(新版)科室质量和安全管理活动记录本模板2.0.pdf

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1、科室质量与安全管理活动记录本科室：_ 年度：_ 科室质量与安全管理小组工作制度一、科室质量与安全管理小组在科主任领导下负责本科室质量与安全管理的各项工作，下设四个质量控制组：医疗质量管理组、护理质量管理组、医院感染管理组、临床路径与单病种质量组。二、负责制定科室管理制度、质控方案，并组织实施；对全科的医疗质量与安全进行管理监督、指导、检查，开展科室日常质控工作。三、负责组织本科室人员学习有关规章制度、岗位责任、各种技术标准、操作规程、质量控制标准，进行全员质量教育，提高质量意识。四、按质量管理标准，对科室医疗工作的全过程进行质量控制，采取有效措施对基础质量、环节质量、终末质量进行督促、检查、分

2、析、评价，提出改进措施。五、每月召开一次医疗质量与安全讨论会，对科室诊疗活动的各个环节进行指导和监控，对医疗护理质量进行动态评判，对科室的医疗质量控制工作进行总结，并做好活动记录，作为科室质量持续改进依据，由科室主任审阅后签名负责。六、定期（每季度或每半年或每年）对相关质量与安全指标进行汇总分析，做出阶段小结。七、每年度科室要制订年度医疗质量控制计划、实施方案，对本年度科室医疗质量控制情况进行总结。科室质量与安全管理小组成员文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码

3、:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3

4、 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4

5、ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档

6、编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10

7、G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P

8、4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7

9、文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7科室质量与安全管理小组成员名单：人员组成姓 名职 称职 务组 长副组长质控员成 员各质量控制组成员及工作职责一、医疗质量管理组1、人员构成组长：文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7

10、E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D

11、9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1

12、B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4

13、H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R

14、5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:C

15、Q1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 H

16、T4H7E9P7P4 ZN5R5D9R9P7秘 书：成员：2、工作职责1）负责本科室医疗质量管理的各项工作，根据本科室的特点，制定科室管理制度、质控方案，并组织实施。2）对全科的医疗质量与安全进行管理监督、指导、检查，开展科室日常质控工作。3）负责组织本科室人员学习医疗相关规章制度、各种技术标准、操作规程、质量控制标准，进行全员质量教育。4）讨论总结本科室的医疗运行情况，对诊疗质量（超长住院、并发症、核心制度执行情况等）、病历质量、合理用药、输血管理、围手术期质量管理、医疗差错、投诉纠纷、医疗安全(不良)事件、医疗质量管理科所发整改通知书等进行有针对性的质控。5）针对发现的问题提出改进措施，并

17、在下次会议中（或下个周期中）对改进措施的效果进行评价，以做到医疗质量的持续改进。二、护理质量控制组1、人员构成组 长：秘 书：成 员：2、工作职责1）在护理部及科主任领导下，全面负责科室的护理质量及安全文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5

18、D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ

19、1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT

20、4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5

21、R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:

22、CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3

23、HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7管理。2）制定护理质量管理计划、目标，落实达标措施，定期检查、

24、考核与评价。3）负责督查各级护士护理工作质量，落实核心制度、护理常规和岗位职责。4）开展科室护理质量自查活动。负责对病房管理、患者安全、优质护理服务质量、基础护理、专科护理、技术操作、文件书写等质量检查和指导。5）定期组织护理业务学习、护理查房、工休会，推行护理新技术、新业务。6）召开护理质量与安全持续改进会议，对护理工作中存在的质量安全问题进行原因分析，提出改进措施，落实细节管理，解决护理问题，持续质量改进。三、医院感染管理组1、人员构成组 长：秘 书：成 员：2、工作职责1)负责本科室医院感染管理的各项工作，根据本科室医院感染的特点，制定科室管理制度，并组织实施。2）对医院感染病例及感染环

25、节进行监测，采取有效措施，降低文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9

26、P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J

27、3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E

28、9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9

29、R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B

30、3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H

31、7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7本科室医院感染发生率；发现有医院感染流行趋势时，及时报告医院感染管理科，并积极协助调查。3）组织本科室预防、控制医院感染知识的培训。督促本科室人员加强学习，掌握医院感染突发应急处理能力；监督医院感染散发病历报告落实情况，清洁、消毒、灭

32、菌执行情况，手卫生与自身防护落实情况等，加强医院感染预防与控制的各项工作。4）总结本科室感染控制情况，对反映感染控制质量的个案、指标和感染管理科所发的整改通知书等进行有针对性的质控。针对发现的问题提出改进措施，总结经验教训，以做到持续改进。四、临床路径与单病种质量组1、人员构成组 长：秘 书：成 员：2、工作职责1)负责本科室临床路径与单病种的质量管理工作，根据本科室的特点，制定科室相关管理制度，并组织实施。2）对科室临床路径与单病种的质量数据进行收集、整理、分析，动态监测临床路径中相关指标（平均住院日、平均住院费用等）的趋势，采取有效措施完成医院对临床路径的相关要求。3）对科室单病种的质量数

33、据进行收集、整理、分析，根据动态监测结果对单病种质量进行实时的控制管理。4）针对发现的问题提出改进措施，并在下次会议中（或下个周文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 Z

34、N5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编

35、码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G

36、3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4

37、 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文

38、档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J1

39、0G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7期中）对改进措施的效果进行评价，以做到医疗质量的持续改进。科主任签字：年 月日XXXX年度科室质量控制计划文档编码:CQ1B3J3J10

40、G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P

41、4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7

42、文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J

43、10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P

44、7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9

45、P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J

46、3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7XXXX月份科室质控活动记录日期：年月日主持人：参加人员（亲笔签名）：（请注意页眉处输入科室名称）结果评价（对上月质控活动改进措施的落实和成效进行评价及反馈）（此部分要求手工书写，请留足空间）本月科室质控活动情况（首行缩进 2 个字符，宋体、小四、段前段后间距0 行，行距固定值 22 磅）一、

47、医疗质量（重点环节、核心制度、关键工程）(一)诊疗质量督查（包括超长住院、危急重症管理等核心制度执行情况等）(二)病历质量（包括环节病历和终末病历）(三)合理用药（包括抗菌药物、抗肿瘤药物、激素类药物及其它辅助用药等）(四)输血管理(五)医院感染文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J

48、10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P

49、7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9

50、P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J3J10G3 HT4H7E9P7P4 ZN5R5D9R9P7文档编码:CQ1B3J