2022年XX中医院医务部2015年前三季度总结 .pdf

1/14 2015 年医务部工作总结（19 月）2015年前三季度，共计出院患者4319 人，门诊患者81418人，急诊患者5614人，急危重症患者149 位，抢救成功率91%。一、建立健全相关制度及规范流程1、修订医疗规章制度35 项。即乌海市蒙中医院处方权审批管理制度、乌海市蒙中医院住院时间超过30 天的患者管理与评价制度、乌海市蒙中医院医患沟通制度、乌海市蒙中医院关于出具医学诊断证明和病假证明有关规定、乌海市蒙中医院门诊出诊医师管理制度、医疗纠纷处理程序及医疗事故纠纷责任者处理制度（试行）、危急值报告制度与工作流程、医院麻醉医师资格分级授权管理制度、乌海市蒙中医院传染病上报流程等。2、组织全员医务人员学习相关工作制度及工作流程共11 场，参加人次300 余人。二、优化诊区设施布局，营造温馨就医环境 (一)优化诊室布局 1、一楼门诊候诊区进行合理调整，最大限度的方便患者。2、开展专家工作室。3、门诊排队叫号系统工作进展：6 月份排队叫号系统硬件设备已完成招标采购，软件前期准备工作已完成，待硬件设备到货后装载软件，并进行调试、测试工作。2/14（二）保持环境整洁1、细化院内外环境保洁内容，与保洁公司共同研究，重新制定了完善职责及考核指标，使得更能够贴近实际。2、同时聘请感控部门对保洁人员进行了感染相关知识的培训，提高保洁员的感染防控意识。特别是加强了重点区域，如诊区、病房、大厅及卫生间等场所的保洁消毒工作。（三）设置醒目标识1、我院就诊办事区域均设有醒目的指示标志，大厅设有建筑平面图和科室分布图，各楼层电梯口设有科室楼层分布指示牌。2、对全院各科室标识标牌宣传栏进行定期全面检查，对损坏、不清、错误的标识标牌进行及时更换制做，达到标识清楚、指示明确、统一醒目的目标。3、对全院各科室、一楼大厅宣传栏进行定期制做更换，使宣传栏内容更加丰富，达到患者及患者家属能够了解到我院更多的特色疗法及蒙中医养生科普知识。4、按消防要求设置安全出口指示牌。5、危险、易燃、易爆、有毒、有害物品和放射源等设置醒目安全警示。（四）提供便民措施 1、对于来我院就诊的蒙族患者得到更好的服务，我院导医台特安排一名蒙医专业人员担任咨询员及蒙文翻译为患者进行文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 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ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P43/14 导诊。2、门诊部设有轮椅2 辆、免费提供开水、一次性纸杯、导医台设有应急电话一部、便民箱一个（内含剪刀、针线、棉签、笔等）。3、在炎炎夏日到来之际，我院暑期推出新的便民措施夏季解暑保健茶，凡是来医院就诊患者均可免费饮用菊花消暑茶同时提供免费一次性纸杯。4、2015 年端午节，我院特推出“迎端午祛疾防病保健康的纯中药香囊”，端午节一直是防疫祛病、避瘟驱毒、祈求健康的民俗佳节。我院制剂中心为广大群众准备了具有提神醒脑、醒脾开胃功效且防流感、驱蚊虫的纯中药香囊。前来咨询的患者众多，活动得到了热烈的反响。5、我院各病区增设微波炉和冰箱，供住院患者提供方便。6、针对一楼超声科检查患者较多的情况，在超声科候诊区增设候诊倚，并安排专职人员进行登记、叫号。三、推进预约诊疗服务，有效分流就诊患者1、为进一步提高医疗服务质量，构建和谐医患关系，推进文明有序就诊，制定了预约挂号制度。2、继续实施电话预约、现场预约、网站预约三种。截至9 月28 日前，我院共接受患者预约诊疗1408 人次；3、实现分时预约，合理安排患者就诊，缩短候诊时间。我院自 6 月 29 日开始实行分时预约，截至 9 月 20 日，共接受患者文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 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ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P44/14 电话预约 605 人；网络预约7 人。四、合理调配诊疗资源，畅通急诊绿色通道1、严格执行门诊医师出诊管理制度。对每天出诊专家的考勤进行登记记录，对于有事不能按时出诊的医师实行请假制度，并提前通知医务部。2、针对上午患者较多的情况，在导医台增设一名咨询员，并对其进行相关培训。3、加强急诊急救力量。2015 年上半年，共选派急诊科医师1 名到宁夏医科大学附属医院进修急救专业半年；安排糖尿病肾病科和肝胆脾胃病科、脑病科医师共七名到急诊科进行轮岗工作，轮岗时间为半年。组织开展急诊应急演练2 次，参与科室有急诊科、手术室、心病科、骨伤科，共出动医护人员38 人。演练结束后，现场观摩的院领导和职能科室负责人对演练进行了总结，充分肯定了演练的成绩，也指出了演练过程中存在的不足。在今后我们会继续加强专业知识的学习，提高自身综合素质，更好的为患者服务。通过演练，体现了突发公共卫生事件的救援中医护人员密不可分的合作关系，也检验了我院应急指挥系统的运转能力，提高了医护人员急救意识，锻炼了全体应急队员应对突发公共卫生事件的应变能力，为以后应对突发公共卫生事件提供了宝贵的实战经验。4、及时救治重患。2015 年 6 月，经过为期一个多月的精心筹划，我院与宁夏医科大学附属医院合作，共同举办“精品课堂文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 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急危重症培训”针对我院初级职称医务人员较多，且大多数均未外出进修的实际情况，邀请宁夏医科大学附属医院医师和护士长来我院进行重点培养，参加培训学员是由各临床科室研究选派，再由医务部护理部审核通过的临床技术骨干。本次培训班区别于以往的培训。是极为针对性的学习，学习形式多样，内容丰富，培训后还需进行技术大比武方可结业。五、坚持依法执业，规范诊疗行为，保障医疗安全（一）落实患者安全措施。1、严格执行手术标识制度，强化医院医务人员感控理念，落实医务人员手卫生规范把手卫生的基本理念和服务宗旨充分展现在医院的每一个角落，让广大医务人员充分认识到手卫生的重要性，强化感染控制理念，改变行为模式，提高医务人员手卫生依从性，预防与控制医院感染的发生，保障医疗质量安全。2、5 月中旬，在院领导高度重视及相关科室大力支持下，由院感科精心组织在全院开展“手卫生宣传周”活动，活动形式多样、内容丰富多彩，通过向院内患者（医务人员）宣传、播放宣传教育短片、知识专题讲座、组织各代表队参加知识竞赛、操作表演、承诺宣誓、承诺书签字等活动，突出“手卫生宣传周”主题内容，且达到活动预期目标，收到了非常好的效果。（二）进一步加强临床路径管理，根据国家中医药管理局发布的临床路径指南，从医院实际及自身特色出发，整理并规范我院现有临床路径，2015 年上半年住院患者共进入临床路径455文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 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HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P46/14 人次，完成路径 333 人次，完成率 73%，目前此项工作仍在进行。根据卫生部临床路径管理指导原则和卫生局相关通知，及医院指导意见，结合实际，2014 年确定 9 个专业、37 个病种。共实践临床路径试点病种844 例，进入临床路径536例，完成率63.5%。（截止 2015 年 9 月）通过临床路径工作的开展，我们进一步优化了医疗流程，规范了医护人员的医疗行为，提高了整体医疗质量，减少了不合理的检查、治疗、用药，降低了总体治疗费用，缩短了平均住院天数，病种同比总费用、住院天数均较未进入路径者减少，提高了工作效率。(三)质量管理1、（1）1-9 月均以时限为检查点，检查运行病历3643份，其中病危患者55 例；手术患者437 例，其中级手术236 例、级手术23 例。（2）重点科室:、手术科室及手麻科的手术安全核查制度2 次；、抽查急诊科留观病历临床科室终末病历96 份。（3）科室上报入院超过30 天患者43 人次。（4）、修改临床路径7 人次。2、医疗质量：为降低医疗风险，提高医疗质量，质控办组织召开医疗质量与安全管理会议及质控小组会议各3次。3、参加院外学习5 次：“山西省儿童医院质量管理学习”3 次、“宁夏中医院医疗集团2015 年医院管理培训班”、文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 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ZB2A8K5V1P47/14“第三届医院质量管理与控制体系建设培训班”。4、组织培训全院医务人员学习：“医疗安全（不良）事件”、“医疗风险的防范”、“核心制度的内容及重要性”、“病历书写的规范”；为新入职员工进行“医疗质量与安全”岗前培训。培训后均以试题测试，参加答题491 人次。与检验科联合举办培训2 次。5、参加“急诊演练”2 次、科室业务培训及学习7 次、参与编辑医院质量管理院刊3 期。（四）加强合理合理用药 1、门诊处方点评。每月随机抽取1 到 25 号西成药处方、中草药处方、蒙药处方、颗粒处方进行处方点评，2015 年上半年共抽取处方数为5855 张，对点评情况进行分析总结，对不合理处方按科室进行统计分析，以通知的形式下发到各科室。2、门诊抗菌药物处方点评。每月抽取全部抗菌药物处方进行点评，2015年前三季度共抽查抗菌药物处方1547 张，对不合理用药处方中出现的问题进行分析，并将分析结果以通知的形式下发到各科室。3、治疗用抗菌药物病历点评。每月随机抽取治疗用抗菌药物病历进行点评，2015 年前三季度共抽查治疗用抗菌药物病历396 份，主要从应用抗菌药物适应症、抗菌药物选择、用法用量、用药疗程等方面进行点评，针对不合理用药方面进行汇总分析，将分析结果通知到各科室。针对用药严重不合理的科室进行沟文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 ZB2A8K5V1P4文档编码:CM9G9Y8T5D4 HY9M5H6L3V4 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