科室医疗质量管理手册范本

医疗质量控制小组成员名单：组长：副组长：成员：具体职责分工：科主任签字：年月日科室人员编制及基本情况职称及任职务及任姓名性别年龄学历职时间职时间----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------一月份：二月份：三月份：四月份：五月份：六月份：七月份：八月份：九月份：十月份：十一月份：十二月份：年度管理目标项目及目标值各类医疗文书正规书写合格率≥%，甲级病历率城职平均住院费用≤元城乡平均住院费用≤住院平均住院日≤%，处方、医嘱合格率≥药品收入占业务收入比例≤%，抗菌药物占药品收入比例≤%临床主要诊断、病理诊断符合率≥％实行临床路径管理，完成医务科下达的工作任务特殊检查、特别治疗等患者告知率为年内医疗事故数为，医疗感染爆发事件为。三级医师查房率医患沟通率达%，管床医师查房每天不少于次%，病人或家属签字。传染病疫情上报率%，无迟报、漏报、瞒报。十三项医疗核心制度知晓率达各项记录本达标时地检查日期检查人员年月日改进措施年月日效果评价年月日科主任签字年月日时地检查日期主要检检查人员查内容年月日改进措施年月日效果评价年月日年月日时地检查日期主要检检查人员查内容年月日改进措施年年年月月月日日日效果评价科主任签字时地检查日期主要检检查人员查内容年月日改进措施年月日效果评价年年月月日日时地检查日期主要检检查人员查内容年月日改进措施年年年月月月日日日效果评价科主任签字时地检查日期主要检检查人员查内容年月日改进措施年月日效果评价年月日年月日-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------时地检查日期主要检检查人员查内容年月日改进措施年年年月月月日日日效果评价时地检查日期主要检检查人员查内容年月日改进措施年年年月月月日日日效果评价科主任签字时地检查日期主要检检查人员查内容年月日改进措施年月日效果评价年年月月日日时地检查日期主要检检查人员查内容年月日改进措施年年年月月月日日日效果评价科主任签字时地检查日期主要检检查人员查内容年月日改进措施年月日效果评价年年月月日日时地检查日期主要检检查人员查内容年月日改进措施年年年月月月日日日效果评价科主任签字----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------