目錄醫(yī)院目錄醫(yī)院制度匯編

醫(yī) 院 制 度 匯 編 目 錄（2010版）第一篇病人服務(wù)管理篇一章臨管理醫(yī)務(wù)人員外出會診管理制度...............................醫(yī)師外出職業(yè)管理辦法...................................門診工作制度...........................................門診工作須知...........................................門急診醫(yī)師力量配備規(guī)定.................................門急診病歷管理制度.....................................門急診巡視制度.........................................門急診病假證明管理制度.................................門診醫(yī)保委托代配藥制度.................................專家門診管理制度.......................................轉(zhuǎn)科、轉(zhuǎn)院制度.........................................入、出院工作制度......................................醫(yī)療質(zhì)量自查制度......................................門急診病人檢查規(guī)定....................................首診醫(yī)師負(fù)責(zé)制........................................12三級醫(yī)師負(fù)責(zé)制........................................13 14 15度..............................................危重病人搶救制度......................................16醫(yī)生值班、交接班制度..................................醫(yī)囑管理..............................................匯報制度..............................................查對制度..............................................病情評估制度..........................................圍手術(shù)期關(guān)鍵環(huán)節(jié)管理制度..............................手術(shù)風(fēng)險評估制度......................................26重大手術(shù)匯報審批制度..................................手術(shù)資格準(zhǔn)入制度......................................27非計劃再次手術(shù)管理制度................................29手術(shù)安全核查與手術(shù)部位標(biāo)志制度........................29醫(yī)療安全（不良）事件與隱患缺陷報告制度................31

....................................................................危急值報告制度........................................37醫(yī)療技術(shù)損害中止制度..................................急診留觀室醫(yī)療安全管理措施............................39臨床用血管理制度......................................40 41 45重大醫(yī)療糾紛預(yù)警機(jī)制..................................尊重和維護(hù)病人權(quán)益制度................................尊重民族風(fēng)俗習(xí)慣和宗教信仰暫行規(guī)定....................醫(yī)患溝通制度..........................................告知制度..............................................

......................................55......................................64病歷管理制度..........................................

............................................................麻醉藥品、第一類精神藥品專用處方管理制度..............麻醉藥品和精神藥品管理實(shí)施細(xì)則........................

......................................89......................................89靜脈補(bǔ)液的標(biāo)準(zhǔn)及相關(guān)規(guī)定..............................處方管理和醫(yī)師門急診用藥規(guī)定..........................藥品不良反應(yīng)監(jiān)測報告制度..............................

95................................感染管理制度..........................................99

......................................100......................................100感染上報制度..........................................101感染流行、暴發(fā)的報告與控制............................101環(huán)境衛(wèi)生學(xué)監(jiān)測制度....................................103消毒滅菌效果監(jiān)測制度..................................104消毒隔離制度..........................................105無菌技術(shù)操作規(guī)范......................................106手衛(wèi)生制度............................................106一次性使用無菌醫(yī)療用品的管理制度......................107消毒滅菌藥械管理制度..................................108職業(yè)安全制度..........................................108醫(yī)療廢物的管理制度....................................112細(xì)菌耐藥監(jiān)測及預(yù)警機(jī)制................................128多重耐藥菌管理制度....................................128感染管理質(zhì)量控制指標(biāo)..................................129請示報告制度..........................................醫(yī)院總值班制度........................................130主診醫(yī)師負(fù)責(zé)制度......................................130住院總制度............................................134醫(yī)療事故處理規(guī)定......................................137門診大病醫(yī)保管理規(guī)定..................................145傳染病報告制度........................................146院務(wù)公開制度..........................................147職工代表大會制度......................................153院長接待日制度........................................154固定資產(chǎn)管理..........................................155固定資產(chǎn)管理規(guī)定......................................156審計工作制度..........................................157醫(yī)院經(jīng)費(fèi)管理暫行規(guī)定..................................158財產(chǎn)物資管理制度......................................162

....................................164....................................167高、中級專業(yè)技術(shù)人員聘任制度..........................168病區(qū)醫(yī)生值班制度......................................169非在編人員管理暫行辦法................................170 171職工培訓(xùn)制度...........................................職工休假制度...........................................醫(yī)師病史書寫違規(guī)處罰細(xì)則...............................科技工作獎懲條例.......................................183科研經(jīng)費(fèi)暫行管理辦法...................................新技術(shù)新項目臨床應(yīng)用管理辦法...........................191院級科研課題管理辦法..................................192關(guān)于學(xué)術(shù)會議的規(guī)定....................................194職工在職攻讀碩士博士學(xué)位管理辦法......................196兼職教師聘任及考核實(shí)施方法............................198教學(xué)經(jīng)費(fèi)管理辦法......................................200教學(xué)管理規(guī)定..........................................201三基培訓(xùn)、考核制度.....................................實(shí)習(xí)帶教管理條例.......................................206重點(diǎn)學(xué)科、特色?？平ㄔO(shè)的實(shí)施辦法.......................）……212住院醫(yī)師規(guī)范化培訓(xùn)實(shí)施方案.............................212醫(yī)療設(shè)備管理論證制度..................................216大型醫(yī)療設(shè)備的成本核算制度............................216醫(yī)療設(shè)備管理工作制度..................................217 217醫(yī)療器械不良事件報告制度..............................218醫(yī)療器械臨床使用安全控制和風(fēng)險管理制度...