Summary of the work of the Medical Department 1 Over the past year, with the strong support of the leaders of our hospital, the guidance of the superior business departments and the enthusiastic help of the brother departments, our hospital has made certain achievements in medical treatment, teaching and scientific research, but there are also many shortcomings, which are summarized as follows:
I. Main Work Achievements
Further establish and improve various rules and regulations, standardize medical behavior, and improve medical quality. In order to meet the people's medical care needs, we drafted and formulated the implementation plan of medical quality management. Notice on carrying out the learning activities of the Regulations on Handling Medical Accidents and its supporting documents. Forwarding the notice of the Ministry of Health and state administration of traditional chinese medicine on the basic norms of medical record writing, organizing the medical staff in the hospital to learn the norms of medical record writing in Hubei Province, clarifying the objectives, measures and business indicators of medical quality this year, standardizing the medical behavior of the majority of business personnel, educating everyone to learn, understand, use and abide by the law, protecting the legitimate rights and interests of both doctors and patients according to law, and laying a foundation for medical safety in the hospital. Strengthen the inspection of clinical medical quality and strive for a first-class medical and health care center. In order to better implement the clinical medical management system and comprehensively improve the medical service level of our hospital, under the leadership of President Peng, we held several meetings of directors of various departments to arrange clinical work and solicit opinions on the medical development of our hospital. In order to further implement it, hospital leaders and other competent departments went deep into various departments and made careful and detailed inspections on business study, medical record writing, difficult medical record discussion and error registration.
Supervise all departments to act in strict accordance with the various systems of the hospital, check for leaks and fill vacancies, and successfully solve many problems that are easily overlooked in clinic through inspection. In order to further strengthen medical safety, medical safety meetings in clinical departments are held regularly to discuss the mistakes and hidden dangers of medical safety in various departments, and to discuss the next step and how to prevent them, which provides a reliable guarantee for clinical safety medical care. Strengthen personnel training and clinical teaching. In order to further improve the quality of medical care, speed up the training of talents, and let the younger generation stand out, hospital leaders sent Zhang Hongcui to a higher-level hospital for further study under the condition of tight economy. At the same time, we sent 10 person-times to participate in various academic activities, and introduced new technologies, methods and experiences to the hospital. After coming back, they were asked to hand in their personal summaries and write plans for future work, which improved the academic level of related disciplines, laid the foundation for the construction and development of disciplines, achieved good results and achieved the expected goals.
Second, business training:
First, strengthen business study, pay close attention to implementation, and strive to improve business level. In order to further improve the professional and technical level of medical technicians in our hospital and improve the popularity of our hospital, 20 lectures were arranged throughout the year, with 50 class hours. The content of the lectures is mostly the frontier issues of various disciplines, and the content is novel, which has aroused the learning interest of comrades and achieved good results. Medical technicians with less than 20 years of experience will be tested once every six months, and senior, middle and junior students will be tested once a year. The content of the examination includes not only the clinical basis, but also the new progress in various disciplines. Through the examination, the technical level of various professional and technical personnel was effectively inspected. Requirements for publishing papers and documents in magazines above the provincial level this year. Training and arrangement of SARS prevention knowledge for all employees.
The second is to train the clinical medical staff in outpatient department on the guiding principles of nosocomial infection control of infectious atypical pneumonia. Third, the medical staff in the hospital were trained in SARS diagnostic criteria, epidemic disinfection, emergency handling regulations for public health emergencies, and medical staff protection.
Summary of Medical Department's Work In the past 2 1 year, under the leadership of hospital leaders and hospital committees, the Medical Department has earnestly implemented the 20xx work plan, continuously improved the work of creating "dimethyl ether", carried out the "100-day medical quality and safety trip" in depth, paid close attention to medical quality management and staff quality education, and established and improved various core systems. It has effectively promoted the rapid and orderly development of medical technology work in our hospital and successfully completed various tasks throughout the year.
First, quality education.
Talent is the key to hospital development and medical quality improvement. Only by continuously strengthening personnel training and improving the ideological quality education of business personnel can we effectively develop and expand our business and improve the visibility and credibility of hospitals in society. Through studying medical and health laws and regulations, assessing medical ethics, setting up supervision posts, publishing complaint telephone numbers, giving criticism and education to the complained medical staff after investigation, and withholding the bonus of the month, the service attitude of our hospital has been obviously improved.
Second, practice according to law.
Conscientiously implement the "Medical Practitioners Law", "Regulations on the Administration of Medical Institutions" and other laws and regulations. The Medical Department strictly examines and records the qualifications of all kinds of professional and technical personnel, standardizes medical practice and carries out diagnosis and treatment activities according to law.
1, which standardizes the management measures of prescription authorization. Those who have not obtained the corresponding qualification certificate will not be granted the prescription right, and they may not arrange shifts, treat patients and issue checklists separately. Must obtain the corresponding qualification certificate, the department audit, medical department audit qualified rear can be engaged in.
Corresponding medical activities.
2. Medical professionals may not go to work alone without obtaining the corresponding qualification certificate, and the diagnosis report, signature and report issued must be signed by qualified teachers.
3. Newly transferred professional and technical personnel can engage in professional and technical work only after changing their practice places.
4. It is strictly forbidden for the staff in the B-ultrasound room to illegally identify the sex of the fetus, and the staff in obstetrics and gynecology to illegally terminate the pregnancy.
Third, the quality of medical care.
1, pay close attention to medical quality management, implement scientific management, and promote the steady development of medical work.
The focus of the hospital is medical treatment, and the quality of medical treatment is the top priority. According to the hospital management regulations, administrative rounds should be conducted every week to prevent the weekly inspection from becoming a formality and going through the motions, and to ensure that the inspection is rule-based and effective. At the beginning of the year, the Detailed Rules for the Implementation of Medical Administrative Warding in Jingbian County People's Hospital was formulated, which divided the inspection team into three areas, and the inspection contents were divided into: surgical medical record inspection, medical record inspection, nursing and hospital sense spot check, logistics support inspection, on-the-job inspection and outpatient inspection, all of which performed their duties. Give feedback to the problems found in the inspection in each district and rectify them on the spot. After the inspection in the third district, summarize them once, and make a written summary in Hospital work briefing, and make informed criticism and punishment. At the same time, the daily work arrangement and monthly report of Jingbian County People's Hospital were formulated, which made the work of the department more detailed and improved the medical quality of the hospital obviously.
2. Further improve the implementation of various core systems. Combined with the actual work in our hospital
As well as the relevant medical management regulations, the department system is classified in a more standardized and detailed way, and all systems are bound into volumes: medical work system, disease diagnosis and treatment routine, core system, technical operation specification, emergency plan, etc. In order to reduce the workload of medical workers, the' ten working notebooks' required by various departments in 20xx were reduced to seven: notebooks for discussion of difficult and critical cases, notebooks for discussion of death cases, notebooks for discussion before operation, notebooks for medical quality and safety, notebooks for departmental meetings, notebooks for three-basic training and notebooks for doctor handover. In order to implement various systems, irregular inspection and year-end evaluation are adopted, and the evaluation results are directly linked to the department's year-end evaluation.
3. Strictly control the quality of medical records and improve the writing level of doctors' medical records.
Medical record writing is not only the key to medical quality, but also the strong evidence of law. We mainly manage medical records from two aspects: the management of running medical records and the management of terminal medical records. Take administrative rounds and irregular spot checks to run the medical records. If the handwriting is scrawled, the records are incomplete and not recorded on time, the whole hospital will notify and impose a fine, and 50 yuan will be punished for an unfinished medical record. Review the archived medical records once a month, and the C-level medical records will be returned for rewriting and fined. 1 C-level medical records will be punished by 50 yuan, and the chief physician 50 yuan will be punished for failing to file the medical records on time, with 4 copies in total, and 50 yuan will be punished for each additional copy. A medical record exhibition was held in May. All clinicians consulted each other's medical records and corrected them in time when they found problems, which set up a good platform for young doctors to write medical records.
Fourth, medical safety.
Throughout the year, * * * handled medical disputes 10, accepted patients' complaints and compensated 5 cases. The rest settle disputes through patient persuasion, education and explanation. We pay attention to strengthening medical personnel.
It is necessary to study laws and regulations, pay attention to communication between doctors and patients, and sign a consent form for informing each hospitalized patient of the disease, requiring doctors to make detailed records, and both doctors and patients should sign at the same time. Strengthen the responsibility system for first-time doctors, strictly implement medical accident prevention measures and medical dispute settlement plans, and implement the accountability system for medical defects. Medical dispute compensation 10% shall be borne by the competent doctor.
Verb (abbreviation for verb) infection control
According to the epidemic situation of hand, foot and mouth disease in influenza A (H 1N 1) cases in recent years, the hospital immediately set up an infectious disease expert treatment team, and the medical department formulated the "Diagnosis and Treatment Process of Influenza A (H 1N 1) in Jingbian County People's Hospital" in combination with the actual situation of our hospital, which truly achieved scientific prevention and orderly treatment of infectious diseases. Relevant personnel have been sent out to attend academic lectures on swine flu, plague and brucellosis, and specialized training on plague, brucellosis and swine flu diagnosis and treatment plan (first edition, second edition and third edition) has been organized for the professionals in the hospital to ensure that medical personnel can know the latest diagnosis and treatment information at the first time.
Continuing education of intransitive verbs
Talent is a prerequisite for the development of hospitals, especially in recent years, with the continuous expansion of hospital scale, a large number of professionals have been introduced. In order to train young professional and technical personnel to become talents as soon as possible, we have implemented the strategy of rejuvenating the hospital through science and education, formulated a talent training plan and scheme suitable for hospital development, and strived to reserve talents for hospital development.
1, three basic training books
Strengthen on-the-job and pre-job training and assessment. This year, the recent staff of our hospital not only studied the relevant systems, laws, regulations and rules of the hospital, but also participated in the theoretical and practical examinations. Those who failed the examinations were not allowed to work in the corresponding positions. The department comes once a month.
Less training and assessment, and should be put on record, the three basic training is included in the important indicators of department assessment.
2. Continuing medical education
In the whole year, 242 people participated in the website of Good Doctor, and each person got 25 credits. * * * 12 people were sent to hospitals inside and outside the province for further study, and 26 people participated in short-term study classes, seminars and academic conferences. After taking part in the study, organize relevant professionals to give lectures in time to ensure that the new knowledge and technology learned can be passed on to every professional, which improves the medical technology level of our hospital as a whole. Twenty-six medical papers were published this year, twice as many as last year.
3. Teaching management
In order to further strengthen the management of interns, on the basis of the original (management measures for interns), the "assessment measures for interns" and "assessment registration form for interns" have been formulated, and those who fail the assessment may not be transferred to the next department. Throughout the year, * * * received 72 interns from various colleges and universities, 19, and received free interns from township hospitals 15.
However, in this year, although we have made some achievements, there are still many shortcomings. In the future work, we will make persistent efforts to make up for and improve the shortcomings in the work, strive to achieve better results and contribute to the development of the hospital.
Summary of the work of the medical service 3. In the first half of the year, the medical service was implemented item by item under the guidance of the work plan at the beginning of the year, and all the work achieved initial results. Now, summarize the work in the first half of the year:
First, medical quality management
1, the medical department shall inspect the medical core system, the quality of medical documents and related specifications every quarter, and feed back the problems found to the department in time, and find and solve the problems in time, which shall be carried out by the department director and recorded.
2. Quality management of medical documents
(1) Conduct spot checks on archive ratio management every quarter, issue feedback sheets to responsible doctors for problematic medical records, rectify them in time, and the audit is in good condition, and all doctors can seriously correct them.
(2) Every quarter to the department, check the current medical records, on-site rectification.
(3) As of the first half of the year, the Medical Department * * * randomly selected 24 medical records and found no Class C medical records.
3. During the supervision of each department, it was found that all kinds of records were not timely, especially the handover records were too simple, and rectification notices were issued for the problems found, and the review was in good condition.
Second, do a good job in continuing medical education.
1, in order to absorb advanced technology and improve technical level. In the first half of the year, * * * sent two medical staff to advanced units in provinces and cities for further study, which brought new theories, technologies and methods to our hospital.
2. In the first half of the year, * * * conducted six medical "three basics" studies and two "clinical practice" theoretical studies. Conduct a "three basics" theoretical examination every quarter, and conduct a clinical skills operation examination every quarter, and punish unqualified personnel.
Third, prevent medical accidents and ensure medical safety.
From June+10, 5438, our hospital * * * organized five studies on relevant medical laws, regulations and rules. Strictly implement the medical technical operation standard, carry out medical activities according to the scope of practice, and deal with the behavior that damages the image of the hospital strictly and severely.
In the first half of the year, with the support of hospital leaders, our department carried out the plan at the beginning of the year step by step, and all the work achieved good results. In the second half of the year, we will make persistent efforts to make up for and improve the shortcomings in our work, strive for greater achievements, and contribute to the construction of a harmonious hospital.
Summary of Medical Department's Work Over the past 20xx years, under the direct leadership of hospital leaders, with the concept of "quality first, patients first", we have paid close attention to the standardization of medical system, thoroughly studied and implemented the Law of People's Republic of China (PRC) on Medical Practitioners, Regulations on the Management of Medical Institutions, Detailed Rules on the Management of Medical Institutions, Measures for the Management of Medical Institutions in xxx Province, etc., and combined with the actual situation of our hospital, we have taken measures to strengthen medical quality management. Pay attention to the quality training and professional ethics education of medical staff, further emancipate their minds, update their concepts, improve service efficiency, effectively promote medical treatment, teaching and scientific research, and make contributions to the reform and development of hospitals.
First, the quality of medical care.
The quality of medical care is the fundamental problem for the survival and development of hospitals. Paying close attention to medical quality management and improving the quality of medical services in an all-round way is the primary task of the medical department. In strict accordance with the Basic Specification for Medical Records Writing in xx Province (for Trial Implementation), further specification requirements are put forward for the writing of inpatient medical records, course records and related materials, so that one person can have one book, and the study should be carefully organized and combined with the monthly quality appraisal. All kinds of medical quality inspections this year are hereby notified as follows:
(1) Clinical examination
1, medical record quality
The number of inpatients in 20xx is xx, which is xx% higher than that in 20xx.
The total evaluation results of clinical departments from 20xx months to x months are close. The top three excellent departments are: Psychiatry I, Psychiatry II and Western Pharmacy. Three departments * * * won X first places within X months (among them, Psychiatry I and II * * * won X, and Western Pharmacy won X). )。
(1) Archive medical records
(1) (1) 20xx x month -x month * * X copies of medical records were randomly selected and filed, but class B medical records were not checked, and the grade A rate was xx%. This year, xx Municipal Health Bureau randomly selected the medical records of secondary hospitals for evaluation, and our hospital won X.
(2) Each department can submit the medical records of last month before X day of each month.
(2) Current medical records
(1) in strict accordance with the "x province medical record writing basic norms (Trial)", to further standardize the current medical records and course records writing norms. This year, the monthly average examination and X-ray medical records/course records were not completed as required, which was better than last year, but the completion rate increased with the increase of months.
② All of them went through the hospitalization procedures in time.
③ The outpatient medical record examination is basically completed.
(3) Prescription quality
X days of prescriptions were randomly selected every month, and the average pass rate from X month to X month was x%.
2. Hospital infection control
① Infection rate: each medical record was monitored, and X cases were monitored for 20xx years, x months and x cases were infected, with an infection rate of x%. The infection rate was x%.
② Missed report rate: Among the cases monitored from 20xx to X months, X cases were missed, and the missed report rate was x%.
(3) Routine monitoring of environment, air, clothes, hands of medical staff, disinfectants and sterile articles. Every month in the whole hospital.
(4) Participate in the construction of infectious diseases department and guide the disinfection and isolation work of various departments.
⑤ The operation of endoscopy and stomatology is further standardized according to the regulations of the Ministry of Health.
3. Documents and archives
Basically, it can be completed on time and as required. The main problem is that the records of "registration of rescuing critical patients" and "discussion of critical cases" are not detailed enough, which is different from the handover records. The critical illness reporting system was not seriously implemented.
4, "three basics" skills/theory assessment
The "three basics" theory test was taken twice, and the passing rate was x%.
5. Bed utilization rate
20xx x month -x month, the actual number of beds occupied by the whole hospital is xx days, and the previous X names are: X- 1 Department and X-2 Department. These two departments * * * account for x% of the number of beds actually occupied by the hospital. The average bed utilization rate of the whole hospital is xx%, which is higher than last year, and the bed utilization rate of X department is lower than last year.
6, to prevent medical errors and accidents
Strengthen the training of medical staff's professional ethics and professional technical ability, especially the study of Regulations on Handling Medical Accidents, Classification Standards of Medical Accidents and Provisions on Reporting System of Major Medical Negligence and Medical Accidents issued by the Ministry of Health, so as to prevent the occurrence of major medical negligence and medical accidents, continuously improve the quality of medical services, scientifically classify medical accidents, correctly handle medical disputes, and protect the legitimate rights and interests of patients, medical institutions and their medical personnel.
There were 0 medical disputes this year, which was the least over the years. No major medical accidents occurred.
(B) the medical quality of medical technology departments
Strengthen the technical training of medical technicians and improve the service quality, pay attention to the monitoring of the coincidence rate and accuracy of test results, and constantly add new projects to meet clinical needs.
From 10 to 10 this year, more than X patients were admitted to the ECG room, an increase of x% over last year.
(3) outpatient medical quality
Psychiatry: We should increase outpatient service construction, further improve the outpatient functions of various departments, integrate psychiatric outpatient service, epilepsy outpatient service and neurosis outpatient service into comprehensive psychiatric outpatient service, rationally arrange all districts, make preparations for psychiatric emergency, rebuild outpatient hall and add consultation service desk, which greatly improves the medical environment.
The number of outpatients in X-X this year is X, which is x% higher than that in 20xx.
Second, continuing education.
1. Incorporate continuing education into the work plan of our hospital, with the dean personally as the leader of the leading group for continuing education, and attach importance to the training and education of personnel inside and outside the hospital. This year, our hospital * * * sent five people to tertiary hospitals inside and outside the province for further study, and sent nearly X people to various short training classes. Several doctors who returned to the hospital after further study were able to quickly apply the new knowledge and technology they had learned to the clinic and actively carry out their work, which played a great role in improving the level of medical technology in our hospital.
2. This year, nearly X people participated in various adult college entrance examinations and self-taught examinations in our hospital.
3. Actively write papers and publish X articles throughout the year.
4, to carry out various forms of health education, clinical departments on the wall publicity for more than x times a year, to carry out prevention and control publicity activities in the community for more than x times, many times to distribute health education prescriptions inside and outside the hospital.
Third, teaching work.
This year * * * received X advanced students, X interns and X technical secondary school interns.
The Medical Department held all interns and intern meetings in X and X respectively, which will further educate and punish students who violate the rules.
Four. Infectious disease management
1. Conscientiously implement the notice of the general office of the Ministry of Health on the implementation of online direct reporting of infectious diseases and public health emergencies. Since 1 month, direct reporting of infectious diseases has been realized, and single diseases such as unexplained pneumonia, measles, AFP and neonatal tetanus have been monitored, which greatly improves the timeliness and accuracy of epidemic reporting. From X to X, * * * reported two cases of cough, and no class A was found. Strict implementation of the "two-way referral" system for tuberculosis, a total of X cases were transferred.
2, set up infectious diseases department, clean area, semi-polluted area, polluted area layout is relatively reasonable. 10- 10 opened intestinal outpatient service and intestinal isolation ward, and X cases of fecal samples were sent for inspection, but no suspected cholera patients were admitted.
Verb (abbreviation of verb) health care free outpatient activities
1, organized experienced medical staff to go to poor and remote villages for free clinic for local people and disabled people ***x times, cooperated with the Municipal Health Bureau and the Municipal Cancer Association for free clinic, sent doctors and medicines to Qinglian Village and Huxi Village respectively, * * * treated more than x people for the elderly, the weak and the disabled, distributed medicines 1000 yuan, and distributed health prescriptions, which was well received by the masses.
2. Send health care doctors to do health care work for various large-scale meetings and sports meetings of municipal government departments ***x person-times.
3. Do a good job in the registration of planned immunization for newborns, cooperate with disease monitoring institutions to do a good job in planned immunization for school-age children in the city, and handle X cases of planned immunization for children within X-X months.
4, to carry out various forms of health education: every ward and clinic * * * out publicity column X period.
Six, physical examination work
This year, students in the senior high school entrance examination have more physical examinations, conscripts generally have more physical examinations, and organs, enterprises and institutions and retired cadres have more physical examinations. With the attention and support of hospital leaders, X officially established a physical examination department this year, equipped with special physical examination places, B-ultrasound machines, electrocardiographs and other special equipment, and added relevant personnel. A new health check-up package has been introduced, which simplifies the medical check-up procedures and provides high quality, preferential treatment and preferential treatment for medical examiners.
Seven. insufficient
1, doctors take turns to go to the countryside to wait for work in primary clinics, which has not been fully carried out.
2. The scientific research foundation is weak and the scientific research results are insufficient.