2014年_2017年肿瘤医院病理诊断报告书质量检查表

1、肿瘤医院病理诊断报告书质虽检查表科室：病理科检查日期：2017年2月1日病理报告月份：2017年1月项目病理亏报告格式是否规范1分书写内容是否全面准确1分病理诊断是否准确1分病理诊断报告有无涂改1分标本大体描述是否准确1分报告时间是否5个工作日发出1分病理与临床诊断符合情况1分有无假病理诊断报告1分是否双签字及审核1分签字医师是否与授权相符1分分数201700275VVVVVVVVVV10201700276VVVVVVVVVV10201700277VVVVVVVVVV10201700278VVVVVVVVVV10201700279VVVVVVVVVV10201700280VVVV大体描述不准确

2、VVVVV9201700281VVVVVVVVVV10201700282VVVVVVVVVV10201700283VVVVVVVVVV10201700284临床诊断空白VVVVVVVVV9201700285VVVVVVVVVV10201700286VV7V7V7V7V7V7V7V7V710201700287VVVVVVVVVV10201700288VVVVVVVVVV10201700289VVVVVVVVVV10201700290VVVVVVVVVV10201700291VVVVVVVVVV10201700292VVVVVVVVVV10201700293VVVVVVVVVV1020170029

3、4VVVVVVVVVV10201700295VVVVVVVVVV10201700296VVVVVVVVVV10201700297VVVVVVVVVV10201700298VVVVVVVVVV10201700299VVVVVVVVVV10201700300VVVVVVVVVV10201700301VVVVVVVVVV10201700302VVVVVVVVVV10201700303VVVVVVVVVV10201700304VVVVVVVVVV10合格率：96.7%100%100%100%96.7%100%100%100%100%100%科主任点评：整体情况较好，达到质控指标要求，个别病例大体描述不

4、全，项目漏填,需责任到人，核对报告时仔细准确。质控员评价：本月检查30份病理报告，总体质量较好，个别存在问题，201700280为大体描述不全，201700284为临床诊断空白，责任人詹世宁，需在核对报告时仔细，严格遵守报告规范。签名:签名:备注：“r”表示该质量符合，“数字”表示该质量问题分数徐州市肿瘤医院徐州市第三人民医院病理诊断报告书质量检查表科室：病理科检查日期：2017年3月1日病理报告月份：2017年2月项目病理号'报告格式是否规范1分书写内容是否全面准确1分病理诊断是否准确1分病理诊断报告有无涂改1分标本大体描述是否准确1分报告时间是否5个工作日发出1分病理与临床诊断符合

5、情况1分有无假病理诊断报告1分是否双签字及审核1分签字医师是否与授权相符1分分数201701128VVVVVVVVVV10201701129VVVVVVVVVV10201701130VVVVVVVVVV10201701131VVVVV退发报告VVVV9201701132VVVVVVVVVV10201701133VVVVVVVVVV10201701134VVVVVVVVVV10201701135VVVVVVVVVV10201701136VVVVVVVVVV10201701137V7V7V7V7V7V7V7V7V7V710201701138VVVVVVVVVV10201701139VVVVVVVV

6、VV10201701140VVVVVVVVVV10201701141VVVVVVVVVV10201701142VVVVVVVVVV10201701143VVVVVVVVVV10201701144VV°VVVVVVV10201701145VVVVVVVVVV10201701146VVVVVVVVVV10201701147VVVVVVVVVV10201701148VVVVVVVVVV10201701149VVVVVVVVVV10201701150VVVVVVVVVV10201701151VVVVVVVVVV10201701152VVVVVVVVVV10201701153VVVVVVVVV

7、V10201701154VVVVVVVVVV10201701155VVVVVVVVVV10201701156VVVVVVVVVV10201701157VVVVVVVVVV10合格率：100%100%100%100%100%96.7%100%100%100%100%质控员评价：本月常规病理报告整体质量较好，达到指标要求，但201701131为退发报告,原因为补取胎盘绒毛，退发报告，责任人杜丽，需与临床医师及时沟通说明原因，并且尽量避免补取。签名：备注：表示该质量符合，“数字”表示该质量问题分数。科主任点评：常规病理报告质量较好，个别报告退发，需做好与临床的沟通工作，并且取材要规范，尽量避免补充取

8、材。签名：徐州市肿瘤医院徐州市第三人民医院病理诊断报告书质量检查表科室：病理科检查日期：2017年4月1日病理报告月份：2017年3月项目病理号报告格式是否规范1分书写内容是否全面准确1分病理诊断是否准确1分病理诊断报告有无涂改1分标本大体描述是否准确1分报告时间是否5个工作日发出1分病理与临床诊断符合情况1分有无假病理诊断报告1分是否双签字及审核1分签字医师是否与授权相符1分分数201702270VVVVVVVVVV10201702271VVVVVVVVVV10201702272VVVVVVVVVV10201702273VVVVVVVV10201702274V7V7V7V7V7V7V7V7V

9、7V710201702275VVVVVVVVVV10201702276VVVVVVVVVV10201702277VVVVVVVVVV10201702278标本名称不全VVVVVVVVV9201702279VVVVVVVVVV10201702280VVVVVVVVVV10201702281VVVVVVVVVV10201702282VVVVVVVVVV10201702283VVVVVVVVVV10201702284VVVVVVVVVV10201702285VVVVVVVVVV10201702286VVVVVVVVVV10201702287VVVVVVVVVV10201702288VVVVVVVVV

10、V10201702289VVVVVVVV10201702290VVVVVVVVVV10201702291VVVVVVVVVV10201702292VVVVVVVVVV10201702293VVVVVVVVVV10201702294VVVVVVVVVV10201702295VVVVVVVVVV10201702296V7V7V7V7V7V7V7V7V7V710201702297VVVVVVVVVV10201702298VVVVVVVVVV10201702299VVVVVVVVVV10合格率：96.7%100%100%100%100%100%100%100%100%100%质控员评价：本月抽查常规病

11、理报告30份，其中一份201702278为标本名称不全，“右前哨淋巴结”写成了“右前哨”，责任人杜丽，在核对报告时需仔细，严格遵守报告规范。签名：科主任点评：本月常规病理报告整体情况良好，无退发报告现象,写/、规范问题，需责任到人，仔细核对报告。签名：但存在标本名称书备注：表示该质量符合，“数字”表示该质量问题分数徐州市肿瘤医院徐州市第三人民医院病理诊断报告书质量检查表科室：病理科检查日期：2017年5月2日病理报告月份：2017年4月项目病理号'报告格式是否规范1分书写内容是否全面准确1分病理诊断是否准确1分病理诊断报告有无涂改1分标本大体描述是否准确1分报告时间是否5个工作日发出1

12、分病理与临床诊断符合情况1分有无假病理诊断报告1分是否双签字及审核1分签字医师是否与授权相符1分分数201703500VVVVVVVVVV10201703501VVVVVVVVVV10201703502VVVVVVVVVV10201703503VVVVVVVVVV10201703504VVVVVVVVVV10201703505VVVVVVVV未审核V9201703506VVVVVVVVVV10201703507VVVVV退发报告VVVV9201703508VVVVVVVVVV10201703509VVVVVVVVVV10201703510VVVVVVVVVV10201703511VVVV大体描

13、述不准确VVVVV9201703512VVVVVVVVVV10201703513VVVVVVVVVV10201703514VVVVVVVVVV10201703515VVVVVVVVVV10201703516VVVVVVVVVV10201703517VVVVVVVVVV10201703518V7V7V7V7V7V7V7V7V7V710201703519VVVVVVVVVV10201703520VVVVVVVVVV10201703521VVVVVVVVVV10201703522VVVVVVVVVV10201703523VVVVVVVVVV10201703524VVVVVVVVVV102017035

14、25VVVVVVVVVV10201703526VVVVVVVVVV10201703527VVVVVVVVVV10201703528VVVVVVVVVV10201703529VVVVVVVVVV10合格率：100%100%100%100%96.7%96.7%100%100%96.7%100%质控员评价：检查30份病理报告，达到指标要求，但存在问题较多，201703505有双签字，但未在电脑病理系统审核，201703507为疑难病例，退发报告，201703511大体描述中为“直径0.5cm”写成了“直0.5cm”，责任人卓静、李家。需在核对报告时仔细，及时审核，记录员在记录取材大体描述时仔细认真。

15、签名：科主任点评：本月筒问题较多，对于未审核及大体描述记录不规范本可避免，任到人，加强培训，对工作严格要求。签名：需责备注：表示该质量符合，“数字”表示该质量问题分数徐州市肿瘤医院徐州市第三人民医院病理诊断报告书质量检查表科室：病理科检查日期：2017年6月1日病理报告月份：2017年5月项目病理号报告格式是否规范1分书写内容是否全面准确1分病理诊断是否准确1分病理诊断报告有无涂改1分标本大体描述是否准确1分报告时间是否5个工作日发出1分病理与临床诊断符合情况1分有无假病理诊断报告1分是否双签字及审核1分签字医师是否与授权相符1分分数201704620VVVVVVVVVV10201704621

16、VVVVVVVVVV10201704622VVVVVVVV未审核V9201704623VVVVVVVVVV10201704624VVVVVVVVVV10201704625VVVVVVVVVV10201704626VVVVVVVVVV10201704627VVVVVVVVVV10201704628VVVVVVVVVV10201704629VVVVVVVVVV10201704630VVVVVVVVVV10201704631VVVVVVVVVV10201704632VVVVVVVVVV10201704633VVVVVVVVVV10201704634V7V7V7V7V7V7V7V7V710201704

17、635VVVVVVVVVV10201704636VVVVVVVVVV10201704637VVVVVVVVVV10201704638VVVVVVVVVV10201704639VVVVVVVVVV10201704640VVVVVVVVVV10201704641VVVVVVVVVV10201704642VVVVVVVVVV10201704643VVVVVVVVVV10201704644VVVVVVVVVV10201704645VVVVVVVVVV10201704646VVVVVVVVVV10201704647VVVVVVVVVV10201704648VVVVVVVVVV10201704649VVV

18、VVVVVVV10合格率：100%100%100%100%100%100%100%100%96.7%100%质控员评价：检查30份病理报告，达到指标要求，个别存在问题，201704622为有双签字，但是未在电脑中审核，责任人杜丽，以后需避免此类问题。签名：科主任点评：本月有一例未在电脑审核，需责任到人，避免再次发生，本月整体情况良好，需继续保持。签名：备注：表示该质量符合，“数字”表示该质量问题分数徐州市肿瘤医院徐州市第三人民医院病理诊断报告书质量检查表科室：病理科检查日期：2017年7月1日病理报告月份：2017年6月项目病理号'报告格式是否规范1分书写内容是否全面准确1分病理诊断是

19、否准确1分病理诊断报告有无涂改1分标本大体描述是否准确1分报告时间是否5个工作日发出1分病理与临床诊断符合情况1分有无假病理诊断报告1分是否双签字及审核1分签字医师是否与授权相符1分分数201705870VVVVVVVVVV10201705871VVVVVVVVVV10201705872VVVVVVVVVV10201705873VVVVVVVVVV10201705874VVVVVVVVVV10201705875格式不规范VVVVVVVVV9201705876VVVVVVVVVV10201705877VVVVVVVVVV10201705878VVVVVVVVVV10201705879VVVVVV

20、VVVV10201705880V7V7V7V7V7V7V7V7V7V710201705881VVVVVVVVVV10201705882VVVVVVVVVV10201705883VVVVVVVVVV10201705884VVVVVVVVVV10201705885VVVVVVVVVV10201705886VVVVVVVVVV10201705887VVVVVVVVVV10201705888VVVVVVVVVV10201705889VVVVVVVVVV10201705890VVVVVVVVVV10201705891VVVVVVVVVV10201705892VVVVVVVVVV10201705893VV

21、VVVVVVVV10201705894VVVVVVVVVV10201705895VVVVVVVVVV10201705896VVVVVVVVVV10201705897VVVVVVVVVV10201705898VVVVVVVVVV10201705899VVVVVVVVVV10合格率：96.7%100%100%100%100%100%100%100%100%100%质控员评价：检查30份病理报告，达到指标要求，个别存在问题，201705875为全子宫及双附件切除标本，病理报告中有3项内容，但序号为1.2.4,为格式错误，责任人詹世宁，诊断医师以后需避免此类问题，严格核对报告。科主任点评：本月整体情况

22、良好，报告都能及时准确发出，但是存在核对不仔细，报告不规范问题，诊断医师在核对报告时需仔细认真，严格要求。签名:签名：备注：表示该质量符合，“数字”表示该质量问题分数徐州市肿瘤医院徐州市第三人民医院病理诊断报告书质量检查表科室：病理科检查日期：2017年9月1日病理报告月份：2017年8月项目病理号、报告格式是否规范1分书写内容是否全面准确1分病理诊断是否准确1分病理诊断报告有无涂改1分标本大体描述是否准确1分报告时间是否5个工作日发出1分病理与临床诊断符合情况1分有无假病理诊断报告1分是否双签字及审核1分签字医师是否与授权相符1分分数20170783020170783120170783220

23、1707833201707834201707858201707859合格率：质控员评价：签名：科主任点评：签名：备注：表示该质量符合，“数字”表示该质量问题分数徐州市肿瘤医院徐州市第三人民医院病理诊断报告书质量检查表科室：病理科检查日期：2017年10月6日病理报告月份：2017年月项目病理亏报告格式是否规范1分书写内容是否全面准确1分病理诊断是否准确1分病理诊断报告有无涂改1分标本大体描述是否准确1分报告时间是否5个工作日发出1分病理与临床诊断符合情况1分有无假病理诊断报告1分是否双签字及审核1分签字医师是否与授权相符1分分数201708396VVVVVVVVVV10201708397VVV

24、VVVVVVV10201708398VVVVVVVVVV10201708399VVVVVVVVVV10201708400VVVVVVVVVV10201708401VVVVVVVVVV10201708402VVVVVVVVVV10201708403VV°VVVVVVV10201708404VVVVVVVVVV10201708405VVVVVVVVVV10201708406VVVVVVVVVV10201708407VVVVVVVVVV10201708408VVVVVVVVVV10201708409标本名称不全VVVVVVVVV9201708410VVVVVV病理与临床诊断不一致VVV92

25、01708411VVVVVVVVVV10201708412VVVVVVVVVV10201708413VVVVVVVVVV10201708414VVVVVVVVVV10201708415VVVVVVVVVV10201708416VVVVVVVVVV10201708417V7V7V7V7V7V7V7V7V7V710201708418VVVVVVVVVV10201708419VVVVVVVVVV10201708420VVVVVVVVVV10201708421VVVVVVVVVV10201708422VVVVVVVVVV10201708423VVVVVVVVVV10201708424VVVVVVVVV

26、V10201708425VVVVVVVVVV10合格率：96.7%100%100%100%100%100%96.7%100%100%100%质控员评价：检查30份病理报告，达到指标要求，个别存在问题，201708409标本名称未写全，201708410病理诊断与常规诊断不一致，临床医师在填写申请单还需注意，病理科及时与临床及时沟通。签名：科主任点评：本月整体情况良好，报告都能及时准确发出，诊断医师在核对报告时需仔细认真，严格要求。签名：备注：表示该质量符合，“数字”表示该质量问题分数徐州市肿瘤医院徐州市第三人民医院病理诊断报告书质量检查表科室：病理科检查日期：2016年2月1日病理报告月份：2

27、016年1月项目病理号'报告格式是否规范1分书写内容是否全面准确1分病理诊断是否准确1分病理诊断报告有无涂改1分标本大体描述是否准确1分报告时间是否5个工作日发出1分病理与临床诊断符合情况1分有无假病理诊断报告1分是否双签字及审核1分签字医师是否与授权相符1分分数201600660VVVVVVVVVV10201600661VVVVVVVVVV10201600662VVVVVVVVVV10201600663VVVVVVVVVV10201600664VVVVVVVVVV10201600665VVVVVVVVVV10201600666VVVVVVVVVV10201600667-VVVVVVV

28、v-VV10201600668VVVVVVVVVV10201600669VVVVVVVVVV10201600670VVVVVVVVVV10201600671VVVVVVVVVV10201600672VVVVVVVVVV10201600673VVVVVVVVVV10201600674VVVVVVVVVV10201600675VVVVVVVV未审核V9201600676V7V7V7V7V7V7V7V7V710201600677VVVVVVVVVV10201600678VVVVVVVVVV10201600679VVVVVVVVVV10201600680VVVVVVVVVV10201600681VVV

29、VVVVVVV10201600682VVVVVVVVVV10201600683VVVVVVVVVV10201600684VVVVVVVVVV10201600685VVVVVVVVVV10201600686VVVVVVVVVV10201600687VVVVVVVVVV10201600688VVVVVVVVVV10201600689V7V7VV7V7VV7V7V7V710合格率：质控员评价：签名：科主任点评：签名：备注：表示该质量符合，“数字”表示该质量问题分数徐州市肿瘤医院徐州市第三人民医院病理诊断报告书质量检查表科室：病理科检查日期：2016年3月1日病理报告月份：2016年2月项目病理号&#

30、39;、报告格式是否规范1分书写内容是否全面准确1分病理诊断是否准确1分病理诊断报告有无涂改1分标本大体描述是否准确1分报告时间是否5个工作日发出1分病理与临床诊断符合情况1分有无假病理诊断报告1分是否双签字及审核1分签字医师是否与授权相符1分分数201601170VVVVVVVVVV10201601171VVVVVVVVVV10201601172VVVVVVVVVV10201601173VVVVVVVVVV10201601174VVVVVVVVVV10201601175VVVVVVVVVV10201601176VVVVVVVVVV10201601177VVVVVVVVVV1020160117

31、8VVVVVVVVVV10201601179VVVVVVVVVV10201601180VVVVVVVVVV10201601181VVVVVVVVVV10201601182V7V7V7V7V7V7V7V7V7V710201601183VVVVVVVVVV10201601184VVVVVVVVVV10201601185VVVVVVVVVV10201601186VVVVVVVVVV10201601187VVVVVVVVVV10201601188VVVVVVVVVV10201601189VVVVVVVVVV10201601190VVVVVVVVVV10201601191VVVVVVVv-VV10201

32、601192VVVVVVVVVV10201601193VVVVVVVVVV10201601194VVVVVVVVVV10201601195VVVVVVVVVV10201601196VVVVVVVVVV10201601197VVVVVVVVVV10201601198VVVVVVVVVV10201601199V7V7VV7V7VV7V7V7V710合格率：质控员评价：科主任点评：签名：签名：备注：表示该质量符合，“数字”表示该质量问题分数徐州市肿瘤医院徐州市第三人民医院病理诊断报告书质量检查表科室：病理科检查日期：2016年4月1日病理报告月份：2016年3月项目病理号'报告格式是否规范1分书写内容是否全面准确1分病理诊断是否准确1分病理诊断报告有无涂改1分标本大体描述是否准确1分报告时间是否5个工作日发出1分病理与临床诊断符合情况1分有无假病理诊断报告1分是否双签字及审核1分签字医师是否与授权相符1分分数201601830VVVVVVVVVV10201601831VVVVVVVVVV10201601832VVVVVVVV