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深圳市2012年度产科专科护理质量评估细则(4月23日修订)

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深圳市2012年度产科专科护理质量评估细则(4月23日修订)深圳市2012年度产科专科护理质量评估细则(4月23日修订) 深圳市2012年度产科专科护理质量评估细则 评估医院名称: 项 分得评分要素 检查方法 评 分 标 准 扣分原因 目 值 分 1. 科室布局 无隐私保护措施扣1分 1.1产房、病房环境温馨、舒适、有隐私保护措施 现场查看 布局、设置不合理 扣1分/项,扣3 1.2产科产房、病区布局设置合理,分区明确,标识 完为止 清楚 2. 建立完善的护理管理组织体系,落实护理管理职 责 护理部查任免文件,现场2.1组织架构合理,职责明确 3 查阅有关资料...

深圳市2012年度产科专科护理质量评估细则(4月23日修订)
深圳市2012年度产科专科护理质量评估 细则 测试细则下载防尘监理实施细则免费下载免费下载地暖施工监理细则公路隧道通风设计细则下载静压桩监理实施细则下载 (4月23日修订) 深圳市2012年度产科专科护理质量评估细则 评估医院名称: 项 分得评分要素 检查方法 评 分 标 准 扣分原因 目 值 分 1. 科室布局 无隐私保护措施扣1分 1.1产房、病房环境温馨、舒适、有隐私保护措施 现场查看 布局、设置不合理 扣1分/项,扣3 1.2产科产房、病区布局设置合理,分区明确,标识 完为止 清楚 2. 建立完善的护理管理组织体系,落实护理管理职 责 护理部查任免文件,现场2.1组织 架构 酒店人事架构图下载公司架构图下载企业应用架构模式pdf监理组织架构图免费下载银行管理与it架构pdf 合理,职责明确 3 查阅有关资料。 不符合要求不得分 2.2产科病区、产房实行护士长(组长)负责制 (月分娩量?100人的产房应设护士长,月分娩量, 100人的产房应设组长) 科 3.合理配置护理人力资源,动态达到以下 标准 excel标准偏差excel标准偏差函数exl标准差函数国标检验抽样标准表免费下载红头文件格式标准下载 : 室 3.1产房助产士配备符合标准,编制人数与开放产床管 之比合理,能满足工作需求。 理 产房助产士基本编制人数不得少于6人。 现场查看和查阅有关资按实际工作量和开放产床/病床计产床与助产士之比为1:2-3 5 料。 算,配备不足每缺1人扣0.5分 3.2病床护士配备符合标准,编制人数与开放床位之 比合理,能满足工作需求。 产科实际开放床位与病区护士比?1:0.4 母婴同室(新生儿)床护比?1:0.6 3. 3产床与产科床位数之比为1:8,10 4. 根据《广东省护士核心能力评估及层级培训指南》1、 现场查阅有关资料培未开展层级培训和使用扣3分 的要求对助产士(护士)实行分层级培训和使用 3 训和考核记录 各层级的培训 计划 项目进度计划表范例计划下载计划下载计划下载课程教学计划下载 未落实扣1分 2、 考核1名助产士/1名培训记录缺一项扣 0.5分 be limited to no more than 2 days of work, material deposited in special insulated containers, material handling to gently and make use of thermal insulation material in windproof, waterproof, moisture-proof measure. 6.2 thermal design optimization for high-temperature special thermal insulation for piping support and hanger design, reduced heat dissipation of the hangers, ensure that the wall does not overheat. Small-diameter piping, thermal instrument layout and positioning of support and hanger design take fully into account the expansion space and insulation thickness. Large-diameter pipes after heat preservation plastering construction of valves, turbine, checking smooth surface, high temperature powder paint fully dry after. Protective coverings for electric equipment insulation boards designed with pressure plate, when ordering according to the installation diagram, model specifications publishing order, ensure when installing corners neat, uniform appearance, reduce the amount of on-site machining. Before valves, flange insulation shell construction, be sure to make a unified model, all valves, flanges, insulation cover unified, tidy and beautiful. When four parts such as pipes, boiler insulation, must do first article inspection, proof of design and construction methods, technology can meet the technological requirements, before extensive construction. Boiler steel beams, door opening boxes designed with insulation gaskets, flange cannot be oblique, even fastened. Back into the slope of the tubing during installation pay attention to the piping, oil station is a low point. Refueling must be controlled when casting material parts, select low thermal conductivity materials as far as possible, ensure that these parts do not overheat. 6.3 quality defects of insulation technology management optimization of construction process and develop a reasonable duration, regional transfer of strictly 项 分得评分要素 检查方法 评 分 标 准 扣分原因 目 值 分 护士参加培训掌握内 容的熟练程度。 预防接种合格证;护士执业证;母 婴保健合格证,一人不符合扣4分 5.1 护士必须持有效的相关执业证上岗 查阅护理部及科室有关无相关制度扣 1分 5.2护士排班合理,实行执业护士二级准入制度 4 资料 一人不符合准入条件扣1分 5.3有紧急状态下护理人力资源调配预案 无应急预案或不能在规定时间到 位各扣 1 分 1、无相关 管理制度 档案管理制度下载食品安全管理制度下载三类维修管理制度下载财务管理制度免费下载安全设施管理制度下载 扣2分,不完 善或不规范扣1分 6 和护理常规和操作工作指引不得 6.1落实广东省《护理工作管理规范》及护理工作核分 心制度 现场查阅有关资料 (考2、无专科常见疾病护理常规与护 6.2有完善的各级各类护理人员岗位职责,建立和健6 核1-2名助产士/护士) 理技术(专科常用)操作规程资料 。 规 全产科制度、专科疾病护理,专科常用护理技术操 各扣1分,不完善或未体现专科特章 作规程,并保证实施 点扣0.5分 制 3.考核不合格每人扣1分,一项制度 度未落实每项扣1分 及 工 7(建立并落实产科专科护理工作指引,符合医院安 作 全管理制度及要求: 7(1催产素使用指引 无指引扣6分 指 7(2产程观察及处理指引 指引不健全扣1分/项 引 现场询问和查阅有关资7(3死胎、畸胎婴儿处理流程 指引不落实扣1分/项 6 料 (现场考核2名助产7(4 新生儿窒息抢救流程及指引 助产士/护士不熟悉指引扣1分/士/护士) 7(5阴道分娩肩难产等难产处理指引 项 7(6危急重症孕产妇抢救流程及指引 7(7新生儿沐浴、预防接种及疾病筛查等工作指引 7.8门卫制度,母婴出入登记制度等 diameter pipes after heat preservation plastering construction of val-space and insulation thickness. Large diameter piping, thermal instrument layout and positioning of support and hanger design take fully into account the expansion-es not overheat. Smallthat the wall dotemperature special thermal insulation for piping support and hanger design, reduced heat dissipation of the hangers, ensure -proof measure. 6.2 thermal design optimization for high-mal insulation material in windproof, waterproof, moistured make use of therbe limited to no more than 2 days of work, material deposited in special insulated containers, material handling to gently antechnology management optimization of construction process and develop a reasonable duration, regional transfer of strictlyhermal conductivity materials as far as possible, ensure that these parts do not overheat. 6.3 quality defects of insulation low t ion pay attention to the piping, oil station is a low point. Refueling must be controlled when casting material parts, selectdesigned with insulation gaskets, flange cannot be oblique, even fastened. Back into the slope of the tubing during installatboxes methods, technology can meet the technological requirements, before extensive construction. Boiler steel beams, door opening utiful. When four parts such as pipes, boiler insulation, must do first article inspection, proof of design and construction sulation cover unified, tidy and beasite machining. Before valves, flange insulation shell construction, be sure to make a unified model, all valves, flanges, in-ishing order, ensure when installing corners neat, uniform appearance, reduce the amount of ons publment insulation boards designed with pressure plate, when ordering according to the installation diagram, model specificationves, turbine, checking smooth surface, high temperature powder paint fully dry after. Protective coverings for electric equip2 项 分得评分要素 检查方法 评 分 标 准 扣分原因 目 值 分 现场考察一名孕产妇接8(建全产科接诊制度,提高分诊准确性,确保就诊 诊及交接班 孕妇安全 5 不符合要求扣 1分/项 无催产素静脉滴注观察记录单扣2 现场询问和查阅有关资9(正确使用催产素,确保用药安全 分,记录不符合要求扣0.5分/项 5 料(查2份病历,提问 对催产素使用的适应症、禁忌症及三、 1-2名助产士) 使用方法不掌握扣 1分/项 专 科 10(实施全程助产责任制,落实减痛分娩措施,减现场询问和查阅有关资未实施全程助产责任制扣3分 护 料 (询问孕妇、助产士 轻待产妇疼痛感 4 理 无减痛措施,扣 1分/项 各1名) 服 对孕产妇情况掌握不全面,观察不务 质 现场询问和查阅有关资到位,异常产程发现不及时、未及11(责任护士/助产士对孕产妇产程观察到位,及时量 料(询问1名孕产妇/助时通知医生扣 1分/项 和 发现并处理异常产程 6 产士/产前区护士)查看助产士不掌握第二产程的征象扣 安 全 一份病历 1分/项 管 理 产科抢救物品、药品及设备欠缺或 12(根据《深圳市助产技术服务基本条件》要求,不能正常使用扣1分/项 现场询问和查阅有关资 正确实施助产技术,确保母婴安全 10 对接生流程及产科应急预案流程 料(询问1名 助产士 ) 不熟悉扣2分/项 现场询问和查阅有关资 5 助产士对新生儿处理流程不熟练 powder paint fully dry after. Protective coverings fodiameter pipes after heat preservation plastering construction of valves, turbine, checking smooth surface, high temperature -n take fully into account the expansion space and insulation thickness. Largediameter piping, thermal instrument layout and positioning of support and hanger desig-that the wall does not overheat. Smalltemperature special thermal insulation for piping support and hanger design, reduced heat dissipation of the hangers, ensure -high proof measure. 6.2 thermal design optimization for-d make use of thermal insulation material in windproof, waterproof, moisturebe limited to no more than 2 days of work, material deposited in special insulated containers, material handling to gently aner of strictlys of insulation technology management optimization of construction process and develop a reasonable duration, regional transfdefectal parts, select low thermal conductivity materials as far as possible, ensure that these parts do not overheat. 6.3 quality during installation pay attention to the piping, oil station is a low point. Refueling must be controlled when casting materiubing s, door opening boxes designed with insulation gaskets, flange cannot be oblique, even fastened. Back into the slope of the tnd construction methods, technology can meet the technological requirements, before extensive construction. Boiler steel beamign aunified, tidy and beautiful. When four parts such as pipes, boiler insulation, must do first article inspection, proof of des . Before valves, flange insulation shell construction, be sure to make a unified model, all valves, flanges, insulation coversite machining-el specifications publishing order, ensure when installing corners neat, uniform appearance, reduce the amount of onr electric equipment insulation boards designed with pressure plate, when ordering according to the installation diagram, mod3 项 分得评分要素 检查方法 评 分 标 准 扣分原因 目 值 分 料(询问1名 助产士 ) 13(建立和规范新生儿处置流程,避免因处置不当扣1分/项 导致新生儿受伤害 助产士对新生儿窒息复苏抢救流 程不掌握扣2分/项 现场询问和查阅有关资无风险预警标识扣3分 料(询问1名 产妇) 14 .正确辨识新生儿身份,协助建立亲子关系 3 标识不清楚/不正确扣 1分/项 无协助进行早吸吮、早接触扣1分 对产后出血评估不掌握,扣 1分/15.提高产后舒适度,及早发现异常,预防产后出血 现场询问和查阅有关资 2 项 料(询问1名助产士 ) 对出血量评估不掌握扣 1分/项 16.全面落实责任制整体护理 16.1公示并落实服务项目 16.2改革临床护士工作模式,落实“护士床边工作无公示、基础护理及分级护理的落制” 实不到位扣1分/项 16.3实行护士管床责任制,孕产妇知晓自己的责任 现场询问和查阅有关资无落实护士管床、管病人责任制和护士 护士床边工作制扣1分/项 16.4基础护理落实到位 料(提问2名产科责任护 16.5责任护士熟悉自己负责的孕产妇产程进展情 10 士;现场抽查1,2名病孕产妇不知晓自己的责任护士扣1况、观察重点、主要护理措施、饮食和身体自理能力分/人 重或保胎孕产妇清洁、卧等情况,并及时与医师沟通 16.6责任护士全面履行岗位职责,对孕产妇开展健位和管道等护理) 护士岗位职责落实不到扣1分/项 康教育,母乳喂养指导,提供心理支持 16.8危重孕产妇必须有高级责任护士或组长管 孕产妇健康教育不落实扣1分/项 床、查房,根据评估制定护理措施,并有效实施 hermal conductivity materials as far as possible, ensure that these parts do not overheat. 6.3 quality defects of insulation low t ion pay attention to the piping, oil station is a low point. Refueling must be controlled when casting material parts, selectdesigned with insulation gaskets, flange cannot be oblique, even fastened. Back into the slope of the tubing during installatboxes methods, technology can meet the technological requirements, before extensive construction. Boiler steel beams, door opening utiful. When four parts such as pipes, boiler insulation, must do first article inspection, proof of design and construction sulation cover unified, tidy and beasite machining. Before valves, flange insulation shell construction, be sure to make a unified model, all valves, flanges, in-ishing order, ensure when installing corners neat, uniform appearance, reduce the amount of ons publment insulation boards designed with pressure plate, when ordering according to the installation diagram, model specificationves, turbine, checking smooth surface, high temperature powder paint fully dry after. Protective coverings for electric equipdiameter pipes after heat preservation plastering construction of val-space and insulation thickness. Large diameter piping, thermal instrument layout and positioning of support and hanger design take fully into account the expansion-es not overheat. Smallthat the wall dotemperature special thermal insulation for piping support and hanger design, reduced heat dissipation of the hangers, ensure -proof measure. 6.2 thermal design optimization for high-mal insulation material in windproof, waterproof, moistured make use of therbe limited to no more than 2 days of work, material deposited in special insulated containers, material handling to gently antechnology management optimization of construction process and develop a reasonable duration, regional transfer of strictly4 项 分得评分要素 检查方法 评 分 标 准 扣分原因 目 值 分 未建立质量监控体系及专科质控 标准扣10分 17.健全护理质量控制体系,促进护理质量持续改进 对不良事件无讨论分析、无改正措17.1科室质量监控体系架构合理,职责明确,定期 施,扣1分/项 开展工作,有记录 现场询问和查阅有关资持 无临床护理质量指标统计资料、无17.2、建立专科质控标准,并按照质控标准定期进行料(查不良事件报告及处续 进行分析改进、无体现及时检讨工检查;定期对质量问题进行分析,提出改进措施,10 理程序、追踪2-3个质量质 作流程和制度的有效性等,不符合并有相关资料记录,体现质量持续改进 指标、查护理工作满意度量 要求扣1分/项 17.3有不良事件的防范机制、应急预案及上报制度 调查分析与改进资料) 改 护理工作满意度调查未体现持续17.4主动听取孕产妇及家属意见,接受孕产妇、家进 改进扣1分/项 属、社会的监督。定期开展孕产妇对护理工作满意度 调查,不断改进服务流程和质量 未采用表格式护理记录单扣3分 有重复记录,小综述扣1分 产科各项病历记录有错漏项扣0.5护 分/项 18.简化护理文书,护理记录体现实时、客观、准确、理 10 抽查2份护理病历 新生儿记录填写不符合要求扣 完整,符合专科病情需要,能动态反映孕产妇情况 文 书 0.5分/项 护理记录未体现专科特点酌情扣 1-2分 评估专家: 评估日期: s, door opening boxes designed with insulation gaskets, flange cannot be oblique, even fastened. Back into the slope of the tnd construction methods, technology can meet the technological requirements, before extensive construction. Boiler steel beamign aunified, tidy and beautiful. When four parts such as pipes, boiler insulation, must do first article inspection, proof of des . Before valves, flange insulation shell construction, be sure to make a unified model, all valves, flanges, insulation coversite machining-el specifications publishing order, ensure when installing corners neat, uniform appearance, reduce the amount of onr electric equipment insulation boards designed with pressure plate, when ordering according to the installation diagram, modpowder paint fully dry after. Protective coverings fodiameter pipes after heat preservation plastering construction of valves, turbine, checking smooth surface, high temperature -n take fully into account the expansion space and insulation thickness. Largediameter piping, thermal instrument layout and positioning of support and hanger desig-that the wall does not overheat. Smalltemperature special thermal insulation for piping support and hanger design, reduced heat dissipation of the hangers, ensure -high proof measure. 6.2 thermal design optimization for-d make use of thermal insulation material in windproof, waterproof, moisturebe limited to no more than 2 days of work, material deposited in special insulated containers, material handling to gently aner of strictlys of insulation technology management optimization of construction process and develop a reasonable duration, regional transfdefectal parts, select low thermal conductivity materials as far as possible, ensure that these parts do not overheat. 6.3 quality during installation pay attention to the piping, oil station is a low point. Refueling must be controlled when casting materiubing 5
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