2022年20XX年院感质控科工作总结及20XX年工作计划 .pdf

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1、【20XX年质控办工作计划】20XX年院感质控科工作总结及 20XX年工作计划20XX年院感质控科工作总结本年度院感质控科在院长和分管院长的正确领导和大力支持下，积极开展相关工作，现工作总结如下：在院感环节上，认真贯彻落实卫生部颁布的医院感染管理办法、消毒技术规范、医疗卫生机构医疗废物管理办法等有关医院管理的法律法规，严格质量监测及考核，降低医院感染发病率，保证了医疗安全；认真执行传染病信息报告规范 2015 版，及时上报我院传染病信息，按时完成东胜区疾控中心不定期下发的任务；制定了突发事件的医疗应急预案，每季度报送排污表，顺利通过康巴什环保局的年度检查。在质控环节上，建立三级质控体系、医院质

2、量与安全管理方案与强化环节质量控制及质量与安全持续改进方案，初步制定医疗质量管理办法，建立医疗质量监控指标体系和评价方法。虽然我科做了大量工作，但是仍然存在很多问题。比如医院感染环节质量需进一步加强，部分医生对院感不够重视，质控工作涉及到员工绩效考核，需要院领导大力支持才能在全院实行等。新的一年即将到来，我科将继续开展各项工作，并针对本年度问题不断提高和完善，借鉴兄弟医院经验，做好我院院感质控工作。院感质控科20151221 20XX 年院感质控科工作计划医院院感和医疗质量管理是医院管理的核心工作，现制定20XX 年院感质控科工作计划如下：一、院感工作文档编码:CL4B8V5B6S7 HO8H

3、5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文

4、档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H

5、5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文

6、档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H

7、5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文

8、档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H

9、5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W11、继续加强组织管理，明确工作职责，根据医院感染相关法规、规范和行业技术标准等，更新并细化规章制度和操作规程，提高规范化管理程度。2、常规开展医院感染各项监测（1）医院感染病例监测：目的是掌握本院医院感染发病率、多发部位、高危因素、病原体特点及耐药性等，为医院感染控制工作提供科学依据。包括全面综合性监测和目标性监测。（2）环境卫生学监测：包括对空气、物体表面和医务人员手的监测，每季度一次。当怀疑医院

10、感染与环境卫生学因素有关时，应及时进行监测。各科室主要由感控护士与检验科共同完成，医院感染管理科定期抽查，纳入质量控制考核标准。（3)消毒灭菌效果监测：使用中消毒剂每季度进行一次微生物监测，由监控护士与细菌室共同完成，医院感染管理科定期抽查；消毒物品每季度监测一次，灭菌物品每月监测一次，由消毒供应中心及相关使用科室与细菌室共同完成，医院感染管理科定期抽查。文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文

11、档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H

12、5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文

13、档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H

14、5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文

15、档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H

16、5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1（

17、4）紫外线消毒应进行日常监测、灯管照射强度监测，生物监测必要时进行，由使用科室完成。（5）医院感染病原体及其耐药性监测：检验科负责开展，并每季度进行总结分析，向院感科、医务科报告，向全院公布主要致病菌及其药敏试验结果，以指导临床合理用药。3、对医院感染发病情况实行预警管理，积极防范医院感染暴发流行，杜绝恶性院感事件的发生。落实医院感染管理小组职能，加强医院感染病例的及时报告。对发生医院感染的流行、暴发进行调查与分析，提出控制措施。拟进行一次医院感染暴发的应急演练。4、进一步加强手卫生管理加强手卫生培训、宣传与督查，各科室每月自查，院感科、医务科、护理部每季度督查和随机抽查，努力提高手卫生正确性

18、和依从性。5、加强重点部门、重点部位、重点环节、重点人群管理文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 Z

19、Q1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8

20、V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 Z

21、Q1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8

22、V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 Z

23、Q1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8

24、V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1加强手术室、产科、消毒供应中心、等重点部门院感管理，严格按要求每月检查，并对存在的问题进行整改。加强重点部位、重点环节、重点人群管理，开展风险评估，对高风险因素制定有针对性的控制措施，职能部门对科室监测情况进行定期核查指导，对存在的问题及时反馈，并提出整改建议，以降低发生医院感染的风险，提高医疗质量

25、和保证医疗安全。6、加强医务人员职业防护认真落实医务人员职业卫生防护制度及相关规定，为医务人员提供合格的防护用品，每年对院感高风险部门及医疗废物处置人员进行输血前五项检测，并对乙肝表面抗体及抗原均阴性者进行乙肝疫苗接种。继续加强职业暴露的监测，有效保障医务人员的职业安全。7、进一步加强医疗废物及污水处理的督导对医务人员及保洁员进行医疗废物管理知识培训，进一步提高认识，使医疗废物分类、收集、储存、交接等做到规范化管理。总务科负责组织污水的处理、排放工作，符合国家“污水排放标准”。文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO

26、8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W

27、1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO

28、8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W

29、1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO

30、8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W

31、1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO

32、8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W18、参与抗菌药物管理。加强一次性使用无菌医疗用品及消毒药械的管理加强医院感染知识培训根据各级各类人员医院感染知识培训要求，制定培训计划，落实培训效果追踪。加强对临床科室的督导，使之能够根据本科室的院感特点，制定培训计划，开展有针对性的培训。二、质控工作l、把医疗质量放在首位，加强医疗质量的监控和各种医疗制度的落实，实行医疗质量管理责任追究制，实施全程医疗质量管理与持续改进，保障医疗安全。继续深入开展医院管理年活动，健全医疗核心制度，建立科学管理长效机制，完善医院质量管理委员

33、会、科室质量控制小组和各级医务人员自我控制的三级质量控制体系，致力于医疗质量监控和考评，督促各项医疗制度、诊疗常规、技术操作规程的落实，进行全程医疗质量监控，进一步完善单病种质量控制，不断提高医疗质量，为广大患者提供安全、优质、高效的医疗服务，杜绝医疗事故发生。2、以“病历书写规范手册”为标准，规范病案的书写，不断提高病历的书写质量，争取病历优良率达95，消灭不合格文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2

34、S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7

35、 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2

36、S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7

37、 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2

38、S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7

39、 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2

40、S2W1病历。督促三级医师查房制度、会诊制度、首诊负责制等各项医疗制度的落实，加强医疗环节质量监控，继续完善各科质量控制量化指标管理，使医疗质量管理规范化、科学化。3、加强临床实验室室内质控和室内质控评价，提高临检质量。文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 Z

41、Q1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8

42、V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 Z

43、Q1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8

44、V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 Z

45、Q1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1文档编码:CL4B8V5B6S7 HO8H5I1K4A6 ZQ1V2C2S2W1