2017病理診斷報告質(zhì)量檢查表

1、徐州市腫瘤醫(yī)院徐州市第三人民醫(yī)院病理診斷報告書質(zhì)量檢查表科室：病理科檢查日期：2017年2月1日病理報告月份：2017年1月病理虧報告格式是否規(guī)范1分書寫內(nèi)容是否全面準(zhǔn)確1分病理診斷是否準(zhǔn)確1分病理診斷報告有無涂改1分標(biāo)本大體描述是否準(zhǔn)確1分報告時間是否5個工作日發(fā)出1分病理與臨床診斷符合情況1分有無假病理診斷報告1分是否雙簽字及審核1分簽字醫(yī)師是否與授權(quán)相符1分分?jǐn)?shù)201700275VVVVVVVVVV10201700276VVVVVVVVVV10201700277VVVVVVVVVV10201700278VVVVVVVVVV10201700279VVVVVVVVVV10201700280V

2、VVV大體描述不準(zhǔn)確VVVVV9201700281VVVVVVVVVV10201700282VVVVVVVVVV10201700283VVVVVVVVVV10201700284臨床診斷空白VVVVVVVVV9201700285VVVVVVVVVV10201700286VV7V7V7V7V7V7V7V7V710201700287VVVVVVVVVV10201700288VVVVVVVVVV10201700289VVVVVVVVVV10201700290VVVVVVVVVV10201700291VVVVVVVVVV10201700292VVVVVVVVVV10201700293VVVVVVVVVV

3、10201700294VVVVVVVVVV10201700295VVVVVVVVVV10201700296VVVVVVVVVV10201700297VVVVVVVVVV10201700298VVVVVVVVVV10201700299VVVVVVVVVV10201700300VVVVVVVVVV10201700301VVVVVVVVVV10201700302VVVVVVVVVV10201700303VVVVVVVVVV10201700304VVVVVVVVVV10合格率：96.7%100%100%100%96.7%100%100%100%100%100%質(zhì)控員評價：本月檢查30份病理報告，總體質(zhì)

4、量較好，個別存在問題，201700280為大體描述不全，201700284為臨床診斷空白，責(zé)任人詹世寧，需在核對報告時仔細(xì)，嚴(yán)格遵守報告規(guī)范。簽名：科主任點(diǎn)評：整體情況較好，達(dá)到質(zhì)控指標(biāo)要求，個別病例大體描述不全，項(xiàng)目漏填，需責(zé)任到人，核對報告時仔細(xì)準(zhǔn)確。簽名：備注：“r”表示該質(zhì)量符合，“數(shù)字”表示該質(zhì)量問題分?jǐn)?shù)徐州市腫瘤醫(yī)院徐州市第三人民醫(yī)院病理診斷報告書質(zhì)量檢查表科室：病理科檢查日期：2017年3月1日病理報告月份：2017年2月、項(xiàng)目病理號'報告格式是否規(guī)范1分書寫內(nèi)容是否全面準(zhǔn)確1分病理診斷是否準(zhǔn)確1分病理診斷報告有無涂改1分標(biāo)本大體描述是否準(zhǔn)確1分報告時間是否5個工作日發(fā)出

5、1分病理與臨床診斷符合情況1分有無假病理診斷報告1分是否雙簽字及審核1分簽字醫(yī)師是否與授權(quán)相符1分分?jǐn)?shù)201701128VVVVVVVVVV10201701129VVVVVVVVVV10201701130VVVVVVVVVV10201701131VVVVV退發(fā)報告VVVV9201701132V7V7V7V7V7V7V7V7V7V710201701133VVVVVVVVVV10201701134VVVVVVVVVV10201701135VVVVVVVVVV10201701136VVVVVVVVVV10201701137VVVVVVVVVV10201701138VVVVVVVVVV10201701

6、139VVVVVVVVVV10201701140VVVVVVVVVV10201701141VVVVVVVVVV10201701142VVVVVVVVVV10201701143VVVVVVVVVV10201701144VVVVVVVVVV10201701145VVVVVVVVVV10201701146VVVVVVVVVV10201701147VV-v-VVVVv-VV10201701148VVVVVVVVVV10201701149VVVVVVVVVV10201701150VVVVVVVVVV10201701151VVVVVVVVVV10201701152VVVVVVVVVV10201701153

7、VVVVVVVVVV10201701154V7V7V7V7V7V7V7V7V7V710201701155VVVVVVVVVV10201701156VVVVVVVVVV10201701157VVVVVVVVVV10合格率：100%100%100%100%100%96.7%100%100%100%100%質(zhì)控員評價：本月常規(guī)病理報告整體質(zhì)量較好，達(dá)到指標(biāo)要求，但201701131為退發(fā)報告，原因?yàn)檠a(bǔ)取胎盤絨毛，退發(fā)報告，責(zé)任人杜麗，需與臨床醫(yī)師及時溝通說明原因，并且盡量避免補(bǔ)取。簽名：科主任點(diǎn)評：常規(guī)病理報告質(zhì)量較好，個別報告退發(fā)，需做好與臨床的溝通工作，并且取材要規(guī)范，盡量避免補(bǔ)充取材。簽名：備

8、注：“r”表示該質(zhì)量符合，“數(shù)字”表示該質(zhì)量問題分?jǐn)?shù)徐州市腫瘤醫(yī)院徐州市第三人民醫(yī)院病理診斷報告書質(zhì)量檢查表科室：病理科檢查日期：2017年4月1日病理報告月份：2017年3月項(xiàng)目病理號'報告格式是否規(guī)范1分書寫內(nèi)容是否全面準(zhǔn)確1分病理診斷是否準(zhǔn)確1分病理診斷報告有無涂改1分標(biāo)本大體描述是否準(zhǔn)確1分報告時間是否5個工作日發(fā)出1分病理與臨床診斷符合情況1分有無假病理診斷報告1分是否雙簽字及審核1分簽字醫(yī)師是否與授權(quán)相符1分分?jǐn)?shù)201702270VVVVVVVVVV10201702271VVVVVVVVVV10201702272VVVVVVVVVV10201702273VVVVVVVVVV

9、10201702274VVVVVVVVVV10201702275VVVVVVVVVV10201702276VVVVVVVVVV10201702277VVVVVVVVVV10201702278標(biāo)本名稱不全VVVVVVVVV9201702279VVVVVVVVVV10201702280VVVVVVVVVV10201702281VVVVVVVVVV10201702282VVVVVVVVVV10201702283VVVVVVVV10201702284VVVVVVVVVV10201702285VVVVVVVVVV10201702286VVVVVVVVVV10201702287VVVVVVVVVV1020

10、1702288VVVVVVVVVV10201702289VVVVVVVVVV10201702290V7V7V7V7V7V7V7V7V7V710201702291VVVVVVVVVV10201702292VVVVVVVVVV10201702293VVVVVVVVVV10201702294VVVVVVVVVV10201702295VVVVVVVVVV10201702296VVVVVVVVVV10201702297VVVVVVVVVV10201702298VVVVVVVVVV10201702299VV-v-VVVVv-VV10合格率：96.7%100%100%100%100%100%100%100%

11、100%100%質(zhì)控員評價：本月抽查常規(guī)病理報告30份，其中一份201702278為標(biāo)本名稱不全，“右前哨淋巴結(jié)”寫成了“右前哨”，責(zé)任人杜麗，在核對報告時需仔細(xì)，嚴(yán)格遵守報告規(guī)范。簽名：科主任點(diǎn)評：本月常規(guī)病理報告整體情況良好，無退發(fā)報告現(xiàn)象,寫/、規(guī)范問題，需責(zé)任到人，仔細(xì)核對報告。簽名：但存在標(biāo)本名稱書備注：“r”表示該質(zhì)量符合，“數(shù)字”表示該質(zhì)量問題分?jǐn)?shù)徐州市腫瘤醫(yī)院徐州市第三人民醫(yī)院病理診斷報告書質(zhì)量檢查表科室：病理科檢查日期：2017年5月2日病理報告月份：2017年4月項(xiàng)目病理號'、報告格式是否規(guī)范1分書寫內(nèi)容是否全面準(zhǔn)確1分病理診斷是否準(zhǔn)確1分病理診斷報告有無涂改1分標(biāo)

12、本大體描述是否準(zhǔn)確1分報告時間是否5個工作日發(fā)出1分病理與臨床診斷符合情況1分有無假病理診斷報告1分是否雙簽字及審核1分簽字醫(yī)師是否與授權(quán)相符1分分?jǐn)?shù)201703500VVVVVVVVVV10201703501VVVVVVVVVV10201703502VVVVVVVVVV10201703503VVVVVVVVVV10201703504VVVVVVVVVV10201703505VVVVVVVV未審核V9201703506VVVVVVVVVV10201703507VVVVV退發(fā)報告VVVV9201703508VVVVVVVVVV10201703509VVVVVVVVVV10201703510VVV

13、VVVVVVV10201703511VVVV大體描述不準(zhǔn)確VVVVV9201703512V7V7V7V7V7V7V7V7V710201703513VVVVVVVVVV10201703514VVVVVVVVVV10201703515VVVVVVVVVV10201703516VVVVVVVVVV10201703517VVVVVVVVVV10201703518VVVVVVVVVV10201703519VVVVVVVVVV10201703520VVVVVVVVVV10201703521VVVVVVVVVV10201703522VVVVVVVVVV10201703523VVVVVVVVVV1020170

14、3524VVVVVVVVVV10201703525VVVVVVVVVV10201703526VVVVVVVVVV10201703527VVVVVVVVVV10201703528VVVVVVVVVV10201703529VVVV|V7|VV7|V7V10合格率：100%100%100%100%96.7%96.7%100%100%96.7%100%質(zhì)控員評價：檢查30份病理報告，達(dá)到指標(biāo)要求，但存在問題較多，201703505有雙簽字，但未在電腦病理系統(tǒng)審核，201703507為疑難病例，退發(fā)報告，201703511大體描述中為“直徑0.5cm”寫成了“直0.5cm”，責(zé)任人卓靜、李家。需在核對報

15、告時仔細(xì)，及時審核，記錄員在記錄取材大體描述時仔細(xì)認(rèn)真?？浦魅吸c(diǎn)評：本月筒問題較多，對于未審核及大體描述記錄不規(guī)范本可避免，任到人，加強(qiáng)培訓(xùn)，對工作嚴(yán)格要求。需責(zé)簽名：簽名:備注：表示該質(zhì)量符合，“數(shù)字”表示該質(zhì)量問題分?jǐn)?shù)徐州市腫瘤醫(yī)院徐州市第三人民醫(yī)院病理診斷報告書質(zhì)量檢查表科室：病理科檢查日期：2017年6月1日病理報告月份：2017年5月項(xiàng)目病理號'報告格式是否規(guī)范1分書寫內(nèi)容是否全面準(zhǔn)確1分病理診斷是否準(zhǔn)確1分病理診斷報告有無涂改1分標(biāo)本大體描述是否準(zhǔn)確1分報告時間是否5個工作日發(fā)出1分病理與臨床診斷符合情況1分有無假病理診斷報告1分是否雙簽字及審核1分簽字醫(yī)師是否與授權(quán)相符1

16、分分?jǐn)?shù)201704620VVVVVVVVVV10201704621VVVVVVVVVV10201704622VVVVVVVV未審核V9201704623VVVVVVVVVV10201704624V7V7V7V7V7V7V7V7V7V710201704625VVVVVVVVVV10201704626VVVVVVVVVV10201704627VVVVVVVVVV10201704628VVVVVVVVVV10201704629VVVVVVVVVV10201704630VVVVVVVVVV10201704631VVVVVVVVVV10201704632VVVVVVVVVV10201704633VVVV

17、VVVVVV10201704634VVVVVVVVVV10201704635VVVVVVVVVV10201704636VVVVVVVVVV10201704637VVVVVVVVVV10201704638VVVVVVVVVV10201704639VV-v-VVVVv-VV10201704640VVVVVVVVVV10201704641VVVVVVVVVV10201704642VVVVVVVVVV10201704643VVVVVVVVVV10201704644VVVVVVVVVV10201704645VVVVVVVVVV10201704646V7V7V7V7V7V7V7V7V7V710201704

18、647VVVVVVVVVV10201704648VVVVVVVVVV10201704649VVVVVVVVVV10合格率：100%100%100%100%100%100%100%100%96.7%100%質(zhì)控員評價：檢查30份病理報告，達(dá)到指標(biāo)要求，個別存在問題，201704622為有雙簽字，但是未在電腦中審核，責(zé)任人杜麗，以后需避免此類問題。簽名：科主任點(diǎn)評：本月有一例未在電腦審核，需責(zé)任到人，避免再次發(fā)生，本月整體情況良好，需繼續(xù)保持。簽名：備注：“r”表示該質(zhì)量符合，“數(shù)字”表示該質(zhì)量問題分?jǐn)?shù)徐州市腫瘤醫(yī)院徐州市第三人民醫(yī)院病理診斷報告書質(zhì)量檢查表科室：病理科檢查日期：2017年7月1日

19、病理報告月份：2017年6月項(xiàng)目病理丹報告格式是否規(guī)范1分書寫內(nèi)容是否全面準(zhǔn)確1分病理診斷是否準(zhǔn)確1分病理診斷報告有無涂改1分標(biāo)本大體描述是否準(zhǔn)確1分報告時間是否5個工作日發(fā)出1分病理與臨床診斷符合情況1分有無假病理診斷報告1分是否雙簽字及審核1分簽字醫(yī)師是否與授權(quán)相符1分分?jǐn)?shù)201705870VVVVVVVVVV10201705871VVVVVVVVVV10201705872VVVVVVVVVV10201705873VVVVVVVVVV10201705874VVVVVVVVVV10201705875格式不規(guī)范VVVVVVVVV9201705876VVVVVVVVVV10201705877VV

20、VVVVVVVV10201705878VV-VVVVVv-VV10201705879VVVVVVVVVV10201705880VVVVVVVVVV10201705881VVVVVVVVVV10201705882VVVVVVVVVV10201705883VVVVVVVVVV10201705884VVVVVVVVVV10201705885VVVVVVVVVV10201705886VVVVVVVVVV10201705887V7V7V7V7V7V7V7V7V7V710201705888VVVVVVVVVV10201705889VVVVVVVVVV10201705890VVVVVVVVVV1020170

21、5891VVVVVVVVVV10201705892VVVVVVVVVV10201705893VVVVVVVVVV10201705894VVVVVVVVVV10201705895VVVVVVVVVV10201705896VVVVVVVVVV10201705897VVVVVVVVVV10201705898VVVVVVVVVV10201705899VVVVVVVVVV10合格率：96.7%100%100%100%100%100%100%100%100%100%質(zhì)控員評價：檢查30份病理報告，達(dá)到指標(biāo)要求，個別存在問題，201705875為全子宮及雙附件切除標(biāo)本，病理報告中有3項(xiàng)內(nèi)容，但序號為1.2.

22、4,為格式錯誤，責(zé)任人詹世寧，診斷醫(yī)師以后需避免此類問題，嚴(yán)格核對報告。簽名：科主任點(diǎn)評：本月整體情況良好，報告都能及時準(zhǔn)確發(fā)出，但是存在核對不仔細(xì)，報告不規(guī)范問題，診斷醫(yī)師在核對報告時需仔細(xì)認(rèn)真，嚴(yán)格要求。簽名：備注：“r”表示該質(zhì)量符合，“數(shù)字”表示該質(zhì)量問題分?jǐn)?shù)徐州市腫瘤醫(yī)院徐州市第三人民醫(yī)院病理診斷報告書質(zhì)量檢查表科室：病理科檢查日期：2017年9月1日病理報告月份：2017年8月項(xiàng)目病理號'報告格式是否規(guī)范1分書寫內(nèi)容是否全面準(zhǔn)確1分病理診斷是否準(zhǔn)確1分病理診斷報告有無涂改1分標(biāo)本大體描述是否準(zhǔn)確1分報告時間是否5個工作日發(fā)出1分病理與臨床診斷符合情況1分有無假病理診斷報告1

23、分是否雙簽字及審核1分簽字醫(yī)師是否與授權(quán)相符1分分?jǐn)?shù)201707830201707831201707832201707833201707834201707835201707836201707837201707838201707839201707840201707841201707842201707843201707844201707845201707846201707847201707848201707849201707850201707851201707852201707853201707854201707855201707856201707857201707858201707859合格率：

24、質(zhì)控員評價：科主任點(diǎn)評：簽名：簽名：備注：“r”表示該質(zhì)量符合，“數(shù)字”表示該質(zhì)量問題分?jǐn)?shù)徐州市腫瘤醫(yī)院徐州市第三人民醫(yī)院病理診斷報告書質(zhì)量檢查表科室：病理科檢查日期：2017年10月6日病理報告月份：2017年月項(xiàng)目病理號報告格式是否規(guī)范1分書寫內(nèi)容是否全面準(zhǔn)確1分病理診斷是否準(zhǔn)確1分病理診斷報告有無涂改1分標(biāo)本大體描述是否準(zhǔn)確1分報告時間是否5個工作日發(fā)出1分病理與臨床診斷符合情況1分有無假病理診斷報告1分是否雙簽字及審核1分簽字醫(yī)師是否與授權(quán)相符1分分?jǐn)?shù)201708396VVVVVVVVVV10201708397VVV7VVV7VV7VV10201708398VVVVVVVVVV1020

25、1708399VVVVVVVVVV10201708400VVVVVVVVVV10201708401VVVVVVVVVV10201708402VVVVVVVVVV10201708403VVVVVVVVVV10201708404VVVVVVVVVV10201708405VV°VVVVVVV10201708406VVVVVVVVVV10201708407VVVVVVVVVV10201708408VVVVVVVVVV10201708409標(biāo)本名稱不全VVVVVVVVV9201708410VVVVVV病理與臨床診斷不一致VVV9201708411VVVVVVVVVV10201708412VVV

26、VVVVVVV10201708413VVVVVVVVVV10201708414VVVVVVVVVV10201708415VVVVVVVVVV10201708416VVVVVVVVVV10201708417VVVVVVVVVV10201708418V7V7V7V7V7V7V7V7V7V710201708419VVVVVVVVVV10201708420VVVVVVVVVV10201708421VVVVVVVVVV10201708422VVVVVVVVVV10201708423VVVVVVVVVV10201708424VVVVVVVVVV10201708425VVVVVVVVVV10合格率：96.7

27、%100%100%100%100%100%96.7%100%100%100%質(zhì)控員評價：檢查30份病理報告，達(dá)到指標(biāo)要求，個別存在問題，201708409標(biāo)本名稱未寫全，201708410病理診斷與常規(guī)診斷不一致，臨床醫(yī)師在填寫申請單還需注意，病理科及時與臨床及時溝通。簽名：科主任點(diǎn)評：本月整體情況良好，報告都能及時準(zhǔn)確發(fā)出，診斷醫(yī)師在核對報告時需仔細(xì)認(rèn)真，嚴(yán)格要求。簽名：備注：“r”表示該質(zhì)量符合，“數(shù)字”表示該質(zhì)量問題分?jǐn)?shù)徐州市腫瘤醫(yī)院徐州市第三人民醫(yī)院病理診斷報告書質(zhì)量檢查表科室：病理科檢查日期：2016年2月1日病理報告月份：2016年1月項(xiàng)目病理號'報告格式是否規(guī)范1分書寫內(nèi)

28、容是否全面準(zhǔn)確1分病理診斷是否準(zhǔn)確1分病理診斷報告有無涂改1分標(biāo)本大體描述是否準(zhǔn)確1分報告時間是否5個工作日發(fā)出1分病理與臨床診斷符合情況1分有無假病理診斷報告1分是否雙簽字及審核1分簽字醫(yī)師是否與授權(quán)相符1分分?jǐn)?shù)201600660VVVVVVVVVV10201600661VVVVVVVVVV10201600662VVVVVVVVVV10201600663VVVVVVVVVV10201600664VVVVVVVVVV10201600665VVVVVVVVVV10201600666-VVVVVVVv-VV10201600667VVVVVVVVVV10201600668VVVVVVVVVV1020

29、1600669VVVVVVVVVV10201600670VVVVVVVVVV10201600671VVVVVVVVVV10201600672VVVVVVVVVV10201600673VVVVVVVVVV10201600674V7V7V7V7V7V7V7V7V7V710201600675VVVVVVVV未審核V9201600676VVVVVVVVVV10201600677VVVVVVVVVV10201600678VVVVVVVVVV10201600679VVVVVVVVVV10201600680VVVVVVVVVV10201600681VVVVVVVVVV10201600682VVVVVVVVV

30、V10201600683VVVVVVVVVV10201600684VVVVVVVVVV10201600685VVVVVVVVVV10201600686VVVVVVVVVV10201600687VVVVVVVVVV10201600688VVVVVVVVVV10201600689V7V7VV7V7VV7V7V7V710合格率：質(zhì)控員評價：簽名：科主任點(diǎn)評：簽名：備注：“r”表示該質(zhì)量符合，“數(shù)字”表示該質(zhì)量問題分?jǐn)?shù)徐州市腫瘤醫(yī)院徐州市第三人民醫(yī)院病理診斷報告書質(zhì)量檢查表科室：病理科檢查日期：2016年3月1日病理報告月份：2016年2月項(xiàng)目病理號'報告格式是否規(guī)范1分書寫內(nèi)容是否全面準(zhǔn)確1

31、分病理診斷是否準(zhǔn)確1分病理診斷報告有無涂改1分標(biāo)本大體描述是否準(zhǔn)確1分報告時間是否5個工作日發(fā)出1分病理與臨床診斷符合情況1分有無假病理診斷報告1分是否雙簽字及審核1分簽字醫(yī)師是否與授權(quán)相符1分分?jǐn)?shù)201601170VVVVVVVVVV10201601171VVVVVVVVVV10201601172VVVVVVVVVV10201601173VVVVVVVVVV10201601174VVVVVVVVVV10201601175VVVVVVVVVV10201601176VVVVVVVVVV10201601177V7V7V7V7V7V7V7V7V7V710201601178VVVVVVVVVV1020

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