住院诊疗情况分析与持续改进.pdf

住院诊疗情况分析与持续改进

AnalysisandContinuousImprovementofnDiagnosisand

TreatmentinJinniuCentralHospital

nCriteria:

1.Qualifiedphysiciansandnursesprovidestandardized

servicestopatientsinaccordancewiththesystem。res。and

assessmentresultsofthepatientsn.

2.Medicalstaffwhocarryoutassessmentshavelegalnsand

havereceivedrelevanttrainingonpatientnassessment.

3.Basedontheassessmentofthepatientsn。adiagnosisand

treatmentplanisformulatedforthepatientandregulatory

responsibilitiesarefulfilledbynaldepartments.

Continuousimprovementisnecessarytoprovide

homogenizedservicestopatients。Diseasediagnosisand

treatmentguidelinesandclinicalnguidelinesfordrugsshouldbe

followedtostandardizeclinicalns。diagnosis。treatment。useof

drugsandmedicaldevices.

nofqualitycontrolforkeydiseasesshouldbecarriedoutin

accordancewiththeseventhchapterofthisstandard。。。

departmentnsandnpathwaysforotherkeydiseases.

Clinicalnsshouldbecarriedoutstrictlyinaccordancewithns

forclinicallaboratorytests。imagingns。endoscopicns。usnal

ns。logy。pathology。andothernitems。Beforeperforming

invasivens。patientsshouldbefullyinformedandtheirconsent

obtained.

Theappropriatenessofclinicalnsshouldberegularly

analyzedandevaluated。andcontinuousimprovementshouldbe

made。Theuseandmanagementofantibacterialdrugsshouldalso

bestandardizedaccordingtorelevantnsandguidelines.

医师负责核准。

3.持续改进诊疗方案，确保医疗质量与安全。

1.每位住院患者均有适宜的诊疗计划，由上级医师负责核

准。

2.根据检查结果分析判断，适时调整诊疗方案，并分析调

整原因和背景。

3.持续改进诊疗方案，确保医疗质量与安全。同时，对存

在问题及时反馈并完善改进方案。

3.高年资主治医师负责评价和核准上述诊疗活动，并在病

历中记录。

4.诊疗方案及时与患者沟通，确保患者出院时能够得到出

院指导。

A.有多种措施保证诊疗计划的适宜性，并实施院科两级的

质量监督管理，对存在问题及时反馈。

B.监管检查有效，上级医师对诊疗方案核准率达到95%以

上。规范院内会诊管理，明确院内会诊任务，提高会诊质量和

效率。

C.有院内会诊管理相关制度和流程，