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首页 三甲医院评审细则目录

三甲医院评审细则目录.doc

三甲医院评审细则目录

你的爱其实我早已不痛
2017-10-18 0人阅读 举报 0 0 暂无简介

简介:本文档为《三甲医院评审细则目录doc》,可适用于综合领域

三甲医院评审细则目录实行麻醉医师资格分级授权管理制度与规范有定期能力评价与再授权的机制。【C】实行麻醉医师资格分级有麻醉医师资格分级授权管理相关制度与程序。授权管理并有明确的制麻醉分级授权管理落实到每一位麻醉医师权限设臵与其资格、能力相符。度。独立实施麻醉的医师须具备中级以上专业技术职务任职资格。麻醉医师知晓率。【B】符合“C”并职能部门对授权情况实施动态管理。有监督检查、反馈、处理。【A】符合“B”并麻醉医师资格分级授权管理执行良好无超权限操作情况。对麻醉医师有【C】定期执业能力评价和再有定期对麻醉医师执业能力评价与再授权的制度并落实。授权制度。麻醉医师均能知晓。【B】符合“C”并有麻醉医师定期执业能力评价与再授权的档案资料。【A】符合“B”并公开麻醉医师权限及时更新相关信息。【C】麻醉医师经过严格的专麻醉医师经过严格的专业理论和技能培训考核合格。业理论和技能培训完成每一位麻醉医师均经心肺复苏高级教程培训能熟练掌握。跟踪最新指南继续教育。及时更新心肺复苏流程。【B】符合“C”并麻醉医师定期(至少每年)接受继续教育知识更新。【A】符合“B”并麻醉医师继续教育达标率。【C】手术麻醉人员配臵合理。人员配臵合理基本满足临床需要。有明确的岗位职责相关人员知晓本岗位的履职要求。【B】符合“C”并麻醉科主任具有副高级及以上专业技术职务任职资格。护士长应当具有中级及以上专业技术职务任职资格。toandthetreatmentBonemarrowaspirationMaster:kidneyunitsandkidneyphysiologicalfunctionkidneyballdiseaseofcauses,andonsetmechanism,andclinicalpointstype,andclinicalperformance,anddiagnosis,andidentificationdiagnosisandtreatmentsugarcortexhormone,andimmuneinhibitorsandanticoagulantagentapplicationurinarytractinfectionofdiagnosis,andidentificationdiagnosisandtreatmentacuteandchronickidneyfailureofcauses,andonsetmechanism,anddiagnosisandtreatmentnondialysistherapyinthenutritiontreatmentofpurposeandrequirementsblood,andperitonealdialysistherapyofadaptedcardkidneyfunctioncheckofusingandresultsjudgekidneypunctureindicationsandtaboosyndromeUnderstanding:thepathologicalclassificationofglomerulardiseasesinterstitialnephritisandrenaltubulardiseaseetiology,pathogenesis,diagnosisandtreatmentprincipleskidneytransplantantirejectiontherapyotherclinicaldiagnosticandtreatmenttechnologiesbasicstandard()learningdiseasespeciesandthecasesnumberrequirementsdiseasespeciesacutenephritisintegratedlevychronicnephritis【A】符合“B”并麻醉医师人数与手术台比例,:。每张手术台配备一名麻醉住院医师及一名主治及以上的麻醉医师。toandthetreatmentBonemarrowaspirationMaster:kidneyunitsandkidneyphysiologicalfunctionkidneyballdiseaseofcauses,andonsetmechanism,andclinicalpointstype,andclinicalperformance,anddiagnosis,andidentificationdiagnosisandtreatmentsugarcortexhormone,andimmuneinhibitorsandanticoagulantagentapplicationurinarytractinfectionofdiagnosis,andidentificationdiagnosisandtreatmentacuteandchronickidneyfailureofcauses,andonsetmechanism,anddiagnosisandtreatmentnondialysistherapyinthenutritiontreatmentofpurposeandrequirementsblood,andperitonealdialysistherapyofadaptedcardkidneyfunctioncheckofusingandresultsjudgekidneypunctureindicationsandtaboosyndromeUnderstanding:thepathologicalclassificationofglomerulardiseasesinterstitialnephritisandrenaltubulardiseaseetiology,pathogenesis,diagnosisandtreatmentprincipleskidneytransplantantirejectiontherapyotherclinicaldiagnosticandtreatmenttechnologiesbasicstandard()learningdiseasespeciesandthecasesnumberrequirementsdiseasespeciesacutenephritisintegratedlevychronicnephritis实行患者麻醉前病情评估制度制订治疗计划方案风险评估结果记录在病历中。有患者麻醉前病情评估和麻醉前讨论制度。【C】有患者麻醉前病情评估制度内容包括:()明确患者麻醉前病情评估的重点范围。()手术风险评估。()术前麻醉准备。()对临床诊断、拟施行的手术、麻醉方式与麻醉的风险、利弊进行综合评估。有术前讨论制度对高风险择期手术、新开展手术或麻醉方法进行麻醉前讨论。B】符合“C”并【职能部门履行监管职责有监管检查、反馈、改进措施。【A】符合“B”并评估与讨论的病历记录完整性。由具有资质和授权的麻醉医师进行麻醉风险评估制定麻醉计划。【C】由具有资质和授权的麻醉医师为每一位手术患者制订麻醉计划。麻醉计划记录于病历中包括拟施行的麻醉名称、可能出现的问题与对策等。根据麻醉计划进行麻醉前的各项准备。按照计划实施麻醉变更麻醉方法要有明确的理由并获得上级医师的指导和同意家属知情记录于病历麻醉单中。【B】符合“C”并科室对变更麻醉方案的病例进行定期回顾、总结、分析。职能部门履行监管职责有定期监管检查、分析、反馈有改进措施。【A】符合“B”并对措施落实情况进行追踪评价有持续改进。toandthetreatmentBonemarrowaspirationMaster:kidneyunitsandkidneyphysiologicalfunctionkidneyballdiseaseofcauses,andonsetmechanism,andclinicalpointstype,andclinicalperformance,anddiagnosis,andidentificationdiagnosisandtreatmentsugarcortexhormone,andimmuneinhibitorsandanticoagulantagentapplicationurinarytractinfectionofdiagnosis,andidentificationdiagnosisandtreatmentacuteandchronickidneyfailureofcauses,andonsetmechanism,anddiagnosisandtreatmentnondialysistherapyinthenutritiontreatmentofpurposeandrequirementsblood,andperitonealdialysistherapyofadaptedcardkidneyfunctioncheckofusingandresultsjudgekidneypunctureindicationsandtaboosyndromeUnderstanding:thepathologicalclassificationofglomerulardiseasesinterstitialnephritisandrenaltubulardiseaseetiology,pathogenesis,diagnosisandtreatmentprincipleskidneytransplantantirejectiontherapyotherclinicaldiagnosticandtreatmenttechnologiesbasicstandard()learningdiseasespeciesandthecasesnumberrequirementsdiseasespeciesacutenephritisintegratedlevychronicnephritis患者麻醉前的知情同意包括治疗风险、优点及其他可能的选择。履行麻醉知情同意。【C】有麻醉前由麻醉医师向患者、近亲属或授权委托人进行知情同意的相关制度。向患者、近亲属或授权委托人说明所选的麻醉方案及术后镇痛风险、益处和其他可供选择的方案。签署麻醉知情同意书并存放在病历中。【B】符合“C”并针对不同患者采取通俗易懂的方式确保知情同意的效果。【A】符合“B”并患者对知情同意内容充分理解。知情同意书内容完整性。toandthetreatmentBonemarrowaspirationMaster:kidneyunitsandkidneyphysiologicalfunctionkidneyballdiseaseofcauses,andonsetmechanism,andclinicalpointstype,andclinicalperformance,anddiagnosis,andidentificationdiagnosisandtreatmentsugarcortexhormone,andimmuneinhibitorsandanticoagulantagentapplicationurinarytractinfectionofdiagnosis,andidentificationdiagnosisandtreatmentacuteandchronickidneyfailureofcauses,andonsetmechanism,anddiagnosisandtreatmentnondialysistherapyinthenutritiontreatmentofpurposeandrequirementsblood,andperitonealdialysistherapyofadaptedcardkidneyfunctioncheckofusingandresultsjudgekidneypunctureindicationsandtaboosyndromeUnderstanding:thepathologicalclassificationofglomerulardiseasesinterstitialnephritisandrenaltubulardiseaseetiology,pathogenesis,diagnosisandtreatmentprincipleskidneytransplantantirejectiontherapyotherclinicaldiagnosticandtreatmenttechnologiesbasicstandard()learningdiseasespeciesandthecasesnumberrequirementsdiseasespeciesacutenephritisintegratedlevychronicnephritis执行手术安全核查实施麻醉操作的全过程必须记录于病历麻醉单中。执行手术安全核查麻醉的全过程在病历麻醉单【C】按照规定执行手术安全核查。按规定内容书写麻醉单。上得到充分体现。麻醉的全过程在病历麻醉单上得到充分体现。【B】符合“C”并科室有专门质控人员负责定期检查、反馈。职能部门有检查、反馈、总结有改进措施。【A】符合“B”并麻醉师参加手术安全核查并签字达。麻醉单及相关记录真实、准确、完整符合规范合格率。有麻醉过程中的意外与并发症处理规范。【C】有麻醉过程中的意外与并发症处理规范与流程。()有及时报告的流程。()处理过程应该得到上级医师的指导。()处理过程记录于病历麻醉单中。麻醉医师对规范和流程的知晓率。各项麻醉意外与并发症的预防措施落实到位。B】符合“C”并【职能部门有检查、反馈、总结有改进措施。对麻醉意外和并发症专题讨论定期自查、分析、整改。【A】符合“B”并。有效预防麻醉意外与并发症持续改进有成效。有麻醉效果评定。【C】有麻醉效果评定的规范与流程。【B】符合“C”并科室能定期对麻醉效果资料进行分析、评价、总结有改进措施。【A】符合“B”并麻醉效果优良率高。toandthetreatmentBonemarrowaspirationMaster:kidneyunitsandkidneyphysiologicalfunctionkidneyballdiseaseofcauses,andonsetmechanism,andclinicalpointstype,andclinicalperformance,anddiagnosis,andidentificationdiagnosisandtreatmentsugarcortexhormone,andimmuneinhibitorsandanticoagulantagentapplicationurinarytractinfectionofdiagnosis,andidentificationdiagnosisandtreatmentacuteandchronickidneyfailureofcauses,andonsetmechanism,anddiagnosisandtreatmentnondialysistherapyinthenutritiontreatmentofpurposeandrequirementsblood,andperitonealdialysistherapyofadaptedcardkidneyfunctioncheckofusingandresultsjudgekidneypunctureindicationsandtaboosyndromeUnderstanding:thepathologicalclassificationofglomerulardiseasesinterstitialnephritisandrenaltubulardiseaseetiology,pathogenesis,diagnosisandtreatmentprincipleskidneytransplantantirejectiontherapyotherclinicaldiagnosticandtreatmenttechnologiesbasicstandard()learningdiseasespeciesandthecasesnumberrequirementsdiseasespeciesacutenephritisintegratedlevychronicnephritis有麻醉后复苏室管理措施到位实施规范的全程监测记录麻醉后患者的恢复状态防范麻醉并发症的措施到位。麻醉后复苏室合理配臵管理措施到位【C】麻醉后复苏室床位与手术台比不低于:。麻醉复苏室配备医护人员满足临床需要至少有一位能独立实施麻醉的麻醉医师。复苏室每床配备吸氧设备包括无创血压和血氧饱和度在内的监护设备复苏室配备足够的呼吸机、抢救用药及必需设备等满足需求。【B】符合“C”并对麻醉复苏室的医护人员进行定期培训与考核。对设施设备进行定期维护。【A】符合“B”并配臵符合规定要求管理措施到位。有麻醉复苏室患者转入、转出标准与流程。【C】有麻醉复苏室患者转入、转出标准与流程。患者在复苏室内的监护结果和处理均有记录。转出的患者有评价标准(全身麻醉患者Steward评分)评价结果记录在病历中。有患者转入、转出麻醉复苏室交接流程与内容规定。准确记录患者进、出麻醉术后复苏室的时间。【B】符合“C”并科室定期自查、分析、整改。职能部门进行检查、反馈有改进措施。【A】符合“B”并患者的监护和处理记录真实、准确、完整病历记录完整率。toandthetreatmentBonemarrowaspirationMaster:kidneyunitsandkidneyphysiologicalfunctionkidneyballdiseaseofcauses,andonsetmechanism,andclinicalpointstype,andclinicalperformance,anddiagnosis,andidentificationdiagnosisandtreatmentsugarcortexhormone,andimmuneinhibitorsandanticoagulantagentapplicationurinarytractinfectionofdiagnosis,andidentificationdiagnosisandtreatmentacuteandchronickidneyfailureofcauses,andonsetmechanism,anddiagnosisandtreatmentnondialysistherapyinthenutritiontreatmentofpurposeandrequirementsblood,andperitonealdialysistherapyofadaptedcardkidneyfunctioncheckofusingandresultsjudgekidneypunctureindicationsandtaboosyndromeUnderstanding:thepathologicalclassificationofglomerulardiseasesinterstitialnephritisandrenaltubulardiseaseetiology,pathogenesis,diagnosisandtreatmentprincipleskidneytransplantantirejectiontherapyotherclinicaldiagnosticandtreatmenttechnologiesbasicstandard()learningdiseasespeciesandthecasesnumberrequirementsdiseasespeciesacutenephritisintegratedlevychronicnephritis建立术后、慢性疼痛、癌痛患者的镇痛治疗管理的规范与流程能有效地执行。建立术后、慢性疼痛、癌痛患者的镇痛治疗管理的规范与流程能有效地执行。【C】有术后、慢性疼痛、癌痛患者的镇痛治疗规范。对参与疼痛治疗的相关医护人员进行定期培训与考核。麻醉医师掌握操作规范与流程并能在镇痛治疗中认真执行镇痛治疗效果正确评价有记录。相关器材与药品使用合理。【B】符合“C”并科室定期自查、分析、整改。职能部门进行检查、反馈有改进措施。【A】符合“B”并持续改进有成效。toandthetreatmentBonemarrowaspirationMaster:kidneyunitsandkidneyphysiologicalfunctionkidneyballdiseaseofcauses,andonsetmechanism,andclinicalpointstype,andclinicalperformance,anddiagnosis,andidentificationdiagnosisandtreatmentsugarcortexhormone,andimmuneinhibitorsandanticoagulantagentapplicationurinarytractinfectionofdiagnosis,andidentificationdiagnosisandtreatmentacuteandchronickidneyfailureofcauses,andonsetmechanism,anddiagnosisandtreatmentnondialysistherapyinthenutritiontreatmentofpurposeandrequirementsblood,andperitonealdialysistherapyofadaptedcardkidneyfunctioncheckofusingandresultsjudgekidneypunctureindicationsandtaboosyndromeUnderstanding:thepathologicalclassificationofglomerulardiseasesinterstitialnephritisandrenaltubulardiseaseetiology,pathogenesis,diagnosisandtreatmentprincipleskidneytransplantantirejectiontherapyotherclinicaldiagnosticandtreatmenttechnologiesbasicstandard()learningdiseasespeciesandthecasesnumberrequirementsdiseasespeciesacutenephritisintegratedlevychronicnephritis建立麻醉科与输血科的有效沟通积极开展自体输血严格掌握术中输血适应证合理、安全输血。建立麻醉科与输血科的有效沟通严格掌握术中输血适应症合理、安全输血。【C】有手术中用血的相关制度与流程手术用血有严格的指征。有麻醉科与输血科沟通的流程。积极开展自体输血。有手术用血前评估和用血疗效评估。相关人员知晓术中用血的制度与流程。【B】符合“C”并麻醉科与手术科室和输血科等人员能有效沟通保障术中输血及时、合理、安全。科室定期对术中用血进行总结、分析、整改。职能部门进行检查、反馈对存在的问题及时整改。【A】符合“B”并符合条件的自体输血率不断提高术中合理用血率达。toandthetreatmentBonemarrowaspirationMaster:kidneyunitsandkidneyphysiologicalfunctionkidneyballdiseaseofcauses,andonsetmechanism,andclinicalpointstype,andclinicalperformance,anddiagnosis,andidentificationdiagnosisandtreatmentsugarcortexhormone,andimmuneinhibitorsandanticoagulantagentapplicationurinarytractinfectionofdiagnosis,andidentificationdiagnosisandtreatmentacuteandchronickidneyfailureofcauses,andonsetmechanism,anddiagnosisandtreatmentnondialysistherapyinthenutritiontreatmentofpurposeandrequirementsblood,andperitonealdialysistherapyofadaptedcardkidneyfunctioncheckofusingandresultsjudgekidneypunctureindicationsandtaboosyndromeUnderstanding:thepathologicalclassificationofglomerulardiseasesinterstitialnephritisandrenaltubulardiseaseetiology,pathogenesis,diagnosisandtreatmentprincipleskidneytransplantantirejectiontherapyotherclinicaldiagnosticandtreatmenttechnologiesbasicstandard()learningdiseasespeciesandthecasesnumberrequirementsdiseasespeciesacutenephritisintegratedlevychronicnephritis科主任、护士长与具备资质的人员组成的质量与安全管理团队能用麻醉工作质量和安全管理制度、规章、岗位职责、各类麻醉技术操作规程、质量与安全指标来确保患者麻醉安全定期评价服务质量促进持续改进。由科主任、护士长与具备资质的人员组成质量与安全管理小组开展质量与安全管理。【C】由科主任、护士长与具备资质的人员组成质量与安全管理小组负责科室质量与安全管理。有完善的规章制度、岗位职责、诊疗规范、操作常规。有质量与安全管理小组工作职责、工作计划和工作记录。【B】符合“C”并质量与安全管理小组履行职责定期对制度进行自查、评估、分析有整改措施。()术后随访制度。()麻醉不良事件无责上报制度。()手术安全核查与手术风险评估制度。)麻醉药品管理制度。(职能部门履行监管职责定期进行评价、分析、反馈。【A】符合“B”并对措施落实情况进行追踪评价有持续改进。。开展质量与安全管理培训。【C】依据医院质量与安全管理计划制定本科室质量与安全培训计划并实施。相关人员知晓培训内容掌握并执行核心制度、岗位职责、诊疗规范、技术操作常规并严格遵循。【B】符合“C”并对质量与安全管理制度、诊疗规范、操作常规、等进行检查落实。对质量与安全管理的培训重点内容进行考核。【A】符合“B”并培训覆盖率高培训效果明显。定期开展麻醉质量评价。【C】定期开展麻醉质量评价。运用适宜的评价方式与工具。将麻醉并发症的预防措施与控制指标作为科室质量与安全管理与评价的重点内容。定期评价“手术安全核查与手术风险评估制度”的执行情况。toandthetreatmentBonemarrowaspirationMaster:kidneyunitsandkidneyphysiologicalfunctionkidneyballdiseaseofcauses,andonsetmechanism,andclinicalpointstype,andclinicalperformance,anddiagnosis,andidentificationdiagnosisandtreatmentsugarcortexhormone,andimmuneinhibitorsandanticoagulantagentapplicationurinarytractinfectionofdiagnosis,andidentificationdiagnosisandtreatmentacuteandchronickidneyfailureofcauses,andonsetmechanism,anddiagnosisandtreatmentnondialysistherapyinthenutritiontreatmentofpurposeandrequirementsblood,andperitonealdialysistherapyofadaptedcardkidneyfunctioncheckofusingandresultsjudgekidneypunctureindicationsandtaboosyndromeUnderstanding:thepathologicalclassificationofglomerulardiseasesinterstitialnephritisandrenaltubulardiseaseetiology,pathogenesis,diagnosisandtreatmentprincipleskidneytransplantantirejectiontherapyotherclinicaldiagnosticandtreatmenttechnologiesbasicstandard()learningdiseasespeciesandthecasesnumberrequirementsdiseasespeciesacutenephritisintegratedlevychronicnephritis【B】符合“C”并根据评价结果进行分析、总结针对存在的问题采取改进措施。【A】符合“B”并持续改进有成效质量有提高。建立麻醉质量管理数据库。【C】建立麻醉质量数据库。麻醉质量与安全相关的数据。()麻醉工作量:各种麻醉例数、心肺复苏例数、麻醉复苏室例数等。()严重麻醉并发症:麻醉意外死亡、误咽、误吸引发梗阻、出麻醉复苏室全身麻醉患者Steward评分分的例数等。()各类术后患者自控镇痛(PCA)。【B】符合“C”并定期分析指标的数据变化趋势和原因有年度麻醉质量安全报告。根据分析结果及时制定提高麻醉质量的各项措施。【A】符合“B”并通过运用监控指标分析有效落实各项针对性的改进措施麻醉质量与安全水平提高。toandthetreatmentBonemarrowaspirationMaster:kidneyunitsandkidneyphysiologicalfunctionkidneyballdiseaseofcauses,andonsetmechanism,andclinicalpointstype,andclinicalperformance,anddiagnosis,andidentificationdiagnosisandtreatmentsugarcortexhormone,andimmuneinhibitorsandanticoagulantagentapplicationurinarytractinfectionofdiagnosis,andidentificationdiagnosisandtreatmentacuteandchronickidneyfailureofcauses,andonsetmechanism,anddiagnosisandtreatmentnondialysistherapyinthenutritiontreatmentofpurposeandrequirementsblood,andperitonealdialysistherapyofadaptedcardkidneyfunctioncheckofusingandresultsjudgekidneypunctureindicationsandtaboosyndromeUnderstanding:thepathologicalclassificationofglomerulardiseasesinterstitialnephritisandrenaltubulardiseaseetiology,pathogenesis,diagnosisandtreatmentprincipleskidneytransplantantirejectiontherapyotherclinicaldiagnosticandtreatmenttechnologiesbasicstandard()learningdiseasespeciesandthecasesnumberrequirementsdiseasespeciesacutenephritisintegratedlevychronicnephritis

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