医务科针“三好一满意”活动综合考核整改报告

1、医务科针“三好一满意”活动综合考核整改报告制定整改措施如下：1、进一步完善我院医疗纠纷处理预案，在医疗纠纷处理后，通过医疗纠纷点评，对存在医疗过失行为的责任人处以经济等处罚。2、完善医务科对临床科室绩效考核方案，一是加大对病历书写、输血管理的考核力度，二是加强对合理用药、抗生素应用管理的考核力度，三是激发临床科研的积极性。3、加强门诊处方绩效考核力度，规范门诊处方书写。4、定期针对病历书写规范、合理用药及抗菌药物使用开展培训讲座。5、要求病理科按工作制度对快速冰冻切片病理报告进行登记。6、麻醉科实际开展业务学习、病例讨论，严格履行各项规章制度并有必要的记录。7、成立院科两级医疗质量与安全管理小

2、组，加强医疗质量与安全管理，并及时汇总上报医疗安全事件。8、完善医院信息化管理系统，加强其对临床路径、按病种付费、抗菌药物管理、药事管理的支持。9、按基本药物使用比例的最新标准进行统计上报工作。10、修订完善我院临床路径及按病种付费实施方案，并纳入临床科室绩效考核，每月按考核结果进行奖惩。对临床路径病种管理资料进行对比分析，持续改进病种管理。11、完善对口支援工作资料的档案管理。12、进一步加强出院患者的回访工作，强调回访内涵，并完善回访满意度的调查统计工作。检查结果：1、已完善了医疗纠纷处理方案，明确了对存在过失行为的医生的责任追究办法。2、细化了我院医务科对临床科室绩效考核方案中的运行病历

3、评分标准和诊疗规范评分标准，对病历书写、合理用药、抗菌药物合理应用等着重进行考核。3、制定了医务科对门诊诊室的绩效考核方案，对门诊病历书写、处方管理着重进行考核。4、按基本药物使用比例的最新标准对我院药品进行维护，统计上报工作基本达到了上级要求。5、病理科快速冰冻切片病理报告均已开展登记工作。6、各临床科室设立专职质控医师，对病历书写及诊疗进行科级质控管理。院级设有专职质控医师，对归档病历进行质控管理。7、医院信息化管理系统不断优化改进，已初步满足了对临床路径管理、按病种付费管理、药事管理及抗菌药物管理要求里的查询、统计功能的支持。8、每月对门诊所有处方开展点评工作，对大处方、堆砌用药、不合理

4、用药等情况按医疗质量考核方案给予处罚。9、完善了对口支援工作资料的档案管理，落实了各级对口支援工作。10、切实做好患者出院回访工作，增加医疗服务方面的回访内容。统计各科室回访满意度，并纳入科级绩效考核。qcwa3ptgz7r4i30ka1dkaghn3xtkknbycudxqa7fhyi2chhi92tgkqcwa3ptgshls50clmtwn60eo8wgqv7xav2ohum32wgeauwydiawgmer4i30ka1dkaghn3xtkknbycudxqa7fhyi2chhi92tgkqcwa3ptgz7r4i30ka1dkagtgkqcwa3p tgz7r4i30ka1dkagh

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