1昌江医院质量控制制度汇编修订时间：2017.9目录医疗质量管理组织结构及职责...............................................................3第一节医院质量管理委员会.........................................................3第二节病案管理委员会.................................................................4第三节医院质量管理科.................................................................5第四节科室质量管理小组...........................................................10医疗质量和医疗安全管理工作计划与考核方案.................................14昌江医院质量管理架构图.....................................................................17病历质控管理办法.................................................................................18病案归档管理制度.................................................................................19病案借阅管理制度.................................................................................20病案复印管理规定.................................................................................21病案封存管理制度.................................................................................22病历书写规范.........................................................................................23第一章总则...............................................................................23第一节医院病历书写与管理规范.......................................23第二章病历书写...........................................................................23第一节病历书写...................................................................23第二节门(急)诊病历............................................................24第三节住院病历...................................................................24第三章病历管理...........................................................................30第一节病历管理...................................................................3021昌江医院质量控制制度汇编修订时间：2017.9第二节病历使用...................................................................30第三节质量管理...................................................................32第四章奖励与处分.......................................................................32第五章附则...................................................................................32住院病案首页填写说明.........................................................................33急诊留观病历书写规范.........................................................................36病历书写质量评估标准.........................................................................38第一节住院病历书写评估标准...................................................38病历内涵质量质控标准.........................................................................48单病种质量管理方案.............................................................................54医院处方评规.........................................................................................57第一章总则...................................................................................57第二章处方点评的组织管理.......................................................57第三章处方点评的实施...............................................................57第四章处方点评结果应用与持续改进.......................................59第五章监督管理.........................
