康复医疗文书要求及质控标准

康复医疗文书要求及质控标准 神经外科医疗文书书写要求 1.纳入本要求进行质控管理的医疗文书，是指在我院进行康复医学诊疗活动过程中所形成的所有记录，包括文字、符号、图表、影像等资料。 2.本要求依据《病历书写规范》、《执业医师法》、《医疗事故处理条例》、《综合医院康复医学科建设指南》、《康复技术指导规范》等法律法规和政策文件，并结合我院康复医学开展情况制定而成。 3.康复医疗相关文书的基本要求:客观、真实、准确、及时、完整、符合康复医学专业特点、体现我院康复医学诊疗技术水平。 4.本要求涉及的医疗文本包括:门诊病历及处方;住院患者相关入院记录、病程记录、护理医疗文书、医患沟通记录、病历讨论记录、医嘱单、检查申请单与 报告 软件系统测试报告下载sgs报告如何下载关于路面塌陷情况报告535n,sgs报告怎么下载竣工报告下载 单、相关出院记录等《病历书写规范》中规定的医疗文书。康复专业专科附件如康复专业评定(包括初期、中期、末期评定)与日常康复治疗记录、康复护理记录、康复治疗特殊治疗项目知情同意文书等同时纳入本要求管理，作为我科痕迹记录由质控管理员检查、评价、建档收集。 5.规范康复相关医疗文书的目的，在于真实记录康复医疗全过程，加强医疗质量管理，促进本专科专业特色发展。 6.相关医疗文书一般采用临床医学模式书写。在书写过程and its alloys 5 low temperature steel welding procedure 6 SH3525-2004 petrochemical JB/ T4708-2000 of welding procedure qualification for steel pressure vessels 7 JB/4709-2000 8 JB4730-2005 pressure vessel welding procedures of steel pressure vessel NDT 9 JB/T4744-2000 steel pressure vessel products mechanical properties test of welded plate II, mechanical equipment installation engineering 1 GB150-98 2 GB50128-2005 vertical cylindrical steel pressure vessel steel welded specification for construction and acceptance of oil tank 3 JB/ T4735-1997 steel welded atmospheric pressure vessel 4 GB50231-2009 mechanical equipment installation engineering construction and acceptance specification for 5 GB50275-98 compressor, fan and pump installation engineering construction and acceptance specification for lifting 6 HG20201-2000 construction installation engineering construction standard 7, HG ... Pressure gauges, using an installed spark arrestor for acetylene cylinders, illegal carrying, using gas cylinders, each operator fined 20 Yuan. Gas bottle without the hot sun exposure measures, responsibilities of team a fine of 50 Yuan. (7) at height and the opening and provisional protective measures have been taken, the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the 中应充分反映康复医学的特点，围绕患者的功能状况运用康复医学专业术语进行记录。 7.在为每一位患者提供康复医疗服务期间，康复医师均需进行相关医疗文书记录，标准与要求参照《病历书写规范》并体现康复专业特色，由科室质控小组依据病案管理相关规定进行质量控制。 8.我院康复医疗科有统一规范的康复治疗评定 记录表 体温记录表下载消防控制室值班记录表下载体温记录表 下载幼儿园关于防溺水的家访记录表绝缘阻值测试记录表下载 。在为每一位患者提供康复医疗服务期间，康复治疗师要根据开展的康复治疗服务项目(如PT、OT、ST等)进行相关专业评定，评定结果均需有文字记录;康复治疗记录同时由责任治疗师按照病程进行书写。书写标准参见康复治疗记录规范与康复治疗效果评定标准。主管治疗师与科主任负责定期检查相关文书书写质量，科室质控小组定期对相关文书进行质量评价与反馈。 9.康复医疗文书的质量由我康复医疗科质量控制与管理小组对进行质控管理，并将相关要求医疗文书提交病案管理科。康复专业评定与治疗记录由该科质控小组统一归档。 10.定期组织医疗文书书写培训及考核，由三级医师、护士长、主管治疗师负责考核。未通过考核者不得继续进行诊疗活动。 and its alloys 5 low temperature steel welding procedure 6 SH3525-2004 petrochemical JB/ T4708-2000 of welding procedure qualification for steel pressure vessels 7 JB/4709-2000 8 JB4730-2005 pressure vessel welding procedures of steel pressure vessel NDT 9 JB/T4744-2000 steel pressure vessel products mechanical properties test of welded plate II, mechanical equipment installation engineering 1 GB150-98 2 GB50128-2005 vertical cylindrical steel pressure vessel steel welded specification for construction and acceptance of oil tank 3 JB/ T4735-1997 steel welded atmospheric pressure vessel 4 GB50231-2009 mechanical equipment installation engineering construction and acceptance specification for 5 GB50275-98 compressor, fan and pump installation engineering construction and acceptance specification for lifting 6 HG20201-2000 construction installation engineering construction standard 7, HG ... Pressure gauges, using an installed spark arrestor for acetylene cylinders, illegal carrying, using gas cylinders, each operator fined 20 Yuan. Gas bottle without the hot sun exposure measures, responsibilities of team a fine of 50 Yuan. (7) at height and the opening and provisional protective measures have been taken, the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the 神经外科科医疗文书书写质控标准 标 项目 准评分标准 评分证明 分 有一处不符合要求扣病历 2 各项目填写完整、正确、规范 0.5分，药敏不填扣1首页 分 a 姓名、年龄、性别、一地址四项中有一项缺或般错写，扣1分。 1 一般项目齐全、填写正确 项 b其他项目有缺或错写目 扣0.5分。 a(如用体征代主诉，而 在病史中发现有症状的 扣1分。 主要症状或体征简明，不超过20个字。主2 一般不用诊断名称。病理确诊再入院除b( 无近况描述扣0.5诉 外。 分。 c. 时间不准确扣0.5 分。 1)起病时间与诱因。(1分) a(时间不准，无诱因各入扣1分。b(部位、时间、2)主要症状、体征的部位、时间、性院性质、程度及伴随病情质、程度描述;伴随病情，症状 与体记不明确各扣1分。 c(疾征描述。(5分) 录 病发展情况未描述扣 3)有鉴别诊断意义的阴性症状与体征。1.5分。 现(1分) 病12 d(入院前曾就诊如诊断 4)疾病发展情况，入院前诊治经过。史 无记录扣0.5分，治疗 (3分) 未具体记录扣1分。确 未诊治不扣分。 5)一般情况(饮食、睡眠、二便等)。 (0.5分) e(同治病应有主要病情 与治疗，太简单扣0.5, 6) 记录与本病虽无紧密关系，但需同1.0分 时治疗的疾病。(1.5分) 1)既往一般健康情况、心、脑血管、a(重要脏器疾病史如不既肺、肾、内分泌系统等重要的疾病史。具体扣0.5,1.0分。 往3 (1.5分) b( 药物过敏史缺，扣史 2)手术、外伤史，重要传染病史，输2分;与首页不一致， and its alloys 5 low temperature steel welding procedure 6 SH3525-2004 petrochemical JB/ T4708-2000 of welding procedure qualification for steel pressure vessels 7 JB/4709-2000 8 JB4730-2005 pressure vessel welding procedures of steel pressure vessel NDT 9 JB/T4744-2000 steel pressure vessel products mechanical properties test of welded plate II, mechanical equipment installation engineering 1 GB150-98 2 GB50128-2005 vertical cylindrical steel pressure vessel steel welded specification for construction and acceptance of oil tank 3 JB/ T4735-1997 steel welded atmospheric pressure vessel 4 GB50231-2009 mechanical equipment installation engineering construction and acceptance specification for 5 GB50275-98 compressor, fan and pump installation engineering construction and acceptance specification for lifting 6 HG20201-2000 construction installation engineering construction standard 7, HG ... Pressure gauges, using an installed spark arrestor for acetylene cylinders, illegal carrying, using gas cylinders, each operator fined 20 Yuan. Gas bottle without the hot sun exposure measures, responsibilities of team a fine of 50 Yuan. (7) at height and the opening and provisional protective measures have been taken, the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the 血史。(1.5分) 扣1分。 3) 药物过敏史必问。 c( 手术史、传染病史、 输血史缺一项扣0.5分。 a(个人史是有关的生活 习惯、嗜好和职业、地1)个人史。(1分) 个方病接触史及冶游史。 人2 2)婚育史:婚姻、月经、生育史。(1b(婚育史不全扣0.5史 分) 分，三项中缺一项扣0.5 分。 a(如系遗传疾病，病史 询问少于三代家族成1)与疾病有关的遗传或具有遗传倾向员，扣0.5分。b( 家家的病史及类似本病病史。 族中有死亡者，死因未族1 描述扣0.5分，父母必2)直系家族成员的健康、疾病及死亡史 问，如未记扣0.5分，情况。 (年久确实不明者不扣 分)。 a头颅四肢及神经系统 检查如缺扣2分。 b 体表、腹肿块应图示， 缺扣0.5分 1)项目填写完整、正确(2分) 体c肿瘤或诊断需鉴别者2)与该病症鉴别诊断有关的体检项目格应查相关区域淋巴结，9 充分。(3分) 检缺相关区域扣1分 查 3)专科检查情况全面、正确、(4分) d 专科检查不全面酌情 扣1-2分，应有的鉴别 诊断体征不全或未记扣 1.5-3分。 a 辅助包括实验室、影 像学、特殊检查，据病1)有辅助检查(实验室、影像学、内种不同而定。 镜等)结果(1分) b 主要诊断以症状、体诊2)初步诊断合理、主次分明、全面。3 征待查代替诊断，扣2断 (1分) 分 3)有医师签名并注明日期。(1分) c 非执业医师写入院记 录，无执业医师修正、 签名的超扣10分。 and its alloys 5 low temperature steel welding procedure 6 SH3525-2004 petrochemical JB/ T4708-2000 of welding procedure qualification for steel pressure vessels 7 JB/4709-2000 8 JB4730-2005 pressure vessel welding procedures of steel pressure vessel NDT 9 JB/T4744-2000 steel pressure vessel products mechanical properties test of welded plate II, mechanical equipment installation engineering 1 GB150-98 2 GB50128-2005 vertical cylindrical steel pressure vessel steel welded specification for construction and acceptance of oil tank 3 JB/ T4735-1997 steel welded atmospheric pressure vessel 4 GB50231-2009 mechanical equipment installation engineering construction and acceptance specification for 5 GB50275-98 compressor, fan and pump installation engineering construction and acceptance specification for lifting 6 HG20201-2000 construction installation engineering construction standard 7, HG ... Pressure gauges, using an installed spark arrestor for acetylene cylinders, illegal carrying, using gas cylinders, each operator fined 20 Yuan. Gas bottle without the hot sun exposure measures, responsibilities of team a fine of 50 Yuan. (7) at height and the opening and provisional protective measures have been taken, the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the a 如书写内容与住院志 有严重不一致者扣2分 1)入院病史、体检及辅助检查归纳重b 非执业医师书写，此首点突出，逻辑性强。(1分) 项不得分，扣5分 次2)诊断依据、鉴别诊断合理。(1分) c 单纯外(烧)伤、骨病5 3)诊断、诊疗计划具体明确(2分) 折，有病理结果、生理程4)首次病程记录患者入院8h内完成。妊娠及同病一年内再次记(1分) 入院者，可免写鉴别诊录 5)必须由执业医师书写。 断 d 诊疗计划不全或不具 体扣1分 a 对危重疑难及抢救病 人的查房记录须注明病时、分，违者扣1分 程b 上级医师查房记录未记1)主管医生对新病人、危重、疑难病标示或未签名各扣0.5录 人、抢救病人及时查房。(2分) 分，扣至1.5分止 上2)主治医生首次查房于患者入院48小c 副高以上查房无诊治 级时内完成。(1分) 分析扣1分，不明确或 医3)每周必须有一次副高以上医生(或科太简单扣0.5分 6 师主任)查房(1分) d 上级医师签字如为他 查4)查房诊疗 意见 文理分科指导河道管理范围浙江建筑工程概算定额教材专家评审意见党员教师互相批评意见 明确、具体，副高以人冒签，发现一处超扣 房 上医生查房应有诊治分析(尤其首次)，5分 诊断未明应有鉴别分析、处理方案(2e 危重患者缺上级医生 分) 查房记录或请示、汇报 记录，超扣10分 f 疑难患者缺上级医生 查房、科室讨论记录， 超扣10分 备注:1、本表依据卫生部规范制订。2、标准总分为100分;甲级?90分，乙级<90-80分，丙级<80分。3、对病历书写中严重不 符合规范处，而本检查未能涉及的，可说明理由直接扣分。适用于三、二级各等级医院，专科医院参照执行。4、另自订病历书写规范不予承认;与本表不一，按本表要求评。5、电子病历应符合本规范内容。6、按标准与评分说明评分。 and its alloys 5 low temperature steel welding procedure 6 SH3525-2004 petrochemical JB/ T4708-2000 of welding procedure qualification for steel pressure vessels 7 JB/4709-2000 8 JB4730-2005 pressure vessel welding procedures of steel pressure vessel NDT 9 JB/T4744-2000 steel pressure vessel products mechanical properties test of welded plate II, mechanical equipment installation engineering 1 GB150-98 2 GB50128-2005 vertical cylindrical steel pressure vessel steel welded specification for construction and acceptance of oil tank 3 JB/ T4735-1997 steel welded atmospheric pressure vessel 4 GB50231-2009 mechanical equipment installation engineering construction and acceptance specification for 5 GB50275-98 compressor, fan and pump installation engineering construction and acceptance specification for lifting 6 HG20201-2000 construction installation engineering construction standard 7, HG ... Pressure gauges, using an installed spark arrestor for acetylene cylinders, illegal carrying, using gas cylinders, each operator fined 20 Yuan. Gas bottle without the hot sun exposure measures, responsibilities of team a fine of 50 Yuan. (7) at height and the opening and provisional protective measures have been taken, the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the