(1) timely review the doctor's orders issued by junior doctors and give necessary guidance to the operation of junior doctors.

(2) Ordinary patients newly admitted to the hospital should make the first rounds within 24 hours. In addition to supplementary medical history and physical examination, the contents of rounds also require:

① Diagnosis and diagnostic basis; ② Necessary differential diagnosis; ③ Treatment principle; ④ Matters needing attention in diagnosis and treatment.

(3) The newly admitted acute, dangerous and severe patients should be examined and treated at any time, and the condition should be reported to the superior doctor.

(4) Check and modify the medical records written by junior doctors in time to ensure the quality of discharged medical records, and sign the first page of medical records.

(5) If there are cases that cannot be diagnosed within 3 days after admission or have cross-disciplinary diseases, intra-departmental or cross-departmental consultation should be conducted in time.

(6) When the patient to be diagnosed is still unknown within 1 week after admission, please ask the director for case discussion or in-hospital consultation.

(7) In accordance with regulations, use antibacterial drugs and specialized drugs of different grades correctly.

(8) Check the patients personally before operation and interventional therapy, make good preparations before operation, and formulate and implement a strict surgical plan according to the management standard of surgical classification. Postoperative records were completed immediately after operation, and surgical records were completed within 24 hours.

(9) Closely observe the changes of patients' condition after operation and do a good job after operation.

(10) is responsible for the examination and approval procedures for cured discharged patients, and reports to the superior doctors.

4, director (deputy director) physician:

(1) Organize or participate in the formulation of undergraduate quality management plans, various rules and regulations, diagnosis and treatment, and operational routines.

(2) Guide junior doctors to do a good job in medical treatment, and supervise and inspect junior doctors to implement various systems and routine diagnosis and treatment.

(3) For ordinary patients newly admitted to the hospital, it is required to make the first rounds within 48 hours; Critically ill patients should make rounds at least once a day 1 time; The patient's condition should be checked at any time; Organize regular rounds twice a week.

(4) In addition to supplementing medical history and physical examination, the contents of rounds should also include: ① diagnosis and its diagnostic basis; ② Differential diagnosis; ③ Treatment principle; (4) New progress in related fields.

Undiagnosed patients should have: ① differential diagnosis; ② Clear diagnosis ideas and methods; ③ Formulate corresponding treatment measures.

Critically ill patients should have: ① main problems at present; (2) Methods to solve the main problems.

(5) For the difficult cases and undiagnosed cases within 1 week after admission, organize discussion within the department or in-hospital consultation, and apply to the medical department for out-of-hospital consultation or remote consultation when necessary.

(6) To guide and supervise junior doctors to correctly use different grades of antibacterial drugs and specialized drugs.

(7) Organize case discussion before operation and important treatment, and guide junior doctors to do well the medical work during and after operation. Major surgery and important treatment should be attended in person.

(eight) to examine and approve the discharge of patients who have not recovered, and to guide the patients to continue their treatment after discharge.

(9) Shen Qian's attending physician reviews the change of major and discharge medical records.

(2) Quality requirements for nursing staff:

1, head nurse:

(1) Organize and coordinate the work of nurses in various departments according to the responsibilities of head nurses.

(2) Newly admitted patients must meet twice.

(3) Nurses in the organization department must make rounds twice a day.

(4) Check the health education and basic nursing of nurses in charge of wards.

2, admissions nurse:

(1) Arrange beds immediately according to the patient's condition and do a good job in admission education.

(2) Establish medical records and notify the competent doctors and nurses.

(3) Newly-admitted patients should complete the cleaning and hygiene treatment within 24 hours, and be responsible for the first health education and basic nursing work of nurses.

3, treatment nurse:

(1) Get the medicine and dispense it in time according to the doctor's advice, and the patient's medicine must be used in place within 1 hour.

(2) Strictly carry out aseptic operation procedures, carefully observe the special reaction during treatment, and give feedback to the competent doctor and head nurse in time.

4. Night nurse:

(1) Every patient should be treated in time, and patients who leave the hospital without authorization should be recorded in time.

(2) Complete all preparations and treatments for new patients.

(3) Record what you have done and finish what you have written in time according to the requirements of writing nursing documents.

(three) the quality requirements of pharmacy staff:

1, pharmacy pharmacist:

(1) Seriously implement the prescription system, and timely complete the correct deployment of drugs according to prescriptions or ward doctor's orders.

(2) Unreasonable drug use or incompatibility, contact the doctor in time.

(3) Ensure that the stored drugs meet the preservation conditions and there are no expired drugs.

2. Warehouse Pharmacist:

(1) Complete the drug plan in time. (2) Complete the drug quality acceptance in time. (3) Send medicine in time.

3. Clinical pharmacists:

(1) Communicate with doctors and nurses in time about rational drug use for critically ill patients in the department. (2) Patients must observe the medication twice a day. (3) A medication calendar must be established for special patients.

(4) Quality requirements of laboratory staff: according to the responsibilities of laboratory staff.

(5) Quality requirements of functional personnel: according to the responsibilities of functional personnel.

(6) Quality requirements for radiology staff: according to the responsibilities of radiology staff.

(7) Requirements for the quality of staff in other inspection and treatment departments: The requirements for work quality must be implemented in accordance with the departmental work system.

Fourth, the assessment content:

The whole process of medical quality control includes outpatient medical treatment, ward medical activities and other components. The assessment content is divided into:

(a) outpatient medical treatment:

1, registration, triage consultation office, registration room: guide patients to register according to professional diseases and priorities.

2, the first physician:

First-visit doctor responsibility system:

A, ask the medical history in detail, carefully check the body, draw up a preliminary diagnosis, carry out appropriate treatment, and write the outpatient (emergency) medical records according to the requirements of medical records (monthly inspection focuses on the quality of medical records).

B. it is recommended to go to a specialist clinic.

C. admission.

(2) Follow-up visit: ① The original doctor should: a, recommend specialist treatment; B, hospitalization. ② Newly admitted doctors should: a. Admission; B, outpatient treatment.

(3) Third visit: the diagnosis has not been confirmed. The attending physician should: a. Admission; B. Patients who refuse to be hospitalized shall go through the signing formalities.

(4) When a patient needs to be admitted to hospital for treatment, the doctor who issued the admission notice should indicate the special way of admission according to the condition: car transport or escort.

(2) Ward medical treatment:

1, completed within 24 hours:

(1) Patients should receive initial treatment within 30 minutes of admission.

(2) The attending physician puts forward the preliminary diagnosis and treatment opinions and completes the medical record writing (complete the hospitalization medical record within 24 hours).

(3) When necessary, the attending physician shall propose and ask the superior physician to organize intra-departmental discussion, inter-departmental or intra-hospital consultation.

(4) Acute, dangerous and severe patients should consult their superiors at any time, and complete the medical record writing within 6 hours.

2. Within three days of admission:

(1) Diagnosis was made according to routine diagnosis and treatment.

(2) the undiagnosed, do further inspection, organize intra-departmental discussion and inter-departmental consultation when necessary.

3, 65438+ 0 weeks after admission, undiagnosed cases must be discussed in the department or consulted in the hospital. Confirmed cases should be implemented according to the diagnosis and treatment plan, and those who are not diagnosed within 2 weeks must be consulted outside the hospital or remotely. (Special specialties are performed according to routine diagnosis and treatment).

4, treatment measures:

(1) drug therapy

① Drug selection: a. Formulate and strictly implement special drug use specifications; B, strengthen the rational use of antibiotics.

② Observe the curative effect after medication.

③ According to the condition and curative effect, change and adjust the medication plan in time.

④ Pay attention to the adverse reactions of drugs, the interactions between drugs and the effects of drugs on other organs and other diseases.

(2) Surgical treatment:

(1) Prepare for routine diagnosis and treatment before operation, and examine and approve according to surgical classification. (2) according to the conventional operation. ③ Do a good job of postoperative treatment according to routine diagnosis and treatment.

(3) Special diagnosis and treatment shall be carried out with reference to routine diagnosis and treatment of various professions.

5. Results:

(1) cured and discharged, followed up in the specialist clinic. (2) Improvement-follow-up in specialist clinics. (3) Not healed-the patient needs to perform the signing formalities when he asks to be discharged from hospital or transferred to another hospital. (4) Death-complete the death record within 24 hours, complete the death case discussion within 1 week and hand in the medical records in time.

6. Discharge:

(1) The cured personnel can be discharged only after being examined and approved by the attending physician and reported to the superior physician for approval.

(2) For those who get better, the director (or chief physician or deputy chief physician) will explain to the patients the matters needing attention in continuing treatment or returning to hospital for treatment, and they can be discharged after approval.

(3) Those who have not recovered can be discharged only after further treatment guidance and approval by the director (or chief physician and deputy chief physician).

(4) The bed-managing physician must write on the patient's outpatient medical record? Discharge summary? .

note:

1, according to the condition, organize various forms of consultation in time, such as out-of-hospital consultation, remote consultation, etc.

2, critically ill patients should be bedside succession, succession records every day.

3. Reporting method: For critically ill patients, the critically ill notice must be sent to the medical office; For special and emergency rescue patients, it is necessary to call the director of the department, who will report to the medical department and the dean in charge; Death and undiagnosed cases within two weeks after admission should be reported to the medical department in writing. Nursing inspection is carried out by the nursing department according to the quality requirements. Other quality shall be implemented according to various functional departments or assessment rules.

Five, assessment methods and reward and punishment system:

(1) The Medical Quality Management Committee shall organize medical departments, nursing departments, hospital infection departments, information departments, pharmacy departments and other functional departments to evaluate the medical departments, and distribute the evaluation results to all departments in the form of Bulletin every month. Medical documents such as medical records, prescriptions, maternal health care manuals, operation records of family planning services, and various application reports in the process of diagnosis and treatment shall be assessed item by item according to the contents of the Standards for Supervision and Evaluation of Medical Quality Management, with weekly spot checks and feedback; The medical department, nursing department and information department (medical record room) are mainly responsible for monthly spot checks and evaluation feedback.

(two) analysis of the impact of various medical activities on the overall medical quality and the implementation of medical quality management control measures in various departments.

1, according to the hospital's Medical Quality Management Supervision and Evaluation Standard, the full score is 100. Each item with a total score greater than 80 is qualified, and the unqualified department shall be punished according to the Hospital's Performance Appraisal Method for Post Target Responsibility.

2, major medical quality problems will be punished according to the relevant provisions of the hospital depending on the circumstances, cancel the annual review of advanced departments and impose administrative penalties on those responsible.

3. Education and punishment for outpatients who have not been admitted to the hospital in time, resulting in serious adverse consequences, shall be punished in accordance with the relevant provisions of the Hospital's Medical Quality and Professional Work Supervision and Assessment Reward and Punishment System, Medical Error Accident Registration, Reporting and Handling System, Medical Accident Accountability System and Complaint Management Measures.