操作规范培训情况1
记录
2.有合理使用麻醉药品的规范～有督?缺合理使用麻醉药品的规范 1
查记录及处理措施 ?无合理使用麻醉药品的督查记录2 3
及处理措施
二、 3.有麻醉设备操作规程～员工能熟练?缺麻醉设备操作规程 1
操作麻醉设备～有使用记录。麻醉与?员工不能熟练操作麻醉设备～抽2 医
术中生命监护系统、空气调节系统定考每人次不合格扣1分 7 疗 期保养～有记录～手术药品和器材有?缺麻醉设备、术中生命监护系统2
适度储备 和空气调节系统使用保养记录 规
?手术药品器材储备不足 2 5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
4.制定具有专业特色的医院感染控制?缺医院感染控制管理方案或制2 范
管理方案或制度、重点措施及应急预度、重点措施及应急预案
,25, 案～有对感染控制缺陷进行整改与效?缺针对感染控制缺陷进行整改与2
果再评价的制度和程序～并落实到位。效果再评价的制度和程序 8
对员工进行医院感染控制教育～有记3 ?每项制度落实不到位扣1分
录 1 ?未对员工进行医院感染控制教育
或缺相关记录
1.医护人员熟悉《医疗事故处理条例》?员工对《条例》内容不了解 1
内容要求～落实“科室防范医疗纠纷?缺科室组织学习《条例》计划及1
及事故发生的重点措施”～制定科室记录
“医疗差错及事故登记本～对发生的?医护人员不掌握紧急封存病历及1
医疗差错及事故要立即报告医务科～反应标本的程序
并登记～讨论 ?未制定“医疗差错及事故报告处2
理制度“ 10
?医护人员不了解发生医疗差错及三、 1
事故后报告处理程序 医
1 ?未建立医疗差错及事故登记本
疗 2 ?医疗差错或事故后未及时报告医
务科～每漏报1次扣0.5分 安
1 ?未登记、讨论发生的差错事故
全
2.有麻醉方案确定过程和实施流程～?缺麻醉方案确定过程或实施流程 3
,40,
有麻醉医师分级管理制度～规定各级?缺麻醉医师分级管理制度 2
麻醉医师权限。患者病情发生变化需?未落实麻醉方案确定过程或实施1 8
临时改变麻醉方案时要按照“住院患流程 1
者麻醉方案临时改变时决定的程序”?未落实麻醉医师分级管理制度 1
进行～麻醉记录应在24h内完成 ?改变麻醉方案未按规定进行 5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
3.对医疗活动中发生的异常医疗信息?员工对“异常医疗信息请示报告2
要及时请示报告～增加工作的危机感制度”不了解 4 和机敏性 ?异常医疗信息发生后科室难以处2
臵时未及时上报～每漏报1次扣0.5
分
4.建立“危重患者管理制度”对科室?缺“危重患者管理制度” 2
难以处臵的危重患者应及时填写“危?科室对危重患者难以处臵时未及2 4
重患者报告书”上报医务科 时上报医务科～每漏报1次扣0.5
分
5.建立“新技术新业务准入管理制度”?缺“新技术新业务准入管理制度” 1
及“新开展有创操作报批制度” ?缺“新开展有创操作报批制度 1 2
?员工对制度内容不了解或未执2
行～每发现1人次扣0.5分 5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
6.履行各项告知程序～充分尊重患者?对告知内容不了解～每人次扣1 权益。知情同意书由麻醉者或上级医0.5分 师负责谈话及签发～用易于理解的语?未落实告知程序～每例次扣0.51 言解释麻醉、处臵、操作的必要性和分 目的及利害得失等告知内容～并记录 ?非规定人员与患者、家属或其委2
4 在同意书中。术中意外处理或改变麻托人进行术前谈话及签字～每人次醉方式时由具备资格的医师负责向患扣0.5分
者家属告知,对新开展的麻醉方法及
其他特定范围的手术麻醉方法及其他
特定范围的手术麻醉由具备资质的上
级医师或科主任负责告知谈话
7.处理急危重症患者的应急反应能?缺科室处理急危重症患者应急2 力。制定“科室处理急危重症患者的预案 应急预案”～对预案内容进行模拟训?员工对处理急危重症患者应急2 练～要求熟练掌握、反应迅速。有“人预案不熟悉。抽考每人次不合格扣 员紧急替代制度”并保证联系通讯工0.5分～扣完为止
8 具畅通～以便出现各种突发事件时相?未进行模拟训练～出现应急情况1 关人员能确保按时到位 忙乱无章
?对急危重症患者未按制度要求按1
时、按规定程序处理
?缺人员紧急替代制度或替代人员2
不明确或联系通讯工具不畅通
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
1 1 .重要制度健全:具有会诊制度、病重要制度不健全～每缺一项扣0.51
例讨论制度、麻醉管理制度等工作制分 ?工作中有违规表现～发现一人次1
3 度～要求科内员工了解并得到落实扣 0. 0 5分
?工作人员对科室重要制度内容不1
了解
2.术前麻醉查房:接到手术通知单后～?未进行术前麻醉查房 1 四、
麻醉师应按要求进行术前访视～通过?未签订手术麻醉同意书 1 医
充分的术前检查对病情进行评估～决?未选择适宜的麻醉方法和麻醉方1 疗
定适宜的麻醉方案～并记录于病历～案 核
由主治医师以上人员签字确认。确定?麻醉方案未经主治医师以及上人1 心
麻醉方案时要考虑患者年龄、全身状员签字确认 制
态～对麻醉、处臵的适宜性应进行讨?缺术前麻醉访视记录 1 度 6
论～选择最适宜的时机与麻醉方法。?未执行术前查对制度 1 ,15,
与患者或家属谈话～同意后签订手术
麻醉同意书～开出术前用药～并准备
麻醉器械。落实查对制度。每个患者
外科手术时必须有麻醉方案,计划,～
重点是全麻、危重患者、新开展手术
及特殊患者
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
3.术中管理:术中应监测患者生理状?术中未作麻醉效果评定或未对患0.5
态～进行麻醉效果评定～发生意外情者者生理状态未进行监测
况及改变麻醉方式要按规定流程进?缺术中麻醉记录及效果评定记录 0.5 2
行。要由具备资格的医师负责谈话～?术中意外处理术中改变麻醉方式0.5
落实查对制度 时未进行谈话及签字
?未落实查对制度 0.5
4.术后随访:麻醉师对患者术后麻醉?缺苏醒判断标准 1
复苏阶段的生理状态进行监测～对苏?未监测患者术后麻醉复苏阶段的1
醒的判断有具体判断基本标准,意识生理状态 4 状态、血压、呼吸状态等,。应按规定?未按规定时限查看患者 0.5
时限去病区查看手术患者～并向责任?未向责任护士交待术后注意事项 0.5
护士交待注意事项～防止发生麻醉并?缺术后随访记录 1
发症～并做记录
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
4、检验科质量安全管理与持续改进评价标准
扣分
项目 分值 基本要求 缺陷内容 得分
标准
1.科主任负责质量管理与持续改进?科主任不了解全面质量管理内容1
工作～落实“医疗质量管理与持续或不清楚科室质量管理重点～对质
改进方案”内容要求～建立科室质量存在问题的改进缺乏计划性。
量管理小组及制度～体现全面质量?缺科室质量管理小组及制度 0.5
4 管理与持续改进。应有适宜的实验?科室质量管理小组未按PDCA循环0.5
室信息系统,LIS,进行检验数据管开展有效质量管活动 一、
理～存在问题有分析、处理程序及?科室存在问题改进力度不够～相1 质
改进措施～有记录文件 同质量问题重复出现无改进 量
?缺完善的实验室信息系统 1 管
理 2.每月召开1次科室质量与安全工?未按规定召开科室质量与安全工2
,20, 作会议～内容要体现全面、全过程作会议
4
质量管理、有记录 ?缺改进工作措施及督办记录 1
?未体现全面、全过程质量管理 1
3.制定全员培训计划～全员参与质?缺全员培训计划 1
2 量管理与持续改进的全过程。员工?员工对质量管理要求不熟悉 1
知晓质控要求、质控程序及方法
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
4.制定专业人员继续教育计划～做?无专业人员的知识更新继续教育1.5 到知识不断更新。对特殊检测项目内容 和新技术新业务实施准入管理～有?无开展特殊检验项目和新技术新1 制度～有相关培训内容、讨论记录业务准入管理制度 和操作规程～有代表科室特色及水?无开展特殊检验项目的审批报告 1 平的技术项目。有本科工作统计数?无开展特殊检验项目的工作培2 据资料～有与院外先进水平比较的训、讨论记录和操作规程 检查项目 ?无开展新技术、新业务的批准文1
10
件
?无开展新技术、新业务的批准的1.5
工作培训、讨论记录和操作规程
?缺乏代表科室特色及水平的技术1
项目
?缺本科工作统计数据资料 0.5
?无与院外先进水平比较的诊治项0.5
目
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
1.开展临床检验项目必须是经批准?缺检查服务项目清单 1
的准入项目～开展特殊检查的实验?不能提供24h急诊服务 2
室应有验收、准入程序。工作人员?不能满足临床工作需要 2
有上岗资格证明文件、应建立实验?开展的检验项未经批准、准入程2
项目临床应用指南或手册～定期更序
新～对本院尚未开展或条件不具备?开展特殊检查的实验室未经验2
12
开展的部分检验项目应有规范的外收、准入程序 二、
送运行机制～并签订有保障
合同
劳动合同范本免费下载装修合同范本免费下载租赁合同免费下载房屋买卖合同下载劳务合同范本下载
或?缺实验项目应用指南或手册 1 工
协议及委托合同或协议。有检查服?缺未开展检验项目的完善的外送 作
务项目清单～能够提供2h急诊服运行机制 1 规
务～能够满足临床工作需要 ?工作人员存在无证上岗情况～每 范
发现1人扣0.5分 1 ,50,
2.科室布局与流程合理、符后医院?科室布局与流程不符合医院感染2
感染控制要求～有医院感染控制制控制要求
度～有废弃物处理程序～并落实到?缺医院感染控制制度 1
8 位。做到“一人、一针、一管、一?缺废弃物处理程序 1
片”～实验室废弃物、尖锐器具的处?未落实医院感染控制制度 2
理应符合医院感染控制规范要求～?未落实废弃物处理程序 2
具有生物危害标志～使用正确
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
3.有室内质控制度及室内质控失控?缺室内质控制度 1.5 处理程序～参与卫生部或省市临床?缺室内质评记录 1 检验中心组织的室间质评～有记录～?缺室内质控失控处理程序 2.5 有EQA回报不及格结果的处理程?缺对EQA回报不及格结果的处理2.5 序。有工作记录。检测方法、仪器程序 操作须有SOP文件～本专业组人员?缺实施室内质控记录 1.5
15
均知晓并执行 ?缺实施室间质评记录 1.5
?缺实施室内质控失控处理记录 1.5
?缺实施对EQA回报不及格结果的1.5
处理记录
?检测方法、仪器操作未执行SOP1.5
文件规定
4.有设备与试剂的国家许可证明文?缺设备与试剂的国家许可证明文1 件资料。有设备操作规程～有设备件资料 定期校准和保养记录～有主要检验?缺设备操作规程 2 设备,10万元及以上,相关资料。?缺设备定期校准和保养记录 2
7
及时淘汰经鉴定不合格的设备与试?缺主要检验设备,10万元以上,1 剂～有记录资料。应有二级以上生的相关资料 物安全柜配臵～应人个人防护用具?缺及时淘汰经鉴定不合格的设备1 ,护目镜、洗眼装臵等, 与试剂的记录资料
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
5.对检查结果报告实行归口管理～?未对检查结果报告实行归口管理 1.5 有报告管理与签发制度。有为临床?缺报告管理与签发制度和复核规 工作提供咨询服务的制度～有与临定 2 床科室有定期召开联席会议或收集?缺为临床工作提供咨询服务的制 意见的制度与记录文件。科室技术度 1.5 人员要主动下临床科室征求意见～?缺科室技术人员下临床科室征求
8
有记录资料。应定期,半年,或不意见的记录资料 2 定期向临床医师提供抗生素药敏种?缺服务承诺或未落实相应措施 类～应有报告时限的明文规定、公1 示承诺及贯彻执行的对应措施～平
诊检验结果日报时间:生化、临检
?24h～免疫?48h
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
1.有防止意外事故的应急预案并进?缺应急预案或员工对《预案》、《条1
行演练及掌握～消防设备配臵合理～例》内容不了解
标志醒目～有紧急通道。对腐蚀药、?缺科室组织学习《应急预案》、《条2
易爆物、易燃物、毒性试剂等应有例》计划及记录～或安全制度、措
专人、定位、定量保管～并有严格施不到位
的保管与使用制度。医护人员熟悉?未制定“差错及事故报告处理制1 三、
《医疗事故处理条例》内容要求～度” 医
落实“科室防范医疗纠纷及事故发?医护人员不了解发生医疗差错及1 疗
12 生重点措施”～建立安全制度及安全事故后报告处理程序 安
操作规程～有专兼人员进行督查～?未建立差错及事故登记本 1 全
并有记录文件。制定科室“差错及?差错或事故后未及时报告医务1.5 ,30,
事故登记本～对发生的差错及事故科～每漏报1次扣0.5分
要立即报告医务科～并登记、讨论。?未登记、讨论发生的差错或事故 2
新开展的检验项目在临床应用须有?缺腐蚀药、易爆物、易燃物、毒1
审批记录文件及质量保证文件 性试剂的保管使用制度 1
?腐蚀药、易爆药、易燃物、毒性
试剂保管使用不力 1.5
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
2. 应有能够迅速提供临床检查?员工对“异常医疗信息请示报告1
结果的运行机制、制度及程序～对制度”不了解
医疗活动中发生的异常医疗信息要?异常医疗信息发生后科室难以处1 4 及时请示报告～增加工作的危机感臵
和机敏性 ?缺迅速提供临床检查结果的运行1
机制、制度及程序
?不能及时提供检查结果 1
3.履行有关告知程序～落实操作告?对告知内容不了解～每人次扣0.51
知义务～充分尊重患者权益～需患分
者知情同意的诊断、操作项目～科?未落实告知程序～每例次扣扣0.51 4 室要列出目录～各级人员应熟悉目分
录内容 ?科室未列出告知项目目录 1
?未维护尊重患者的权益 1
4.建立规范的急诊实验室和严格的?缺急诊实验室或开展项目不能满2
工作制度～急诊检验人员经过资格足临床工作需要 6 认证～开展适合本院急诊工作的服?急诊报告时间延时 2
务项目～急诊检验结果回报时间:?缺急诊实验室工作制度 1
临检?30min～生化?60min ?急诊检验人员未经过资格认证 1
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
5.科室工作人员要严守工作岗位～?缺人员紧急替代制度 1
有事外出要告知值班人员去向。有?替代人员不能及进到位或通讯工2
4 明确的“人员紧急替代制度”并保具不畅通
证联系通讯工具畅通～以使出现各?工作人员出现脱岗 1
种突发事件时相关人员能按时到位
5、药学专业质量安全管理与持续改进评价标准
扣分 得项目 分值 基本要求 缺陷内容
标准 分
1.在临床用药过程中贯彻落实?缺法规文件 0.5
《药品管理法》、《医疗机构药事?工作人员对相关法律法规内容不0.5 一、
管理暂行规定》等有关法律法规～了解 依
有保证落实的重点措施～有效果?缺落实法律法规的重点措施 1 法
5 评定与改进措施～制定医院“药?缺效果评定与改进措施记录 1 执
品目录”～满足临床及医保患者的?缺医院“药品目录”文件或无落1 业
用药需求 实“药品目录”的措施 ,15,
?“药品目录”未能得到落实或药1
品供应比例达不到要求
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
2.建立医院药事管理委员会并正?药事委员会未正常开展工作或开1
常开展工作。要求人员组成符后展工作无记录
规定～有明确职责～定期召开会?药事委员会活动内容不符合职责1.5
议～有记录～制定本院“临床用要求
药指南”或“抗菌药临床应用管?未对临床用药及药品引进与删除1
理规定”～并起到规范医院临床用进行讨论与干预
7
药行为的作用。讨论同意引进新?药剂科对药事委员会讨论决定的1.5
药和删除药品～讨论医院用药中事项未能进行贯彻执行
存在问题～并提出干预措施～建?未建立新药申请制度与程序或未1
立新药申请制度与程序 得到落实
?药事委员会成员对申请新药程序1
不了解
药剂科主持药事委员会日常工?药剂科未及时向药事委员会报告1.5
作～定期或不定期向药事委员会药事管理工作
3
报告药事管理工作情况 ?未对药事管理工作提出意见和整1.5
改措施
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
1.门诊:要求门诊药房实行大窗?无文明服务规范及用语或工作人2
口发药～有利于和患者进行面对员未落实
面交流及交待用药注意事项～有?无合理用药宣教设施 2
文明服务规范及用语～有合理用?缺少为特殊患者服务的规范或未2
10
药的宣教设施～有为特殊患才,如给特殊患者提供服务 二、
伤残,服务的规范～设立门诊用?未设立用药咨询或药师提供的咨2 服
药咨询服务～有门诊处方审核制询不能满足患者需要 务
度～要求处方复核率100%～ ?门诊处方复核率达不到100% 2 与
2.急诊:急诊药房应提供全天候?无“急诊用药目录” 1 安
的服务～应有“急诊用药目录”～?药品供应不能满足各种应急情况2 全
并确保药品供应～急诊药品应能的救治需要或储备不足 ,20,
满足急诊、危重病人突发公共卫?未制定急救应急用药应对预案或1
4
生事件临床救治工作的需要～制对预案未进行定期演练
定突发事件药品应急预案、制度
及程序～并有质量与品质保障的
机制
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
3.住院药房:能为住院患者提供?药品供应不能满足临床需要 4
全天候的药学服务～夜间药品供?未实行单剂量配发药品 1
应的及时性～药品供应种类应能?未建立静脉药物配制中心 1
满足临床需要～实行单剂量配发
药品～应建立静脉药物配制中心～
6 以完成肠外营养和细胞毒化疗药
物的静脉加液混合配制工作。并
制定相应的质量管理规定和操作
规程～有安全、有效、及时的配
送管理流程～工作人员实行许可
与准入管理。
1.建立药品质量监控体系:药剂?缺质量管理与持续改进方案 2 三、 科门有质量管理与持续改进方?未成立质量监控组织 2
案～成立质量监控组织～制定医?缺药品质量检测的工作记录和检2 药
院制剂、购入药品、在用药品监验记录 品 控制度和措施。有药品质量监测?无发现质量问题时处理的应急措2
的设施、设备有工作规范～有药施 质
品质量检测的各项工作记录和检?质量管理工作未体现持续改进 2 12
量 验记录～有药品发现质量问题时?科室工作人员对质量管理与持续2
的应急措施,换药、召回,和实改进工作情况不知晓 监
施情况～质量管理组织应定期召
控 开工作会议～体现质量管理持续
改进。医院使用的药品全部是国,25,
家批准上市的药品
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
2.药品供应、调剂管理:药品应?药品未分类定位储存 2 在安全、整齐、清洁的环境中分?麻醉、精神、医疗用毒性药品、2 类定位储存、准备和配发～对麻放射性药品等未按国家规定管理与 醉、精神、医疗用毒性药品、放储存 射性药品按国家有关规定进行管?药品效期、淘汰、变质的管理制2 理与储存～有严格的使用管理规度与程序未得到切实执行或发现变 范与程序。要求库内药品标签清质、过期药品
10
楚～储存适当～避热避光。有药?未对处方进行有效审查与核对或2 品效期、淘汰、变质的管理制度发现问题未给予及时有效干预 与程序～并能得到切实执行。有?出现药品调配差错～未及时上报 对处方的审查,如配伍禁忌、超或未采取补救措施 2 剂量、滥用等,、核对、调剂、发
药的程序与管理制度。药品调配
差错按规定程序及时报告
3.建立与完善药学管理信息系?未能应用药学管理信息系统进行1 统～与HIS系统联网运行～能动质量安全监控
3
态反映质量安全的各种影响因?未能给临床提供药学咨询服务 2 素～能为临床提供药学咨询服务
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
1.主任及学科带头人、各专业组?无各级人员业绩考评的制度与规2 四、 长资质符合要求～学历层次、各范 人 级人员比重符合要求～有药学技?未对各级人员工作能力、工作业3 力 术人员实际能力和工作业绩考评绩进行有效评价 资 8 的制度与规范～有药学技术人员?无药学技术人员资质的准入管理2 源 资质的准入管理制度与规范～有制度与规范 配 主管药师及以上人员的资格、实?药学技术人员资质不符合要求～1 备 际水平、能力和工作业绩的评价 每人次扣0.5分
管
理 2.制定药学技术人员继续教育工?无继续教育工作计划与制度 1 ,10, 2 作计划与制度～保证本科员工知?继续教育计划与制度未能有效落实或本1
识更新 科工作人员对新知识了解不够
1.实施临床药师制～开展临床药?无临床药师培训与教育的计划与1 五、 学工作～指导临床合理用药。有机制 合 临床药师培训与教育的计划与机?未设立专职药师从事临床药学工2 理 制～设定专职药师从事临床药学作 用 工作～参与临床查房、会诊、抢?不能提供临床药师参与查房、会2
6
药 救及病例讨论～提出药物治疗意诊、抢救、病例讨论及体现个体化 管 见～为医师、护师提供临床用药给药方案的文字记录 理 咨询～积极推广个体化给药方案～?临床医师对临床药师工作情况不 ,30, 参与严重感染与危重患者合理使了解 1
用抗生素的工作
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
2. 建立与完善药物不良反应监?发现药物不良反应漏报情况～每3 测机制～开展临床合理用药管理～次扣1分 有药物不良反应报告制度和程?药师对处方、医嘱违反治疗原则2 序～有医院合理用药管理制度与时未给予有效干预 贯彻措施～有药师对处方、医嘱?药师发现滥用药物情况未进行报2 所列药品违反治疗原则时拒绝调告或报告后未采取有效制约措施 配的制度与程序～有药师发现滥?药剂科未定期进行临床用药分析
10
用药物或药物滥用者报告制度与或以医院用药情况不掌握,抗菌药2 程序～对临床用药情况定期进行物比例、疗程、费用等, 抽验与分析,并能将有关信息向?未及进将临床用药情况分析报告 医师与相着部门进行通报～促进向临床医师通报 临床合理用药。用量前20位抗生1 素种类?50%应为检验部门提供
的药敏种类
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
3.定期或不定期出版《药讯》～举?未能开展多种形式的合理用药教2 办讲座～与院感、检验部门联合育 为临床医师发布合理使用抗菌药?《药讯》出版不及时或内容无指2 物的信息～为临床提供多种形式导作用 的合理用药教育。科主任及各专?不能及时下临床征求意见或对临2 业组负责人应主动下临床科室征床用药要求无改进措施 求意见～并及时改进工作缺陷。?未给临床提供药品使用注意事项2
14 应为临床提供药品使用注意事项及相关信息 及相关信息～特殊药品、新采购?不能保证临床用药需求或常用药3 药品应提供详细的说明书面文物出现缺药 件。应与检验部门、医院感染管?现场了解临床医师、患者对缺药2 理部门定期、不定期发布抗菌药的评价及对药剂科工作的满意情 物使用信息 况～若不满意～每人次扣0.5分
?未发布抗菌药物使用信息
1
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
6、血液净化质量安全管理与持续改进评价标准
分扣分 项目 基本要求 缺陷内容 得分
值 标准
1、科主任负责管理与持续改进工?科主任不了解全面质量管理内1
作～落实“医疗质量管理与持续改容或不清楚科室质量管理重点～对
进方案”内容要求～建立科室质量质量存在问题的改进缺乏计划性
管理小组及制度～体现全面质量管?缺科室质量管理小组及制度 1
4
理与持续改进 ?科室质量管理小组未按PDCA循1
环开展有效质量活动 一、
?科室质量存在问题改进力度不1 质
够～相同质量问题重复出现无改进 量
管 2、每月召开1次科室质量与安全?未按规定召开科室质量与安全1.5
理 工作会议～内容要体现全面、全过工作会议
3
,15, 程质量管量～有记录 ?缺改进工作措施及督办记录 1
?未体现全面、全过程质量管理 0.5
3、制定全员培训计划～落实“住?缺全员培训计划 1
院医师规范化培训方案”～有记录。?员工对质量管理要求不熟悉 1
3
全员参与质量管理与持续改进的?缺培训记录 1
全过程
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
4、制定员工的继续教育计划～医?无员工的继续教育计划 1
护人员培训合格～有相关培训证明?无人员继续教育内容 1
资料。有代表科室特色及水平的技?缺乏代表科室特色及水平的技1
5
术项目～有科室临床工作统计数据术项目
资料 ?缺本科工作统计数据资料 1
?缺医护人员培训合格证明资料 1
分扣分 项目 基本要求 缺陷内容 得分
值 标准
1、有“诊疗常规”及“操作规程”～?缺“诊疗常规” 2
能熟练运用“诊疗常规”和“操作?未落实“诊疗常规” 3
规程”指导临床工作。有设备运行?缺“操作规程” 2 二、 记录与设施安全管理制度～透析区?未落实“操作规程” 3 医 视野开阔、通道通畅、明亮通风～?缺少“操作规程”和“操作规程”3
20
疗 每个透析单元装备情况符合要求 内容培训情况 规 ?缺设备运行与设施安全管理制2 范 度及落实记录 ,45, ?透析单元装备情况不符合要求～5
每个扣1分
2、有血液透析患者适应证规定～?缺血液透析患者适应证的规定 3
6
认定过程合理 ?适应证认定过程不合理 3
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
3、有医务科的质量安全监督制度～?缺医务科的质量安全监督制度 1
有监督记录～能为患者提供适宜的?缺医务科的质量监督记录 4
治疗技术服务及检查和用药 ?未向患者提供适宜的治疗～检查1
和用药服务 2
4、有医院感染控制制度和一次性?缺医院感染控制制度 1.5
医疗用品使用与管理制度～落实到?未落实医院感染控制制度 2
位 ?缺一次性医疗用品使用与管理1.5 7
制度
?未落实一次性医疗用品使用与2
管理制度
5、透析区布局合理～水处理室符?透析区布局不合理 2
合制水机规范要求～消毒室符合医?水处理室不符合制水机规范要2
院感染监控要求。有透析机和水处求 8
理机性能资料与运行记录 ?消毒室不符合感染监控要求 2
?缺透析机和水处理机性能资料 1
?缺透析机和水处理机运行记录 1
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
1.医护人员熟悉《医疗事故处理条?员工对《条例》内容不了解 2
例》,简称条例,内容要求～落实?缺科室组织学习《条例》计划及1
“科室防范医疗纠纷及事故发生记录
的重点措施”～制定科室“医疗差?医护人员不掌握紧急封存病历2
错及事故报告处理制度”～建立医及反应标本的程序
疗差错及事故登记本～对发生的医?未制定“医疗差错及事故报告处1
12 疗差错及事故要立即报告医务科～理制度” 三、
并登记、讨论 ?医护人员不了解发生医疗差错2 医
及事故后报告处理程序 疗
?未建立医疗差错及事故登记本 1 安
?医疗差错或事故后未及时报告1 全
医务科～每漏报1次扣0.5分 ,40,
?未登记、讨论发生的差错事故 2
2.对医疗活动中发生的异常医疗?员工对“异常医疗信息请示报告1
信息要及时请示报告～增加工作的制度”不了解
危机感和机敏性。有急救与运送设?异常医疗信息发生后科室难以1
3
备 处臵时未及时上报～每漏报1次扣
0.5分
?缺急救与运送设备 1
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
3.建立“危重患者管理制度”～科?缺“危重患者管理制度”?危重4
室应加强对危重患者的管理观察～患者抢救未进行全科讨论 3 9 进行全科讨论～对科室难以处臵的?科室对危重患者难以处臵时未
危重患者应及时填写“危重患者报及进上报医务科～每漏报1次扣2
告书”上报医务科 0.5分
4、履行各项告知程序～落实诊断、?对告知内容不了解～每人次扣2
治疗、操作告知义务、充分尊重患0.5分
者权益～为患者提供心理咨询、健?未落实告知程序～每例次扣0.52
康教育与营养指导服务。需患者知分 9
情同意的诊断、治疗和操作项目～?科室未列出告知项目目录 1.5
科室要列出目录～各级医师应熟悉?未维护和尊重患者的权益 1.5
目录内容 ?未提供心理咨询、健康教育与营2
养指导服务
5、医师要严守工作岗位～有事外?未坚守工作岗位～出现脱岗 2 3
出要告知值班人员去向 ?有事外出未告知值班人员去向 1
6. 有明确的“人员紧急替代制度”?缺人员紧急替代制度 2
并保证联系通讯工具畅通～以使出?替代人员不明确 1 4
现各种突出事件时相关人员能按?联系通讯工具不畅通 1
时到位
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
7、医学影像质量安全管理与持续改进评价标准
扣分 得
项目 分值 基本要求 缺陷内容
标准 分
1、科主任负责质量管理与持续改进?科主任不了解全面质量管理内容或1
工作～落实“医疗质量管理与持续不清楚科室质量管理重点～对质量存
改进方案”内容要求～建立科室质在问题的改进缺乏计划性 1
量管理小组与制度～制定科室质量?缺科室质量管理小组及制度 1
控制标准～定期进行质量评价～体?缺科室质量控制标准 1
8 现全面质量管理与持续改进。建立?缺定期进行质量评价的记录 1
完善的影像信息管理系统 ?科室质量管理小组未按PDCA循环1
开展有效质量管理活动
?科室质量存在问题改进力度不够～2 一、
相同质量问题重复出现无改进 质
?未建立完善的信息管理系统 1 量
管 2、每月召开1次科室质量与安全工?未按规定召开科室质量与安全工作1
理 作会议～每半年召开1次临床科室会议或临床科室联席会
3
,20, 联席会～内容要体现全面、全过程?缺改进工作措施及督办记录 1
质量管理～有记录 ?未体现全面、全过程质量管理 1
3、制定全员培训计划～有业务学习?缺全员培训计划 1
年度计划～有记录～突出“以患者?缺业务学习年度计划 1
4 为中心”的服务理念～全员参与质?员工对总体质量监控指标与持续改1
量管理与持续改进的全过程 进的措施
?缺培训记录 1 5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
4、制定专业人员的继续教育计划～?无人员知识更新继续教育内容 1
做到知识不断更新。诊断医师具备?缺乏代表科室特色及水平的技术项1
本科以上学历～开展新技术新业务目
5 要进行事先培训～有代表科室特色?缺本科工作统计数据资料 1
及水平的技术项目。有本科工作统?无与院外先进水平比较的诊治项目 0.5
一数据资料～有与院外先进水平比?新技术新业务未进行事先培训 1
较的项目 ?诊断医师学历不符合要求 0.5
1、有常规、急诊的医学影像专业检?缺科室检查服务项目清单 1
查服务项目清单～能够提供2h急诊?缺急诊服务项目清单 1
5
服务～专业设臵及设备能够满足临?不能提供24h急诊服务 1
床工作需要 ?不能满足临床工作需要 2
2、有报告签发制度～有复核制度～?缺报告签发制度 1
能够按规定时间、中文形式出具正?未落实报告签发制度或出现错误报2
二、 确报告。急诊报告时限?30min报告
6
工作 告～签发人资质经过程序认定 ?出具报告时间超过规定时限 1
规范 ?未以中文形式出具报告 1
,50, ?报告、签发人不符合资质规定 1
3、诊断报告的内容和书写符合基本?诊断报告的内容和书写不符合基本2
规范～有集体读片会制度并落实到规范
位。有影像诊断与临床病例讨论会?缺影像诊断与临床病例讨论会的规2
8
的规定与记录。为患者提供咨询服定或记录
务～与临床病例的诊断符合率有专?缺集体读片会制度或未落实集体读2
人管理～有记录 片会制度 5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
?未向患者提供咨询服务 1
?缺临床诊断符合率的有关记录 1 4、建立影像投照质量、操作规程和?未建立影像投照质量、操作规程和1 质量控制标准～员工知晓科室总体质量控制标准 和专业质量监控指标。影像资料的?未落实影像投照质量、操作规程和2 质量指标符合要求～对质量缺陷有质量控制标准 整改记录。对错误报告有上级医师?员工不熟悉相关质量监控指标 1 更正重新报告制度～特殊的阳性发?缺质量缺陷整改记录 1.5 现与阴性有上级医师的复核、更正?对错误报告未落实上级医师更正重1.5 报告制度～有保存图像作依据。有新报告制度
14
专人负责临床阳性率的统计、分析～?上级医师未对特殊阳性发现与阴性1.5 有规范的图像资料的保存、使用流进行复核、更正报告 程及制度～保管条件适宜。普通X?未保存特殊的阳性发现与阴性结果1.5 线阳性率?70%～CT/MRI阳性率?的图像 70% ?临床阳性率的管理不到位 1
?图像资料保存、使用存在缺陷 1
?阳性率等指标每项不达标扣0.5分
2 5、有临床随访、下临床科室征求意?缺临床随访、下临床科室征求意见1 见的制度～有为 临床提供咨询服务的制度
5 制度。有临床对医学影像服务项目?缺临床随访、下临床科室征求意见1 质量的评价记录。科主任与各专业的记录或缺陷改进工作记录 负责人、临床医师密切联系～定期?缺为临床提供咨询服务制度 1
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
召开影像诊断与临床病例讨论会～?缺为临床提供咨询服务记录 1
有记录。 ?未定期召开影像诊断与临床病例讨1
论会或缺有关记录
6、认真执行国家现行的法律、法规～?科室环境与防护不符合国家有关标2
科室环境与防护符合国家有关标准或缺安全防护措施或安全防护措施
准～安全防护措施符合规范并落实落实不到位
到位～有市防疫站、技术监督局及?缺执法部门的环境与设备监测报告 1
其他执法部门的环境与设备监测报?缺设备保养、维护、检测制度
告～有人员体验合格上岗证～有设?缺设备保养～检修记录 1
备保养、维护、检修制度和记录～?缺操作人员对仪器设备维修情况进1.5
操作人员对仪器设备维修情况进行行评价的记录 1 12
评价。有大型医学影像设备使用与?缺大型医学影像设备的相关资料与
维修记录。有设备不足或出现故障维修记录 1
时的应急保障制度。有放射安全方?缺设备应急保障制度
案并得到落实～定期进行剂量、基?缺放射安全方案或未落实放射安全
准监测校正～有记录 方案 1.5
?缺定期进行剂量、基准监测校正的1
记录
?人员存在无资格上岗情况 1
三、 1、医护人员熟悉《医疗事故处理条?缺科室组织学习《条例》计划及记1
医 例》内容要求～落实“科室防范医录
9
疗 疗纠纷及事故发生的重点措施”～制?员工对《条例》内容不了解 1
安 定科室“医疗差错及事故报告处理?医护人员不掌握紧急封存反应标本1 5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
全 制度”～建立医疗差错及事故登记的程序
,20, 本～对发生的医疗差错及事故要立?未制定“医疗差错及事故报告处理1
即报告医务科～并登记、讨论。有制度”
保护患者隐私的制度并落实到位。?医护人员不了解发生医疗差错及事0.5
有员工与患者遭遇意外射线损伤的故后报告处理程序
处理程序并落实到位 ?未建立医疗差错及事故登记本 1
?医疗差错或事故后未及时报告医务1
科～每漏报1次扣0.5分
?未登记、讨论发生的差错事故 1
?缺保护患者隐私的制度或落实不到0.5
位
?缺员工与患者遭遇意外射线损伤的1
处理程序或落实不到位
2、对医疗活动中发生的异常医疗信?员工对“异常医疗信息请示报告制1
息要及时请示报告～增加工作的危度”不了解
3
机感和机敏性 ?异常医疗信息发生后科室难以处臵2
时未及时上报～每漏报1次扣0.5分
3、履行各项告知程序～落实操作告?对告知内容不了解～每人次扣0.52
知义务～充分尊重患者权益～需患分
者知情同意的诊断、治疗和操作项?未落实告知程序～每例次扣0.5分 2
6
目～科室要列出目录～各级人员应?科室未列出告知项目目录 1
熟悉目录内容。有保障患者隐私的?未维护和尊重患者的权益 1
制度并落实到位
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
4、科室工作人员要严守工作岗位～?未坚守工作岗位～出现脱岗 1
有事外出要告知值班人员去向。有?缺人员紧急替代制度 0.5
2 明确的“人员紧急替代制度”并保?替代人员不明确或联系通讯工具不0.5
证联系通讯工具畅通～以使出现各畅通
种突发事件时相关人员能按时到位
四、 1、 门诊患者满意度 随机调查10位患者～检查服务质量 10 服 2、 门诊患者等候时间
务 3、 急诊患者对服务及时性的满意
品 度
质 10 4、 患者对报告时限的评价
调 5、 患者对告知进行放射线检查有
查 害身体健康的知晓程度
,10, 6、 患者获得放射防护的程度
7、 患者对咨询服务的满意度
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
8、输血质量安全管理与持续改进评价标准
分扣分得项目 基本要求 缺陷内容
值 标准 分
1.科主任负责质量管理与持续?科主任不了解全面质量管理内容或2
改进工作～落实“医疗质量管理不清楚科室质量管理重点～对质量存
与持续改进方案”内容要求～建在问题的改进缺乏计划性
立科室质量管理小组及工作制? 缺科室质量管理小组及制度 2
度～制定科室质量控制标准～定? 缺科室质量控制标准 1
10
期进行质量评价。输血质量考核? 缺定期进行质量评价的记录 2
指标纳入临床科室监控范围。 ?科室质量管理小组未按PDCA循环 一、
开展有效质量管理活动 1 质
?科室质量存在问题改进力度不够～2 量
相同质量问题重复出现无改进 管
理 2.每月召开1次科室质量与安?未按规定召开科室质量与安全工作1 ,20, 全工作会议～内容要体现全面、会议
4
全过程质量管理～有记录 ?缺改进工作措施及督办记录 2
?未体现全面、全过程质量管理 1
3.制定全员培训计划～全员参与?缺全员培训计划或培训记录 1
质量管理与持续改进的全过程。 ? 员工对输血质量管理要求不熟悉 1
3
? 医师对输血适应证不掌握或者存1
在违规行为
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
4.制定专业人员的继续教育计?无专业人员的知识更新继续教育 1
划～做到知识不断更新。有代表内容
科室特色及水平的技术项目。有?缺乏代表科室特色及水平的技术项1
3
本科工作统计数据资料～有与院目
外先进水平比较的项目。 ?缺本科工作统计数据资料 0.5
?无与院外先进水平比较的项目 0.5
1.员工熟悉《献血法》、《医疗机?员工不熟悉《献血法》等法律 1.5
构临床用血管理办法》、《临床输?未落实《献血法》等法规 2.5
血技术规范》、《采供血机构和血?缺临床用血管理制度及规范 1.5
8
液管理办法 》～有临床用血管理?未落实用血管理制度与规范 2.5 二、
制度与规范～有保障落实措施～ 工
并落实到位。 作
规 2.有医院输血管理组织及工作?缺输血管理组织及工作制度 1 范 制度～有质量考核指标和技术操?缺输血管理组织开展工作记录 2 ,55, 作规程～有血液入库、核对、交?缺质量考核标准 2
10
叉配血与发血出库技术操作规? 缺技术操作规程 2
程文件～员工能熟练掌握技术操? 员工不熟练掌握技术操作规程 3
作规程。
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
3.有控制输血感染的方案及监?缺控制输血感染的方案及监管制度 3
管制度～有输血反应及输血感染?未落实方案及监管制度 3
疾病的等记报告和调查处理制?缺输血反应及感染的登记报告和调2
11
度～并落实到位。 查处理制度
?未落实输血反应及输血感染疾病的3
等级报告和调查处理制度
分扣分得项目 基本要求 缺陷内容
值 标准 分
4.有输血用血登记制度和用血?缺临床输血用血登记制度和用血报2
报批手续～有输血前检验和核对批手续
制度～有临床用血适应证的 规?未落实临床用血登记制度和用血报3 二、 定～有开展成分输血的记录～并批手续或输血审批流程不规范 工 落实到位。 ?缺输血前检验和核对制度 2 作 ?未落实输血前检验和核对制度 3
18
规 ?缺临床输血适应证的规定 2 范 ?未落实临床输血适应证的规定或缺3 ,55, 定期对临床输血适应证进行修改的记
录
?缺开展成分输血的记录或成分输血3
比例不达标
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
5.有与临床提供的服务项目目?缺为临床提供服务项目目录 1
录～具备为临床提供24小时供?不具备为临床提供24小时供血和3
8 血和成分输血服务的能力。有明成分输血服务的能力
确的急诊用血输血的规定和程?缺急诊用血输血的规定和程序 1.5
序 ?未落实急诊用血输血的规定和程序 2.5
1.医护人员熟悉《医疗事故处理?员工对《条例》内容不了解 1
条例》内容要求～制定发生输血?缺科室组织学习《条例》记录 1
4
反应的应急预案～确保输血安全 ?缺发生输血反应的应急预案 1
?未落实输血反应的应急预案 1
2.有临床发生输血反应与输血?员工对异常医疗信息请示报告制度不了解 1
感染的报告处理规范及再核对?已成医疗信息发生后科室难以处臵2 三、 检验流程～一旦发生有对策和整时未及时上报～每漏报1次扣0.5分 医 6 改措施～有资料备查。对工作中?缺输血反应或输血感染的报告处理1 疗 发生的异常信息要及时请示报及再核对程序 安 告～增加工作的危机感和机敏?缺输血反应或感染处理记录或资料 2 全 感。
,25, 3.有规范的患者签署输血知情?对告知内容不了解每人次扣0.5分 2
同意书的程序～履行各项告知程?未落实告知程序每例次扣0.5分
序～落实操作告知义务～充分尊?科室未列出告知项目目录 2
6 重患者的权益～需患者知情同意?未维护和尊重病人的权益或患者对1
的项目～科室要列出目录～各级输血的必要性、不良反应、继发感染、1
医务人员熟悉目录内容 输血前相关实验室检查的必要性不了
解
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
4.科室工作人员严守工作岗位～?未坚守工作岗位～出现脱岗 2
有事情外出要告知值班人员去?有事情外出未告知值班人员去向
4
向 2
5.有明确的人员紧急替代制度～?缺人员紧急替代制度 1
并保证联系通讯工具畅通～以使?替代人员不明确 2
5
出现各种突发事件时相关人员?联系通讯工具不通畅 2
能按时到位。
9、病理专业质量安全管理与持续改进评价标准
扣分 项目 分值 基本要求 缺陷内容 得分
标准
1.科主任负责质量管理与持续改进?科主任不了解全面质量管理内容2
工作～落实“医疗质量管理与持续或不清楚科室质量管理重点～对质 一、
改进方案”内容要求～建立科室质量存在问题的改进缺乏计划性。 质
量管理小组及制度～体现全面质量?缺科室质量管理小组及制度 2 量
8 管理与持续改进。存在问题有分析、?科室质量管理小组未按PDCA循环2 管
处理程序及改进措施～有记录文件 开展有效质量管活动 理
?科室存在问题改进力度不够～相2 ,25,
同质量问题重复出现无改进
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
2.每月召开1次科室质量与安全工?未按规定召开科室质量与安全工2 作会议～内容要体现全面、全过程作会议 质量管理、有记录～每半年召开一?未按规定召开与临床科室的联席1.5 6
次与临床科室的联系工作会议～有工作会议 记录。 ?缺改进工作措施及督办记录 1.5
?未体现全面、全过程质量管理 1 3.制定全员培训计划～全员参与质?缺全员培训计划 1 4 量管理与持续改进的全过程。员工?员工对质量管理要求不熟悉 1 知晓科室质量监控指标。 ?员工对质量监控指标不熟悉 2 4.制定专业人员继续教育计划～做?无专业人员的知识更新继续教育1 到知识不断更新。对新技术新业务内容 实施准入管理～有制度～有相关培?无新技术新业务准入管理制度 1 训内容、讨论记录和操作规程～能?无开展新技术、新业务的批准的1 开展特殊的细胞学检查等技术项工作培训、讨论记录和操作规程 目～有代表科室特色及水平的技术?不能开展特殊的细胞学检查等技1 7
项目。有本科工作统计数据资料～术项目 有与院外先进水平比较的检查项目 ?缺乏代表科室特色及水平的技术1
项目
?缺本科工作统计数据资料 1
?无与院外先进水平比较的诊治项1
目
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
1.有病理诊断服务项目目录～对本?缺病理诊断服务项目目录 3
院尚未开展或条件不具备开展的部?缺未开展检验项目的完善的外送2
分项目应有规范的外送运行机制～运行机制
10
并签订有保障合同或协议及委托合?不能满足临床工作需要 3
同或协议～能满足临床工作需要。?未建立区域性诊断体制 2
建立区域性的诊断体制。 二、
2.科室布局与流程安全、合理。空?科室布局与流程不符合医院感染2 工
间、温度、通风合理适宜～有害气控制要求 作
体的排放达到环境许可要求。有医?缺医院感染控制制度 1 规
院感染控制制度～有废弃物处理程?缺废弃物处理程序 1 范
序～符合《卫生部医院感染规范》?未落实医院感染控制制度 2 ,55,
10 的要求。 ?未落实废弃物处理程序 2
? 有害气体的排放达不到环境许1
可要求
? 环境空间、温度、通风不合理 1
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
3.能开展手术标本的病理检查、快?缺开展手术标本的病理检查、快3 速标本的病理诊断～有相应的工作速标本的病理诊断工作制度或规范 制度和规范。对全部手术标本都能?未落实手术标本的病理检查、快3 进行病理组织诊断～对肿瘤手术临速标本的病理诊断工作制度或规范 床申请的都要进行快速病理诊断。?未建立病理诊断标本保存的制度3
15
有病理诊断标本保的制度和管理体和管理体系 系。病理组织切片质量与病理报告?未落实病理标本的保存制度 3 质量达到规定有要求。 ?病理切片的质量与病理报告质量3
达不到规定要求
4.设施、设备、机器能够完成全部?缺设备与试剂的国家许可证明文2 病理诊断项目～能满足临床需要～件资料 有设备操作规程～设备与试剂有专?缺设备操作规程 1 人管理和保管～定期进行保养～有?员工对设施、设备操作规程不熟1 相关记录。对鉴定不合格淘汰的设悉～每人扣0.5分。
8
备与试剂有记录资料。 ?缺设备定期保养记录 1
?设施、设备、机器不能满足临床2
需要
?缺及时淘汰经鉴定不合格的设备1
与试剂的记录资料
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
5.有病理报告管理与签发、复核制?缺病理报告管理与签发、复核制1.5 度。病理报告人员资质合格～有为度 患者提供病理报告的咨询服务或病?缺为患者提供病理报告咨询服务1.5 理切片会诊的制度～病理人员要主或病理切片会诊的制度 动下临床科室征求意见～有记录资?未落实病理报告管理与签发、复2 料～病理组织诊断报告?5天～术核制度 中快速病理诊断报告及时完整。 ?未落实为患者提供病理报告咨询1.5
12
服务或病理切片会诊的制度
?缺科室技术人员下临床科室征求1.5
意见的记录资料
?缺病理组织诊断报告时间超过规1.5
定期限
?术中快速病理诊断报告未能及时2.5
完成
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
1.有防止意外事故的应急预案并进?缺应急预案或员工对《预案》、《条1
行演练及掌握～消防设备配臵合理～例》内容不了解
标志醒目～有紧急通道。医护人员?缺科室组织学习《应急预案》、《条1
熟悉《医疗事故处理条例》内容要例》计划及记录～或安全制度、措
求～落实“科室防范医疗纠纷及事施不到位
故发生重点措施”～制定科室“差错?未制定“差错及事故报告处理制1
及事故登记本～对发生的差错及事度”
8
三、 故要立即报告医务科～并登记、讨?医护人员不了解发生医疗差错及1 医 论。 事故后报告处理程序 疗 ?未建立差错及事故登记本 1 安 ?差错或事故后未及时报告医务2 全 科～每漏报1次扣0.5分 ,20, ?未登记、讨论发生的差错或事故 1
2.对医疗活动中发生的异常医疗?员工对“异常医疗信息请示报告1
信息要及时请示报告～增加工作的制度”不了解
危机感和机敏性 ?异常医疗信息发生后科室难以处2
3
臵时未及时上报～每漏报1次扣0.5
分。
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
3.履行有关告知程序～落实操作告?对告知内容不了解～每人次扣0.52
知义务～充分尊重患者权益～需患分
者知情同意的诊断、操作项目～科?未落实告知程序～每例次扣扣0.52
6 室要列出目录～各级人员应熟悉目分
录内容 ?科室未列出告知项目目录 1
?未维护尊重患者的权益 1
5.科室工作人员要严守工作岗位～?缺人员紧急替代制度 1
有事外出要告知值班人员去向。有?替代人员不能及进到位或通讯工1
3
明确的“人员紧急替代制度”并保具不畅通
证联系通讯工具畅通. ?工作人员出现脱岗 1 10、护理专业质量安全管理与持续改进评价标准
由护理质量管理委员会另行实施。
六、考核方法和奖惩制度
1、每月由医院质量考核小组负责组织实施检查一次～结合平时抽查及终未质量考核作出分数评定。
2、每个科室定分100分,外科系统130分,～实行倒扣分制～扣完为止。
3、科室考核评定分为五个档次～考核分?95分为优秀～考核分,95、?85分为良好～考核分,85、?75分为一般～考核分,75、?65分为差～考核分,65分为较差。,外科系统按比例计算,
4、科室考核分值与科室绩效工资挂钩。
5、重大医疗质量问题按医院有关规定视情节给予罚款～取消先进科室评审资格和对责任人进行行政处罚等处理。
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
七、医疗质量管理与持续改进
,一,临床医疗质量管理与持续改进:
1、核心制度管理:
认真执行医疗质量和医疗安全的核心制度～如首诊负责工作制度、查房制度、病例讨论制度、会诊制度、危重患者抢救工作制度、手术审批分级制度、手术准入制度、分级护理制度、查对制度、病历书写规范与管理制度、交接班制度、临床用血管理制度、知情谈话制度等。
加强医疗质量关键环节的管理。进一步抓好各项医疗管理制度的贯彻～真正做到制度落实。定期检查制度～使医疗质量管理制度化。新入院病人48小时内必须有主治医师或高级职称医师查房,术前,非急诊,、术后必须各有一次高级职称医师查房,病人入院一周以上～每周必须有一次高级职称医师查房。每月抽查首次主任,副主任,医师查房及首次主治医师查房制度执行情况、抽查术前小结及谈话、手术审批、麻醉会诊及谈话、输血会诊、输血治疗谈话、科间会诊、入院72小时谈话、术后谈话、病例讨论制度、交接班制度、传染病报告制度、教学制度等制度落实情况。有效防范、控制医疗风险～及时发现医疗质量和安全隐患。
2、病历质量管理:
? 贯彻落实《医疗事故处理条例》、《病历书写基本规范》、《医疗机构病历管理规定》等有关规定。
? 医疗文书书写及时、准确、完整、规范。
? 建立、健全病历全程质量监控、评价、反馈制度～提高甲级病历率。
? 加强运行病历的监控与管理～重点检查与医疗质量和患者安全相关的内容。做好三个环节质量控制。加强病历书写的质量教育～每年新职工上岗前进行病历书写规范教育～特别是实习生及进修生的病历书写质量教育。定期检查病历书写的环节质量和终末质量～每周5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
抽查一次术前准备病历、每月抽查一次入院24小时完成病历及三级查房记录和输血相关记录、每季抽查一次归档病历,包括临床记录、护理记录、医技报告书写质量,。各类检查结果均纳入医疗服务质量管理考核～与当月奖金挂钩。
3、单病种质量管理和临床路径管理:
重点以卫生行政部门规定的单病种和本科前,位住院病种及卫生部的临床路径管理的三类病种。
? 住院患者均有适宜的诊疗计划～符合路径管理病种严格按路径表执行～认真进行路径变异分析～严格符合标准。
? 持续提高诊断、治疗质量～包括:诊断准确～治疗安全、及时、有效、经济。
? 外科系统还应:
A、严格实行手术分级管理制度～重大手术报告、审批制度。
B、严格执行甲乙类手术术前讨论制度～重点是:术前诊断、手术适应证、术式、麻醉与输血选择、预防性应用抗菌药物等。
C、围手术期管理措施到位。术前:诊断、手术适应证明确～术式选择合理～患者准备充分～与患者签署手术和麻醉同意书、输血同意书等。严格执行手术安全核查和手术风险评估制度,术中:意外处理措施果断、合理～术中改变术式等及时告知家属或代理人等,术后:术前诊断与病理诊断相符～并发症预防措施科学～术后观察及时、严密～早期发现并发症并妥善处理。
4、医疗技术管理:
医院的医疗技术服务应与其功能、任务和业务水平相适应。开展的医疗技术应当是其执业诊疗科目内的成熟医疗技术～符合国家有关规定～并且具有相应的专业技术人员、支持系统～能确保技术应用的安全、有效。
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
? 医疗技术管理符合国家有关规定。建立健全并认真贯彻落实医疗技术准入、应用、监督、评价制度～并建立完善医疗技术损害处臵预案。建立医疗技术风险预警机制～并组织实施。
? 具有与开展的技术或项目相适应的技术力量、设备与设施～以及确保患者安全的方案。当技术力量、设备和设施发生改变～可能影响到医疗技术的安全和质量时～应当中止该技术。按规定进行评估后～符合规定的～方可重新开展。
? 对新开展的医疗技术的安全、质量、疗效、费用等情况进行全程追踪管理和评价～及时发现医疗技术风险～并采取相应措施～以避免医疗技术风险或将其降到最低限度。
? 建立新开展的医疗技术档案～以备查。
? 进行医疗技术科研～必须符合伦理道德规范～按规定审批。在科研过程中～充分尊重患者的知情权和选择权～并注意保护患者安全。同时～不得向患者收取相关费用。
? 不得应用未经批准或安全性和有效性未经临床实践证明的技术。
,二, 急诊质量管理与持续改进:
1、 急诊专业设臵合理～人员相对固定。值班医师能够胜任急诊抢救工作。
2、 建立急诊、入院、手术“绿色通道”～急诊服务及时、安全、便捷、有效。及时接受各类急、危、重病人的抢救和诊治。急诊24小时开放～实行医师首诊负责、严格执行急诊各项规章制度。急诊留观时间平均不超过,,小时。重点以急诊检验、放射、输血、药房、会诊、留观、手术、住院、转诊等环节。
3、 急诊抢救工作及时～由上级医师进行指导或主持。急危重症患者抢救成功率较高。
4、 加强运行病历的监控与管理～重点检查与医疗质量和患者安全相关的内容。
5、 急救设备齐备完好～满足急救工作需要。医护人员能够熟练、正确使用。
6、 急诊标志醒目～各窗口标志日夜明显。
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
7、 应诊能力:医院各部门与急诊工作密切配合～紧急传呼系统保证畅通～急诊接诊5分钟内到位。
8、 各种抢救设施定期检查～并有记录～保持运行状态良好。
9、 进修生及低年资住院医师不得单独出急诊值班。急诊病历按病历书写要求执行～病历质量检查与住院病历相同。
,三, 门诊质量管理与持续改进:
1、依据工作量及需求～合理安排专业技术人员～提高门诊确诊能力～保证门诊诊疗质量。
2、 临床专科门诊有副主任医师以上人员把关～各科每周2.5天有副高以上医师出诊。
3、 医疗文书书写规范。加强门诊处方、门诊病历书写、各类申请单书写质量检查制度～每月检查一次门诊处方、门诊病历质量～并与奖金挂钩。
4、 三次门诊未确诊的病人～有相应的会诊讨论。
5、 提高门诊医疗服务质量～门诊病人满意度?90%。每月进行质量检查～并将检查结果纳入医疗服务质量考核～与奖金挂钩。每2个月进行一次门诊医疗服务质量流动红旗评比。
,四, 病理质量管理与持续改进:
1、 病理工作能够满足临床工作需要。
、严格执行各项病理管理制度。 2
3、 建立并严格执行标本验收、核对、登记、归档制度。
4、 努力冰冻切片与石蜡切片的诊断符合率。
5、 病理切片、蜡块保存符合规定。
6、 室内质控:
? 严格执行病理上级医师复片制、科内疑难病理读片制和会诊制。 5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
? 每月进行一次制片质量、诊断质量检查～并有室内质控评价分析记录。 ? 病理报告及时、准确、规范～有审核制度。
? 定期检查实验用试剂及器械的性能～并有记录。有毒及易燃、易爆物品有专人保管。 7、室间质控:参加省级病理质量室间评价活动～力争达到同级医院较高水平。 8、 努力提高患者、医师与护理人员对病理部门服务满意度。
,五, 医学影像质量管理与持续改进:
1、专业设臵及其设备、设施满足临床需要～能提供,,小时急诊检查服务。 2、 执行技术操作规范～实行科学的质量控制标准～开展临床随访～定期进行质量评价。如:常规X线、与手术病理诊断对照分析。
3、 医学影像资料质量符合临床工作要求。
4、 报告及时、准确、规范～有审核制度～报告需经主治医师以上审核签名方可发出。 5、 环境保护与个人防护达到标准。
6、 建立放射科统一管理体系～实行放射科主任对常规X线、与放射诊断及相关放射治疗的统一领导和管理。医技人员实施相应固定。
7、 每天科主任直接主持常规X线诊断统一读片。
8、 严格执行接诊登记、影像片保管、借阅及值班、交接班制度。
9、严格执行设备专人负责与维修保养制度。
、积极参加省级室间质控评价活动～力争取得名次。 10
11、努力提高患者、医师与护理人员对医学影像部门服务满意度。
,六, 检验质量管理与持续改进:
1、 贯彻落实《病原微生物实验室生物安全管理条例》等有关规定。严格执行各种检验制度。
2、 临床检验实验室集中设臵～统一管理～资源共享。实验室管理统一标准～统一质控～5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
保证质量。
3、 临床检验实验室布局与流程应当安全、合理～并符合医院感染控制和生物安全要求。
4、 临床检验项目满足临床需要～并能提供,,小时急诊检验服务。
5、 落实全面质量管理与改进制度～按照规定开展室内质控、参加室间质评。没有质控的临床检验项目或科研项目～不得以创收为目的～不得向临床出具检验报告。
6、 室内质控:开展项目均有室内质量保证措施～室内质控项目每天有质控记录～质控图齐全～失控分析按月小结～有改进措施。有差错事故登记本～如实登记～并有整改措施。
7、 室间质控:积极参加部、省两级临检质控中心组织的生化、细菌、血液、免疫项目室间评价活动～并要求四项全部达标。
8、 临床及临床实验室报告项目必须开展室内质控～有具体措施及记录。
9、 试剂购进渠道正规～无三无产品,生产许可证、批准文号、营业执照,～无过期失效试剂。质控品需按卫生行政部门要求执行。
、开展项目结果正确～无明显误差及漏检。检验报告及时、准确、规范～可长期保存～10
报告单有专人审核。
11、不断加强对放射性试剂、易燃易爆和剧毒物,药,品、污物、废弃标本的管理。
12、 检验标本采集运送和保存符合要求～结果有信息反馈～急诊和重要标本采集时间需记录。
13、 遵守检验项目和检测仪器操作规程～定期校准检测系统～并及时淘汰经检定不合格的设备与试剂。
14、努力提高患者、医师与护理人员对检验部门服务满意度。
,七, 输血质量管理与持续改进:
1、 落实《献血法》和《临床用血管理办法》、《临床输血技术规范》等有关规定。医院严禁非法擅自采血。
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
2、 具备为临床提供,,小时供血服务的能力～满足临床需要。
3、 制定临床输血管理规范。定期召开输血管理会议和科学合理输血知识培训。提高成份输血使用率及红细胞使用率。
4、 建立质量监测、考核和信息反馈制度。
5、 制定、实施控制输血感染的方案～严格执行输血技术操作规范。
6、 落实临床用血申请、登记制度～履行用血报批手续～执行输血前安全检验和核对制度。
7、 掌握输血适应症～科学、合理用血。完善输血反应及输血感染疾病的登记、报告和调查处理制度。
8、定期检查血液检测试剂原始凭据及使用记录。定期冰箱消毒、细菌培养。
9、 定期检查血液出入库专用登记簿记录、核对、检查双签名是否符合要求。
10、 严格执行输血会诊制度,一次用血、备血2000毫升以上需按规定会诊,及输血前告知制度。
11、 根据临床用血量～上报临床用血计划～并做好临床用血统计及上报工作。保证最佳库存量～积极开展术中自血回输术。
12、 输血用器材必须符合国家标准～有三证,产品许可证、卫生许可证、医疗器械注册证,。
13、 努力提高患者与医师、护理人员对输血部门服务满意度。
,八,药事质量管理与持续改进:
1、 贯彻落实《药品管理法》、《医疗机构药事管理暂行规定》、《抗菌药物临床应用指导原则》和《处方管理办法,试行,》等有关规定。
2、 有完善的规章制度和各岗位标准操作规程。制定、落实药事质量管理规范、考核办法并持续改进。
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
3、 药品供应满足临床需要。建立突发事件药品供应与药事管理机制。
4、 药剂科门布局合理～管理规范～能为患者提供安全、及时、人性化的服务。
5、 药剂科门要建立“以病人为中心”的药学管理工作模式～开展以合理用药为核心的临床药学工作～建立临床药师制。临床药师数量合理～负责临床药物遴选、处方审核～参与查房、会诊等。
6、药学专业技术人员负责合理用药的监督、指导、评价～开展药物安全性监测～特别是对用药失误、滥用药物的监测。指导医师开展药物不良反应监测和报告～开展抗菌药物临床应用监测～协助临床做好细菌耐药监测。为患者提供合理用药的咨询服务～积极推广个体化给药方案。禁止非药学专业技术人员从事药学技术工作。
7、 加强对特殊管理药品的管理～包括毒性药品、麻醉药品、精神药品、放射药品购臵、使用与安全保管。剧、毒、麻药做到五专,专人、专柜、专锁、专处方、专登记,。
8、 严格执行由正规渠道进药～从药品招标中标企业按招标结果购进～保证药品质量。有验收记录制度。进药厂家必须有三证,生产许可证、生产合格证、营业执照,,药品必须有批准文号、注册商标、有效期。
9、 药事委员会每年至少召开四次会议～并有会议记录和具体的实施办法。
10、. 每月发布一期临床用药信息～指导合理用药。提供用药咨询～设立用药知识宣传橱窗～每年至少更换宣传内容四期。
11、 每季检查分析临床用药及合理用药情况。
12、 努力提高患者与医师、护理人员对药剂科门服务满意度。
,九, 其他辅助科室质量管理与持续改进:
1、 B超、心电图、内镜等严格按照操作规程。报告书写项目齐全、字迹清楚～检查所见描写应客观、完整、准确。内镜检查前必须有乙肝表面抗原过筛检查～阳性有相应措施。内镜使用后严格按常规清洁消毒。
5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
2、 努力提高患者与医师、护理人员对其他辅助科室服务满意度。
八、 质量管理与持续改进控制办法:
1、医疗质量管理组织人员结构合理～院、科二级质量管理组织分工明确～协作机制
健全。
2、 院长作为医院医疗质量管理第一责任人～领导医疗质量管理工作。将定期或不定期检查的情况由经管院长在院周会上反馈～并提出改进意见。
3、 医疗质量管理职能部门行使指导、检查、考核、评价和监督职能。通过检查、分析、评价、反馈等措施～持续改进医疗质量。
4、 科室主任全面负责本科室医疗质量管理工作。各科室制订医疗服务质量目标管理～每季度自查措施落实情况。
5、 医疗质量管理实行责任追究制。各职能科室要对医疗制度、医疗质量、护理质量、医院感染、劳动纪律、医德医风与规范收费、门诊医疗服务态度、健康教育与仪表、环境卫生、综合满意度、临床教学、治安安全等方面～加强管理～认真督促检查～不断完善、增强激励机制。每月按《医疗服务质量管理考核评分标准》进行检查～并将检查结果与奖金挂钩。
6、 结合卫生部“医院管理评价指南,2008版,”以及省卫生厅“三级综合医院评审评分表”质量管理规范～逐步完善我院的医疗质量管理。
海南省农垦那大医院
医疗质量管理委员会
2011年1月重新修订 5 principles of basic theory and application of Interventional Radiology, the basic techniques of Interventional Radiology, interventional surgical indications and contraindications, and perioperative management of various types of interventions. (2) Department of internal medicine and related: require regular visits and physical examination techniques, and familiarity with the clinical diseases listed in the following table, physical signs, laboratory testing and diagnosis, in particular, to master a variety of first aid. Learning disease species requirements: System disease species breathing, and circulatory system bronchial expansion, bacteria sex pneumonia, Lung abscess, tuberculosis, lung cancer rheumatic heart valve disease, coronary heart disease, pericarditis Digest, and urinary system endocrine system Digest road Ulcer (stomach, and duodenal ulcer), Digest road tumor (gastric cancer, and knot rectal cancer), cirrhosis, liver cell cancer, pancreatic inflammatory, pancreatic cancer various type nephritis, kidney failure, bladder inflammatory various goiter, thyroid gland tumor, thyroid cancer bone joint system bone loose, and bone metabolism disease, and endocrine bone disease According to the professional future work in selected non-specified sections (including Pediatrics, Neurology, etc) Web (you can select a Department). ? Pediatric rotation learn: awareness ...
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