2022年20XX年医院护理部质控年终工作总结 .pdf

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1、20XX年医院护理部质控年终工作总结20XX年，护理部认真贯彻落实 中国护理事业发展规划纲要(2013 20XX年)、中医医院中医护理工作指南、三级中医医院评审标准及实施细则、优质护理服务质量考评标准及 13 种中医护理方案等。坚持“以人为本”的服务理念，以“提升护士素质、优化护理服务”为主题，以维护和促进人民群众健康为宗旨，拓展中医护理文化建设，充分发挥中医护理优势，加强护理质量监控，确保了护理安全及患者安全。具体护理质控工作总结如下：一、充分发挥护理质控组织的监控作用，护理质控工作常态化及规范化20XX年，各级护理质控组织能认真履行职责，定期的开展质控活动，加强了中医、西医及“优质护理”的

2、护理质量管理，促进了护理质量的持续改进。二、完善质控标准，护理质控工作规范化。1.按卫生部 广西壮族自治区三级中医医院分级管理办法与标准实施细则、广西临床护理质量评价及检查标准及优质护理服务示范工程”活动方案要求，不断完善本院的护理质控标准，并要求各科室认真组织学习，对照标准检查：三级护理质控组每月不定期对多个护理质控项目进行检查，护理部每季度把检查结果进行汇总分析，并以护理通迅的形式发放到各个科室。二级护理质控小组每月对全科质量检查一次，并把质控情况及时进行反馈，针对存在问题进行原因分析，提出整改措施。病区能做到每月质控二次，对存在问题有原因分析，有总结记录。2.在护理质控专题会及护士长例会

3、上，护理部反复强调护理文书书写的必要性及重要性，特别强调要以“证据”来对待，要求护士长、质控员对本院“护理文书书写规范及要求”必须充分的掌握并反复组织科室护理人员学习，力求人人掌握。同时要求护士长或质控员对每份入档病历的护理文书进行质量检查，护理部每月进行抽查，在每月的护士长例会上，对护理文书书写的环节文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L

4、1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X

5、1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6

6、T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D

7、8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M1

8、0X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9

9、D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L

10、2D8L1L9 ZL5E2M10X1X7质量及终未质量进行反馈，发现问题及时纠正。3.强化了中西医“三基”理论、操作技能培训，特别是常见疾病中医护理常规、护理核心制度、岗位职责的培训。（1）护理部按20XX年中西医“三基”培训计划要求，分层级对各级护理人员进行中西医“三基”理论及操作考核，较好的完成了中西医理论及操作培训及考核任务。（2）各科室根据各自的专科特点，认真组织学习中医护理方案，对照中医护理方案，认真开展中医护理工作，临床科室开展中医护理操作均在3 项以上。充分体现中医护理的特色，得到了患者的好评。（3）在护理部的倡导下，部份科室针对本科室存在的问题，积极开展了护理品管圈（“QCC”

11、）活动。成果上报科室有：输液室、骨二科、外一科、重症医学科。4.弘扬中医文化，开展有中医特色的护理健康教育开展中医特色的健康教育，一直是我们护理工作中的重点和难点，各病区在原有中文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:C

12、W9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC

13、8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5

14、E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码

15、:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9

16、HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 Z

17、L5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7医健康教育资料的基础上，想方设法，不断的补充中医防病治病及养生知识，使中医建康宣教更具

18、特色，深受患者欢迎。三、加强护理安全管理，确保了护理安全。1.强化护理安全超前意识，重视危险信息反馈，建立了三级护理安全监控网，即护理部大科病区安全监控，逐级收集护理危险因素，每月护士长例会上特别强调护理安全的重要性，就现存的及潜在的安全问题进行讨论，制定制度、流程改进等切实可行的防范措施，有效的防范了严重护理不良事件的发生。2.加强了对护理缺陷、护理投诉的原因分析。护理部对每起护理缺陷及差错都采取认真对待的态度，在每月的护士长例会上组织讨论，分析发生的原因，应吸取的教训，提出改进措施。3.增强了护理人员的风险意识，法律意识，强化护理人员遵章守规，组织了护理规章制度与相关法律法规的学习，并及时

19、向全院护理人员传递有关护理差错事故的案例文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2

20、M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:C

21、W9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC

22、8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5

23、E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码

24、:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9

25、HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7警示，同时，进一步规范了医嘱查对流程，制定了重点环节护理管理程序及应急流程，制定了高危患者的压疮及各种不良事件的防范措施及上报处理流程，有效的保证了全院护理人员有章可循，确保了护理安全。4.加强了护理管理及带教管理。护理部按

26、计划举办了“护理管理培训班”及“带教老师培训班”。通过培训，各科室护士长更新了观念，增强了安全意识，对本科室发生的不良事件，能做到及时上服，及时组织讨论，制定措施，决不隐瞒，严格控制护理不良事件的发生。带教老师能做到尽职尽责，倾囊相教，努力实行一带一的带教制。对护生能做到加强管理，从严要求，在进行各项护理操作时，特别强调护理安全工作，杜绝了护理操作中护理意外事件的发生。5.注重护理人员继续教育，提高护理专业水平。今年选派护理骨干10 人到上级中医院进修学习，其中专科护士培训3 人次。护士长参加上级卫生主管部门举办的护理管理、新业务、新技术学习班53 人次。通过培训与学习，及时了解和掌握国内外护

27、理文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5

28、P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L

29、1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X

30、1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6

31、T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D

32、8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M1

33、0X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7发展动态，更新观念，与时具进，促进了我院中医护理的发展。四.积极开展“优质护理服务”，确保患者满意、社会满意、政府满意 根据年初护理质控工作计划，我院优质护理病区已全院铺开，达到“三级”甲等中医医院100%病区开展优质护理的要求。护理部进一步完善“优质护理服务质

34、量检查与评份标准”，按 20XX年“优质护理服务检查与评价标准”，护理部每季度对各病区的“优质护理服务”质量进行检查、指导与反馈，发现问题及时制定改进措施，要求病区及时进行改进。各病区护士长能按要求，重新修订了“责任包干制”护理各岗位职责，探索新的排班模式，部份科室实行了 APN 排班模式，减少交接班次数，减少护理安全隐患。在整个“优质护理服务示范工程”中，我们不单纯强调基础护理工作，而是围绕患者的病情，医疗安全、诊疗效果、转归和康复的需要去实施基础护理，使基础护理专业化。把基础护理、专科护理、人性化服务、人文关怀等有机地结合在一起，处处体现以病人为中心的服务理念，为文档编码:CW9D6T5P

35、1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1

36、L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1

37、X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T

38、5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8

39、L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10

40、X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D

41、6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7病人提供全程优质的护理服务，年住院患者满意度达97.21%。五.充分发挥激励机制效应，促进护理质量持续改进护理部把护理质量当成护理工作的重中之重，采用科室护理质量与科室经济利益相挂钩的方法，每季度把各科室的护理质控项目（病区管理、分级护理、护理文书、急救药械、消毒隔离、健康教育、教学）的平

42、均分作为科室的护理质量分，上报质控科，参与医院综的绩效分配。另设护理质量单项奖（单项护理质量超过合格分5 分以上），年终护理质量奖励前三名。各种考试考核结果，已按医院“三基”考试奖惩暂行条例进行奖罚。从而增强了大家的质量意识、安全意识及对质控工作的严肃性和责任感，使各病区的护理质量得到了持续的改进。六、护理质量控制指标达标情况：1.护 理 质 量 管 理 目 标 年 达 标 率 95.07%2.病区管理质量合格率100%(合格分 90 分)文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10

43、X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D

44、6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2

45、D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M

46、10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW

47、9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8

48、L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E

49、2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X73.消毒隔离质量合格率100%(合格分95 分)4.特、一级护理合格率100%(合格分80 分)5.基础护理质量合格率100%(标准分40 分，合格分 36 分)6.教学质量合格率100%(合格标准分90 分)7.特殊区域护理质量合格率100%(合格分 95 分)8.健康教育合格率90%（合格分85分）9.病人满意率97.21%10.“三基”理论（含中西医内容）考试合格率 92.96%(合格分 80 分)11.西医护

50、理技术操作合格率100%(合格分 90 分)12.中医护理操作合格率100%(合格分 90 分)13.护 士 长 夜 查 房 质 量 合 格 率100%(合格分 90 分)14.CPR 培训考核合格率100%(合格分文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9 ZL5E2M10X1X7文档编码:CW9D6T5P1C9 HC8L2D8L1L9