急诊系统质量考核标准.doc

these precious and worth cherishing. Second, scientific research situation, grasp the opportunities and challenges of transformation and upgrading of full completion of the "Thirteen-Five" development tasks, start is crucial. Focused grand blueprint, must to history of thinking views trend, put associate times forward of pulse, stepped on associate economic law of drums, find associate transformation upgrade of path, in grasp macro trend in the advance science development; to strategy of vision conspiracy to global, always tight buckle national macro policy oriented, accurate grasp County love actual, based overall caught opportunities, and PCT thought, ensure County economic social development always along right track continued forward; to precision of measures seeking breakthrough, tightly pegged focus task and bottleneck restricted, Science and identify practical and effective measures, advance breakthrough, ensuring all tasks carry out to the letter; based on scientific assessment and strict implementation, persist in combining routine supervision and centralized supervision, accurate assessment Township departments, strictly cash rewards, prompted the departments own implementation at all levels. In working to advance, to truly grasp the Guide, seize the opportunity, finding a position and play to our strengths and take the initiative, ensure that the start of the new year tree, new performance. Grasp the Guide, is to dock in policy measures to seize the initiative. Accurate grasp of the Central Government, provinces and cities to speed up the development of new policies and new initiatives with a high degree of policy acumen to capture opportunities to accelerate development. Follow-up to promote the transformation and upgrading of the five great ideas offer a great chance. Five large development philosophy is the Party Central Committee with a view to promote economic transformation and upgrading, complete the building of a well-off society in major decisions and arrangements, is the development of a profound change. County-wide at all levels should conscientiously study and implement, implement the five ideas, green development, open development, on which to share advantages, and actively explore new path of innovative and coordinated development, changing the concept of leading the transformation of development mode of development, promote the development of quality improvement. Floor supply side structural reform implementation provides an effective strategy for improving the quality of development. Supply side structural reform is future full deepening reform of plays, to according to "macro policy to stability, and industry policy to associate, and micro policy to live, and reform policy to real, and social policy to backing" of requirements, keen grasp Central, and provinces release out of new signal, combined County love actual accurate docking, full grasp "to capacity, and to inventory, and to lever, and drop cost, and fill short Board" five big focus task implementation, prompted County economic transformation upgrade, and continued upgrade. Poverty 急诊系统质量考核标准（280） 一、指标评价 二、医疗质量 三、医疗制度 一、指标评价（41） 考核内容 分 值 扣分原因 1、急诊病历等文件书写甲级率≥90% 3 每下降1%扣1分 2、医疗医技操作合格率≥95% 3 每下降1%扣1分 3、入出院诊断符合率≥95% 3 每下降1%扣1分 4、急诊危重症抢救成功率≥85% 4 每下降1%扣1分 5、对非抢救患者专业分诊的准确率≥90% 3 每下降2%扣1分 6、法定传染病报告率100% 5 漏报1例扣2分 7、医院感染率≤10% 4 每上升1%扣1分 8、医院感染漏报（迟报）率~20% 4 每上升1%扣1分 9、急救物品完好率100% 3 每下降1%扣1分 10、车载抢救设备完好率100% 3 每下降1%扣1分 11、成分输血比例≥85% 3 每下降1%扣1分 12、药品费用占总费用比例≤45%（不同科室药品费用比例不同） 3 每超过2%扣1分 二、医疗质量 考核内容 分 值 扣分原因 得分 1a、门诊病历医疗质量甲级率90% 20 l份乙级病历扣2分，1份丙级病历扣10分。 1b、运行病历书写质量 首次病程8小时完成；急诊留 观察病历24小时完成： 35 未按时完成每项扣2分，每超时1份扣2分；首次病程无诊断依据、鉴别诊断、诊疗计划各扣1分；病历中主诉明显缺陷扣0.5分；体格检查缺陷、前后矛盾扣0.5分；无初步诊断扣1分、诊断缺陷扣0.5分；入院记录医疗信息未填写扣0.1分／项，入院24小时无门诊病历扣0.5务；医嘱单无签字扣0.2分／次；涂改及字迹不清难以辨认各扣0.5分／处。大病历上级医师签字不及时扣0.2分／次；缺入院48小时上级医师首次查房记录，扣0.5分／次。 2、三级查房质量 实行三级医师负责制，主任、教授 每周查房一次，主治医师每天查房，住院医师早晚查房，对危重病人随时巡视。 10 不定期抽查病人及病历查房情况、缺一次扣1分，上级医师查房无指导性意见扣0.2分，不及时签字确认扣0.2分／次。危重病人未按规定记录扣 0.5分。 3、会诊质量 危重病人院内会诊，医师5分钟到位，一般病人院内会诊，医师10分钟到位，10分钟之内对危重病人诊疗处置。 5 查申请单及会诊单、书写不合格1例扣0.5分，会诊科室会诊不及时扣0.5分／次，会诊后24小时内未执行会诊医嘱、而且未注明原因者扣0.5 分／次。 4、有创性诊疗操作质量 紧急有创性诊疗操作有批准授权程序，严格按规定执行并详细填写记录；并严格履行告知谈话、知情同意签字手续。 10 发现操作者无医院相关技术准入许可证不得分。未按规范操作1例扣5分，未按规定填写记录单1例扣0.5分。申请单无上级医师签字扣0.5分／次；并发症发生率≥2%，发生1例扣1分，超过2%，每上升1%扣1分。未履行知情告知同意并双方签字者，每项扣0.5分 5、诊疗及管理质量 医护人员熟练操作与使用抢救设备，及时向病人说明诊疗计划：诊疗方案临时改变有决定程序及病人的知情同意；特殊检查：特殊用药及治疗措施得到病人或家属的同意并签字认可；有危重及紧急意外情况的报告及处理程序、预案、员工教育、演练、科内各类各级人员紧急替代程序及有效联络途径。 20 医护人员不熟练操作与使用抢救设备每次扣0.5分：未向病人说明诊疗计划每次扣0.5分；无改变程序及知情同意扣0.5分；特殊用药及治疗措旋未征得病人或家属的同意并签字认可签字扣0.5分，次；无危重及紧急意外情况的报告及处理程序、预案、员工教育及记录各扣0.5分、无演练及记录各扣0.5分、无科内各类各级人员紧急替代程序及有效联络途径各扣0.5分。 合计 6、临床用药质量 1)合理使用抗菌素，执行《抗菌药物临床应用指导原则》及《内蒙古自治区抗菌药物分级管理实施细则》，抗菌药物分级使用，并在病历中有记录。感染病人药敏试验送 检率≥50%，并按结果调药，对严重感染的病人临床药师应参加查房及病历讨论。限制使用抗菌药 物，由主治医师以上审批、签字；特殊使用抗菌药物，需具备典型临床用药指征或有针对致病菌的特殊抗菌药物敏感的药敏报告，并具备下