醫(yī)院規(guī)章制度匯編（門診管理）

醫(yī)院規(guī)章制度匯編（門診管理）1

第1頁共127頁

最新醫(yī)院規(guī)章制度匯編

（門診治理）

12023年年88月月616日

第2頁共127頁

名目第十一章門診治理....................................................................................6門診工作制度......................................................................................6門診護(hù)理工作制度..............................................................................7門診部會(huì)議制度..................................................................................8門診宣教工作制度..............................................................................8門診統(tǒng)計(jì)工作制度..............................................................................9門診首診負(fù)責(zé)制..................................................................................9門診會(huì)診、轉(zhuǎn)診制度........................................................................11門診疑難病例爭(zhēng)論制度....................................................................12專家門診治理制度............................................................................13門診病歷書寫標(biāo)準(zhǔn)............................................................................13門診處方書寫標(biāo)準(zhǔn)............................................................................15疫情報(bào)告規(guī)定....................................................................................16傳染病疫情信息的登記、報(bào)告........................................................17規(guī)劃免疫工作制度............................................................................19門診注射室工作制度........................................................................20心理詢問門診工作制度....................................................................21康復(fù)醫(yī)學(xué)科工作制度........................................................................22中醫(yī)科工作制度................................................................................23養(yǎng)分科工作制度................................................................................24養(yǎng)分科工作流程................................................................................25

第3頁共127頁高壓氧療科工作制度........................................................................26氧艙應(yīng)急狀況處理規(guī)章....................................................................27安康保健中心工作制度....................................................................28安康體檢中心工作制度....................................................................29胃鏡室工作制度................................................................................30痛苦科工作制度................................................................................33痛苦科工作原則................................................................................34痛苦科治療室工作制度....................................................................36痛苦科治療室查對(duì)制度....................................................................38血液凈化科治理................................................................................39血液凈化科工作制度..................................................................39血液凈化科質(zhì)量掌握制度..........................................................40血液凈化科感染治理制度..........................................................41透析器復(fù)用清洗消毒滅菌操作流程..........................................44血液凈化科水處理間的維護(hù)制度..............................................45血液凈化科設(shè)備修理保養(yǎng)制度..................................................45生殖醫(yī)學(xué)科治理................................................................................46生殖醫(yī)學(xué)科工作制度..................................................................46工作人員行為準(zhǔn)則......................................................................48實(shí)施幫助生殖技術(shù)（ART）技術(shù)人員行為準(zhǔn)則........................49人類幫助生殖技術(shù)倫理原則......................................................50各級(jí)人員工作制度......................................................................54

第4頁共127頁臨床質(zhì)量掌握制度......................................................................61科室自查制度..............................................................................62生殖醫(yī)學(xué)科保密制度..................................................................63ART病歷書寫制度.......................................................................64病歷爭(zhēng)論制度..............................................................................65病例隨訪制度..............................................................................69患者知情同意制度......................................................................71培訓(xùn)制度......................................................................................72接觸配子、胚胎的試驗(yàn)室試劑、材料質(zhì)掌握度......................73特別藥品治理制度......................................................................74病案治理制度..............................................................................75醫(yī)療登記、統(tǒng)計(jì)制度..................................................................84病案統(tǒng)計(jì)室制度..........................................................................85儀器治理制度..............................................................................85材料治理制度..............................................................................87證件復(fù)印制度..............................................................................88ART后代身份確認(rèn)制度...............................................................91參觀制度......................................................................................92安全制度......................................................................................93ART試驗(yàn)室治理...........................................................................93男科試驗(yàn)室治理..........................................................................97檔案工作治理制度....................................................................102

第5頁共127頁檔案收集整理歸檔制度............................................................103檔案保管制度............................................................................104檔案保密制度............................................................................105隱秘文件治理制度....................................................................106檔案查閱、借閱利用制度........................................................107檔案統(tǒng)計(jì)制度............................................................................108檔案庫房治理制度....................................................................109檔案鑒定銷毀制度....................................................................110設(shè)備檔案治理制度....................................................................112科研檔案治理制度....................................................................113聲像檔案治理制度....................................................................114生殖醫(yī)學(xué)科消毒隔離制度........................................................115感染性疾病科治理..........................................................................119感染性疾病科工作制度............................................................119感染性疾病科防護(hù)制度............................................................121感染性疾病科預(yù)檢分診制度....................................................121發(fā)熱病人接診制度....................................................................122感染性疾病科留觀制度............................................................123感染性疾病科病房的治理制度................................................124感染性疾病科消毒隔離制度....................................................125

第6頁共127頁

第十一章門診治理

門診工作制度

一、在分管院長(zhǎng)領(lǐng)導(dǎo)下，科主任應(yīng)加強(qiáng)對(duì)本科門診的業(yè)務(wù)技術(shù)領(lǐng)導(dǎo)和行政治理。

二、對(duì)疑難病癥兩次復(fù)診仍不能確診者，應(yīng)準(zhǔn)時(shí)請(qǐng)上級(jí)醫(yī)師診視。

三、在本院有條件診治的狀況下，不得隨便向院外介紹和轉(zhuǎn)診病人。

四、接診病人要仔細(xì)負(fù)責(zé)，根據(jù)省衛(wèi)生廳規(guī)定的格式記載門診病歷，門診部定期檢查。

五、門診檢查科室所做各種檢查結(jié)果，必需做到精確、準(zhǔn)時(shí)。

六、門診各科應(yīng)與病房加強(qiáng)聯(lián)系，以便依據(jù)病人病情安排病床，使病人準(zhǔn)時(shí)得到救治。

七、做好分診工作，嚴(yán)格消毒隔離制度，防止穿插感染，做好疫情報(bào)告。

八、門診工作人員要做到主動(dòng)熱忱效勞，關(guān)懷愛護(hù)病人，急躁解答問題，簡(jiǎn)化效勞流程。

九、門診醫(yī)師應(yīng)合理檢查，合理用藥，盡可能減輕病人的負(fù)擔(dān)。

十、門診醫(yī)師工作期間不得飲酒，在院區(qū)內(nèi)制止抽煙，

第7頁共127頁接診病人時(shí)不得接聽手機(jī)。

十一、門診各科依據(jù)本專業(yè)特點(diǎn)，建立必要的規(guī)章制度、各種診療常規(guī)、操作規(guī)程以及崗位職責(zé)，并仔細(xì)做好登記、統(tǒng)計(jì)上報(bào)等工作。

十二、門診各科室醫(yī)