国家卫计委《医疗质量管理办法》规定的18项医疗核心制度(DOC38页)VIP专享VIP免费

第1页共21页编号：时间：2021年x月x日书山有路勤为径，学海无涯苦作舟页码：第1页共21页国家卫计委《医疗质量管理办法》规定的18项医疗核心制度兖州九一医院医务部汇编二0一七年元月第2页共21页编号：时间：2021年x月x日书山有路勤为径，学海无涯苦作舟页码：第2页共21页国家卫计委《医疗质量管理办法》规定的18项医疗核心制度目录1.首诊负责制度·······································第1页2.三级查房制度·······································第2页3.会诊制度···········································第4页4.分级护理制度·······································第5页5.值班和交接班制度···································第9页6.疑难病例讨论制度···································第10页7.急危重患者抢救制度·································第12页8.术前讨论制度·······································第13页9.死亡病例讨论制度···································第13页10.查对制度··········································第14页11.手术安全核查制度··································第17页12.手术分级管理制度··································第18页13.新技术和新项目准入制度····························第20页14.危急值报告制度······························第3页共21页编号：时间：2021年x月x日书山有路勤为径，学海无涯苦作舟页码：第3页共21页······第21页15.病历管理制度······································第23页16.抗菌药物分级管理制度······························第32页17.临床用血审核制度··································第34页18.信息安全管理制度··································第35页1.首诊负责制1.患者首先就诊的科室为首诊科室，接诊医师为首诊医师，须及时对患者进行必要的检查，作出初步诊断与处理，并认真书写病历。2.诊断为非本科疾患，及时转至其他科室诊疗。若属危重抢救患者，首诊医师必须及时抢救患者，同时向上级医师汇报。坚决杜绝科室间、医师间推诿患者。3.被邀会诊的科室医师须按时会诊，执行医院会诊制度。会诊意见必须向邀请科室医师书面交待。4.首诊医师请其它科室会诊必须先经本科上级医师查看患者并同意。被邀科室须有主治医师以上人员参加会诊。5.两个科室的医师会诊意见不一致时，须分别请示本科上级医师，直至本科主任。若双方仍不能达成一致意见，由首诊医师负责处理并上报医疗管理部门或总值班协调解决，不得推诿。6.复合伤或涉及多科室的危重患者抢救，在未明确由哪一科室主管之前，除首诊科室负责诊治外，所有的有关科室须执行危重患者抢救制度协同抢救，不得推诿，不得擅自离去。各科室分别进行相应的处理并及时做病历记录。7.首诊医师对需要紧急抢救的患者，须先抢救，同时由患者陪同人员办理挂号和交费等手续，不得因强调挂号、交费等手续延误抢救时机。8.首诊医师抢救急、危、重症患者，在病情稳定之前不得转院，因医院病床、设备和技术条件所限，须由主治医师以上人员亲自察看病情，决定是否可以转院，对需要转院而病情允许转院的患者，须由责任医师(必要时由医疗管理部门或总值班)先与接收医院联系，对病情记录、途中注意事项、护送等均须作好交代和妥善安排。9.首诊医师应当对...