临汾市人民医院制度职责

1、医院制度职责目 录第一部分 工作制度第1章 党群系统第1节 党委工作制度············································

2、·1 一、 政治理论学习制度··········································3 二、 党员廉洁自律制度··

3、3;·······································4 三、 党支部三会一课制度········&#

4、183;·······························4 四、 创先争优制度················

5、83;·························8 五、 党员联系群众制度······················&#

6、183;···················8 六、 党员教育制度····························

7、83;··············9 第二节 团委工作制度·································

8、83;········10 一、 团组织生活制度·······································&#

9、183;·10 二、 学习教育制度··········································11 第三节 工会工作制度··&

10、#183;·······································12 一、 工会会员管理制度········

11、;·······························13 第四节 老干部科工作制度················&#

12、183;····················14 第五节 监察科工作制度···························

13、··········14 第六节 维权办工作制度·····································14 第

14、七节 效能办工作制度·····································15第2章 行政系统第一节 人事管理制度········

15、···································15 一、 职工请销假制度·············

16、;···························23 二、 临时工管理制度····················

17、3;···················25 三、 岗前教育制度····························

18、3;···········25 四、 离岗培训制度····································

19、3;···26 五、 关于在职职工自费脱产学习的有关规定··················28 六、 新参加工作满一年（见习期满）后转正定级有关规定······28 七、 再分配人员管理制度···········

20、83;····························28 八 关于我院中层干部民主考评工作的实施意见·················

21、83;29 第三节 教育科研制度······································30 一、 进修、实习人员管理制度······

22、83;·····························30 二、 进修、实习生管理制度··················

23、;··················31 三、 医务人员外出进修制度·····························&

24、#183;······31 四、 外出参加学术活动管理制度··································32 五、 临床住院医师规范化培训制度···

25、·····························33 六、 科研工作管理制度··················

26、3;···················34 七、 科研工作奖励办法····························&#

27、183;·········36 第四节 预防保健科工作制度··································37一、 健康教育工作制度·

28、83;································37二、 传染病管理制度···············

29、83;··················39（1） 传染病管理网络系统·····························

30、·····39（2） 传染病知识培训制度··································39（3） 法定传染病及性病······&

31、#183;···························40（4） 传染病网络直报制度···················

32、3;··············40（5） 传染病首诊负责制度·································&

33、#183;41（6） 传染病疫情报告程序··································41（7） 传染病疫情自查制度··········&

34、#183;·······················41（8） 传染病消毒隔离制度·······················

35、3;··········42（9） 传染病病例登记和转诊制度····························42（10） 不明原因肺炎会诊排查制度·····

36、83;······················42（11） 传染病预检分诊制度·························

37、;·········44（12） 住院患者传染病登记规范······························45（13） 传染病患者密切接触者管理制度····&#

38、183;···················45（14） 肺结核患者管理实施办法···························&#

39、183;··45 六、死亡病例报告制度··································46 （一） 死亡病例报告工作流程········&#

40、183;·····················46 （二） 死亡病例网络直报制度·························

41、83;·····46 七、突发公共卫生事件制度·······························47 （一）突发公共卫生事件报告制度········

42、·······················48 （二）突发公共事件报告程序和时限························

43、;·····48 八、职工保健制度··································48 （一）医院职工保健制度······

44、3;····························48 （二）医院工作人员发生锐器刺伤的应急处理原则···············48第6节 信息管理制度

45、83;··································49 一、 病案管理制度·············

46、83;·····················51 二、 病历借阅制度··························

47、83;········51 三、 病历复印制度···································51 四、 医疗登记、统计管理制度·

48、3;·································52 五、 图书、期刊借阅制度··············&

49、#183;····················53 六、 电子阅览室管理制度··························

50、3;········54 七、 读者守则···································54第7节 财务管理制度···

51、································551、 物价收费管理制度················

52、;···················58第八节 设备科工作制度····························

53、3;······602、 医疗仪器设备管理制度···································603、 医疗仪器安全使用制度···

54、3;·······························614、 计量管理工作制度················

55、83;··················635、 医疗仪器维修保养制度·····························

56、······646、 中心供氧安全管理制度···································647、 灭火设备的使用····

57、83;······························648、 中心供氧工作制度·················&#

58、183;·················659、 医用氧气管理制度······························&

59、#183;····6510、 设备计划管理制度···································6611、 医疗器械采购制度·····

60、83;·····························6612、 医疗设备更新管理制度··················

61、;·················6613、 抢救设备操作管理制度······························&

62、#183;····6714、 大型医疗仪器资源共享制度·······························6815、 应招标目录外的医疗耗材采购管理制度·······&#

63、183;·············6816、 普通医用耗材采购管理制度·······························6817、 高值耗材和贵重药

64、品使用管理制度··························6818、 一次性使用无菌医疗用品消毒产品管理制度··················6919

65、、 一次性使用无菌医疗用品管理制度·························6920、 医疗器械不良反应报告制度···················&

66、#183;···········7021、 可疑医疗器械不良事件报告表填写说明···················71第10节 总务科工作制度·············

67、······················711、 物资管理工作制度··························

68、;·········722、 用水管理工作制度···································723、 用电管理工作制度·

69、83;·································724、 防火工作制度··············

70、3;····················755、 固定资产管理制度···························

71、83;·······76第3章 医疗管理第一节 医疗质量、安全管理核心制度（十三项）·······················79 一、 首诊负责制············&#

72、183;······················79 二、 三级医师查房制度·························

73、··········79 三、 疑难病例讨论制度···································79 四、 术前病例讨论制度&#

74、183;··································80 五、 死亡病例讨论制度·············

75、······················806、 危重病例抢救制度··························

76、;·········807、 会诊制度···································818、 查对制度···

77、;································829、 手术分级管理制度···············

78、3;···················8310、 值班与交接班制度····························&#

79、183;······8911、 临床用血审批制度···································8912、 病历书写规范与病历管理制度···

80、;·························9013、 分级护理管理制度······················

81、83;············91第2节 医疗准入制度···································92（

82、1） 新技术、新业务准入管理制度····························95（2） 医师及医技人员职业准入制度················&

83、#183;···········92（3） 有创操作准入制度···································93第3节

84、 门、急诊管理制度···································94 （一) 门诊管理制度···········&#

85、183;·······················94 （二） 急诊管理制度························&

86、#183;··········95 （三） 专家门诊管理制度···································96 （四） 医疗证

87、明管理制度···································96 （五） 检验报告管理制度···········

88、3;·······················97第4节 住院相关制度························

89、3;··········97 （一）入院与出院制度···································97 （二）医嘱制度·

90、;··································98 （三）转院与转科制度·············

91、3;····················98第5节 手术有关制度···························

92、3;······991、 手术制度··································992、 围手术期管理制度······

93、····························1013、 手术安全核对与手术风险评估制度··················

94、83;········1054、 实施诊疗技术操作的有关规定·······························105第6节 医疗安全相关制度·····

95、;·····························1091、 知情同意书签字制度··················&#

96、183;···············1092、 医疗安全管理制度································

97、··1133、 防止医疗事故发生的措施和制度·····························1144、 保护性医疗和保护患者隐私制度············&#

98、183;················1145、 实施医疗技术操作的有关规定······························1

99、156、 医疗请示报告制度··································115第7节 报告制度············

100、······················1161、 紧急情况及重大医疗事件报告制度························

101、83;··1162、 危重患者抢救报告制度··································1163、 死亡病例报告制度········

102、83;·························1164、 医疗纠纷、差错、事故报告制度·····················&

103、#183;········1165、 药品不良反应报告制度··································1176、 传染病、性病报告制度··

104、;································117第8节 药品处方管理制度···············&#

105、183;·················1171、 处方规范制度······························&#

106、183;··1172、 关于控制药品费用、加强药品使用环节管理的规定··············1183、 处方权申请、审批制度··························

107、·······1194、 抗菌药物临床使用管理制度·································1195、 特殊药品管理制度····

108、3;····························119第9节 其它相关制度···················

109、83;·············1201、 医院紧急召集制度·································1202、 医

110、院病历管理办法（草案）·································1213、 医师外出会诊管理制度及管理细则···········

111、3;···············1214、 外聘医师来院或受聘外院医师管理制度·······················1225、 医师定期考核实施办法·····&

112、#183;···························1226、 单病种质量管理与控制方案···················&

113、#183;·············1227、 高年资住院医师及主治医师急诊科轮转制度···················1238、 临床输血管理制度··········

114、3;······················124第4章 门诊工作制度第一节 门诊工作管理制度·······················

115、83;·········183第二节 门诊医师管理办法实施细则·································184第三节 专家门诊管理制度··

116、;·······························184第四节 门诊护理工作制度················&#

117、183;················185第五节 门诊首诊负责制度·······························

118、;··185第六节 门诊会诊转诊制度·································186第七节 门诊分诊护士工作制度·········

119、83;·······················186第八节 门诊导医工作制度························

120、·········186第九节 门诊诊前准备制度·································187第十节 门诊预约诊疗制度···

121、······························187第十一节 门诊验诊制度·················

122、3;···············188第十二节 门诊登记统计制度································

123、·188第十三节 门诊消毒隔离制度·································188第十四节 门诊环境管理制度··········

124、3;······················188第十五节 门诊医护人员宣教工作管理制度························

125、··188第5章 护理管理制度第1节 护理行政管理·································1891、 护理部工作制度·········

126、························1892、 护理职业人员准入制度·······················&#

127、183;·········1893、 护理部各种会议制度·································1894、 护理部夜班督导制度··&#

128、183;······························1905、 护理查房制度·················&#

129、183;···············1906、 请示报告制度································&#

130、183;1907、 护理人员考核制度·································1908、 护理人员奖惩制度···········

131、3;·····················1919、 护理人员紧急替代制度··························

132、·······19210、 护理质量管理制度·································19211、 护理新技术、新业务准入制度····&

133、#183;·······················19312、 护理投诉管理制度·······················

134、3;·········19413、 工休座谈会制度·································19414、 护理缺陷登记报告制度··

135、83;······························19515、 临床护理教学管理制度················

136、3;················19516、 新护士岗前培训制度·······························

137、··19617、 护士规范化培训教育制度·······························19618、 在职护士继续教育制度···········&

138、#183;·····················197第2节 护理业务技术管理·························

139、3;·······1981、 病房管理制度·································1982、 病房消毒隔离制度·····&#

140、183;···························2003、 首接制度····················

141、3;············2004、 护理工作制度·································2015、 交接班制度·

142、;································2016、 分级护理制度················

143、;·················2017、 危重患者管理制度······························

144、83;··2028、 危重患者抢救制度·································2039、 执行医嘱制度··········&

145、#183;······················20310、 查对制度·························&#

146、183;·······20411、 接待患者入院、出院、转科制度····························20512、 饮食管理制度········

147、3;························20513、 健康教育制度·······················

148、83;·········20614、 护理病例讨论制度·································20615、 护理会诊制度···

149、;······························20616、 各项护理操作前告知制度·················

150、;················20617、 病房药品管理制度·······························&#

151、183;·20718、 药品管理制度·································207第3节 各室管理制度···········

152、······················211 一、护办室工作制度··························

153、;·······211 二、治疗室工作制度·································211 三、注射室工作制度·····

154、83;···························212 四、抢救室工作制度····················&#

155、183;············212 五、换药室工作制度·································212第6章 医院感染管理

156、制度第1节 医院感染知识培训制度·································231第2节 医院感染临床病例监测制度···········&

157、#183;···················231第3节 医院感染流行、暴发的报告与控制制度·······················232第4节 消毒、灭菌效果监测制度&

158、#183;································232第5节 重要部位医院感染预防控制措施·············

159、3;··············232第6节 清洁、消毒、隔离制度·······························233第7节 医务人员

160、手卫生制度·································234第8节 医务人员职业暴露防护制度·············

161、··················234第9节 消毒药械、一次性使用医疗用品管理制度·····················235第10节 医疗废物管理制度····&

162、#183;····························235第11节 参与抗菌药物临床应用管理制度·················

163、83;·········236第12节 医务人员利器伤报告及处理制度··························236第13节 医务人员HIV、HBV、HCV 职业暴露报告及处理制度·····

164、····236第14节 突发事件的报告与处理制度······························237第15节 职业暴露的处理流程··········

165、;·······················237第16节 医务人员职业防护措施························

166、;·········238第17节 医疗废物泄露、流失、扩散应急预案························238第18节 医院感染流行、暴发应急预案·········&#

167、183;···················238第19节 耐药菌或特殊病原体感染监测上报制度·····················239第20节 无菌技术操作原则··

168、83;······························239第21节 重点部门的医院感染管理制度················

169、···········2401、 ICU医院感染管理制度·································2402、 透析室医院感染管理制度&#

170、183;································2413、 内窥镜室医院感染管理制度··············&#

171、183;··················2414、 检验科医院感染管理制度····························

172、83;····2425、 口腔科医院感染管理制度·································2426、 导管室医院感染管理制度·······

173、;··························2437、 血液病房医院感染管理制度·····················

174、;············2438、 消毒供应室医院感染管理制度·····························2449、 门诊医院医院感染管理制度·············