2022年医疗质量分析和持续改进总结分析2 .pdf

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1、_ 精品资料2017 年 6 月医疗质量分析与持续改进本月医务科分别组织对全院各临床医技科室进行了医疗安全质量抽查，其中抽查了抽查运行病历110 份，出院病历39 份；门诊病历 27 份。检查工程包括运行病历质量、出院病历质量、门诊病历质量、科室管理质量、临床药品合理应用、危急值专项、临床用血安全专项、医保制度执行等。检查结果已于OA 上发至各科室，并发放不合格质量反馈表11 份，督促科室加强整改，在科主任护士长例会上进行了通报及质量分析。一、本月医疗质量存在问题主要集中在以下方面：共性问题：出院病历资料打印不及时；门诊病历书写不规范；医院评审资料准备不全。较突出问题：1、个别外科病历，手术安

2、全相关制度执行不到位，不能按照规定执行三方核查（ID00061197，）；手术知情同意书未签署日期ID0025599。2、医嘱取消不规范，已执行的医嘱不能取消。3、会诊病人管理方面：本月共申请急会诊0 例，常规会诊病例74 例。完成常规会诊72 例，因患者原因取消会诊2 例。会诊超时14 例：其中外科 3 例，口腔科 4 例，中医科 2 例，妇产科 2 例，皮肤科 1 例，急诊 1 例，内二科 1 例，会诊合格率82%。4、因 病 历 资 料 打 印 不 及 时 导 致 病 历 召 回。ID00038309,00057770，ID00006593，ID00011006._ 精品资料5、存在医患

3、沟通方面问题的病例较上月明显减少，但个别病例存在以下问题：知情同意书忘记签署沟通时间，ID00049180；有的医生忘记签字，患者先签字。6、药占比本月为 34.94%，控制目标值为40%，降低 5.06%；二、根据信息科本月汇总的质量目标完成情况分析：本月质量目标已基本完成。床位使用率为68.9%，低于目标值85%-95%。主要是由于医院住院患者相对较少，导致床位使用率较低。药占比本月为34.94%，控制目标值为40%，降低 5.06%；各科室临床医师药占比均不超标。其余各项指标均达到质量目标要求。三、针对以上存在问题，分析原因及制定整改措施如下：（一）、通过对医疗卫生专业技术人员进行医疗风

4、险意识及医患沟通知识培训，本月在医患沟通方面存在的问题较上月明显减少，且没有出现因沟通不到位引起的医疗纠纷，但个别医生仍存在不够注重沟通细节，如沟通时间及签字问题，在今后的工作中需注意加强督导。（二）、针对手术安全管理方面，本月的检查结果不容乐观，存在手术科室临床医生对核心制度执行不到位的问题，特别是手术安全核查、手术风险评估、知情同意书的签署方面，分析原因：主要为外科临床医师责任心不强，风险意识及防范意识较差。改进措施：组织对外科系医务人员进行手术安全相关制度的培训，提高风险防范意识，并加强监督考核。（三）关于会诊制度执行情况，存在的问题如下：文档编码:CM1E7W4I8Y6 HK10B3D

5、4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7

6、ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L

7、10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7

8、文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:C

9、M1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4

10、I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 H

11、K10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7_ 精品资料1、本月各科会诊情况，从下图可以看出：参加会诊较多的科室主要为康复医学科、中医科，其次为口腔科、皮肤科，内科系较少，这与我院收治病人的病种结构特点有关，我院收治病人以内科病人为主，跨专业科室间会诊，也会表

12、现为内科系以外的科室，如康复及中医理疗科室。6月份各科会诊例数分布康复科43%外科7%口腔科12%皮肤科9%中医科16%内三科1%内二科3%妇产科5%五官科3%急诊科1%2、本月各科会诊完成情况，从海泰电子病历系统统计的数据来看，本月统计数据不是很好，详见下图。主要表现为常规会诊不能及时完成，经向各相关科室调查分析，得知主要原因为，我院目前刚开始使用海泰病历系统传输会诊信息的1 月，个别医生对会诊病例系统操作不熟练，在实际完成会诊后，没有及时从病历系统上提交会诊意见导致，导致全院常规会诊合格率为82%。会诊次数越多的科室，合格率越高，如康复科、五官科。而急诊科、内三科仅会诊了1 例，因操作不熟

13、练导致没有及时确认，使不合格率偏高。将存在文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3

14、M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1

15、T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P

16、5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编

17、码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E

18、7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y

19、6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7_ 精品资料的问题及改进措施通过向相关科室针对性督导，加以改正，使会诊质量持续改进。6月份会诊完成情况0%20%40%60%8

20、0%100%120%五官科康复科皮肤科中医科口腔科妇产科内二科外科内三科急诊科全院科室百分比不合格率合格率四、回顾今年年上半年的医疗质量统计数据，分析如下：1、上半年每月平均住院日情况分析：（1）、全院平均住院日情况如下：2017 年上半年平均住院天数月份一月二月三月四月五月六月平均住院日（日）11.1 10.1 10.8 11.1 11 10.4 文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5

21、X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码

22、:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7

23、W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6

24、 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B

25、3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M

26、7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T

27、7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7_ 精品资料2017年上半年全院平均住院日情况9.69.81010.210.410.610.81111.2一月份二月份三月份四月份五月份六月份月份平均住院日平均住院日通过上表可以看出，平均住院天数是呈整体下降趋势。2 月份平均住院日低的明显，主要因为春节的原因。其他月份也呈整体下降趋势。（2）上半年各病区平均住院日情况：0.002.004.006.008.0010.0012.0014.0016.00平均住院日九病

28、区十病区七病区五病区全院一病区八病区三病区四病区口腔科二病区五官科 科室2017年上半年各病区平均住院日文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10

29、P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档

30、编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1

31、E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8

32、Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK1

33、0B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F

34、3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7_ 精品资料2、上半年的住院病人的均次费用情况分析：平均住院费用

35、有波动，但是从整体上看是有明显的下降趋势，7月份和 9 月份略有增加，分析其原因是因为7 月份和 9 月份收治了多科治疗的病人，并有多发性骨折的病人。3、不重视沟通工作繁忙，沟通走形沟通不及时制度不完善医护人员用专业术语重病情沟通，轻情感沟忽视了患者知情权重医院沟通，轻出院后沟通考核力度不够风险防范意识差理解能力差请假离院，重口头沟通，轻书面沟沟通内容不全面医患沟通不到位原因分析培训效果欠佳文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK

36、10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4

37、F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 Z

38、G1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L1

39、0P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文

40、档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM

41、1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I

42、8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7_ 精品资料2、加强医患沟通到位的具体措施：对医护人员加强风险意识培训，医患沟通知识培训；加强医患沟通制度落实，改进知情同意书模板；改进沟通方式，讲究沟通技巧，语言通俗易懂，及时有效与患者做好沟通；职能部门加强对医患沟通的督导检查，加大考核力度。（二）、违反合理用药的问题，药剂科管理小组已进行具体分析。加强医患沟通到位的措施医护人员培训制 度 落 实监 督沟通方式加强医患

43、沟通培训改进知情同意书模板加强制度落实讲究沟通技巧职能部门加强督导检查语言通俗易懂加强风险意识培训患 者沟通方式及时有效沟通加大考核力度文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B

44、3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M

45、7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T

46、7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5

47、X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码

48、:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7

49、W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7文档编码:CM1E7W4I8Y6 HK10B3D4F3M7 ZG1T7L10P5X7_ 精品资料（三）、手术安全质量

50、问题分析本月抽查病历中，外科系病历15 份，存在医疗质量问题的3份，占 20%，其中手术患者沟通不到位的3 例，为没有告知患者可能承担的风险，没有提供不同的治疗方案供患者选择，及对术后可能出现的并发症等没有及时告知等。病程记录不及时的2 例，手术日期与记录日期矛盾者1 例，术前小结对患者病情分析不到位者1例，具体如下图所示：00.511.522.53知情同意书不规范病程记录不及时手术记录日期错误术前小结不规范手术病例质量问题统计手术病例质量问题统计例数分析以上问题原因，主要为外科医师责任心不强，核心制度执行不到位，没有风险防范意识，对患者病情没有全面认识，分析不到位，考虑欠周全，预见性较差。在