二甲医院公文催办制度[合集五篇]

第一篇：二甲医院公文催办制度

二甲医院 公文催办制度

1、一般情况下，有承办时限规定的公文，才需要催办。

2、公文传阅要迅速，急件急送，不积压，不拖延，紧急文件在 24 小时内催办完毕。

3、领导批阅后的文件，根据领导指示，送有关人员传阅或有关科室，并及时向领导汇报办理情况。

4、凡有明确规定限期办理的文件，承办人应及时办理，院办公室负责公文处理人员应定期或随时向承办部门或人员催询，限期完成。

5、催办人员可采取深入现场召集会议、电话催询、制发催办单、函等方式及时了解情况，并记录在案，作为催办依据，及时采取措施克服障碍，解决承办中遇到的问题，及时验收和注销。

6、催办人员要维护催办工作的权威性、严肃性和有效性。

第二篇：公文的催办

催办，指对公文承办过程所实施的督促与检查的活动，即对公文办理决策执行情况的反馈信息，防止办文的迟缓与延误，促进公文效用尽快而有效地实现。

催办工作通常是由本机关的文秘部门（人员）负责催办，此部门负责一个机关文书工作的组织与运转，是各种信息的枢纽，能从整体上全面系统地把握机关各项管理活动，有助于发挥公文催办工作的作用。针对特别重要公文，也可由各级领导人亲自负责。

1．催办不仅仅指公文承办环节的催办，作为一项监督检查机制而设立的控制环节，催办工作应包括对收文拟办、批办及承办等各个环节的督促检查。只是承办工作一个环节高效完成，拟办、批办等环节却延误、拖拉，仍然无法确保整个公文办理的及时、高效；只有公文办理的所有环节都作到科学、合理、及时、准确，才能保证整体高效、经济。因为公文办理是一个完整的有机系统，是各个环节之间彼此关照、相互联系的统一体。

2．催办工作是有特定的对象的，并不是所有的公文都需要催办，需要催办的公文有：上级领导、本机关领导交办的事项或需要办复的公文；同级或其他不相隶属机关要求答复与办理的事项；下级机关的请示；会议决议中需要办理落实的重要事项；人大代表的议案和政协委员的提案；重要事故、事件、人物等专案的处理；人民群众来信来访要求答复与处理的重要事项。针对这些不同种类的公文可以采取不同的方式方法。

根据其内容、对象、手段的不同，催办的形式可以多种多样：

1．就催办对象而言，催办的形式可分为以下两种：对内催办，是指针对收文，对本机关各承办部门的公文办理工作进行督促与检查；对外催办，是指针对本机关的发文，是对本机关的发文在受文机关进行办理情况所进行的催询或检查和督促。

2．就催办手段而言，催办的形式可分为以下几种：文字催办，即以发催办单或便函的形式进行催办；登门催办，指催办人员登门走访口头催询，会议催询；通讯催办，利用电话、电报、电传、电子邮件等手段进行催办。

3．依据公文紧急和重要程度，可将催办形式划分为：跟踪催办，对紧急公文紧随其后督促办理；重点催办，对重要公文应将其放在突出位置重点催促办理；定期催办，对一般公文设定固定的时限（如规定每5天催办一次）按时督促办理。

催办的具体方法：

1．选择催办方式。根据公文的实际情况选用如口头催办。电话催办、电子邮件等经济、高效的催办形式，切忌事无大小、不分缓急一律选用文字催办方式。通常应至少提前一、二天查询、督促有关承办部门，保证公文在有效时限内办毕。催办中，及时督查、及时反馈，无论是成绩与经验，还是失误与教训，均应如实反馈。催办人发现自身确实无法解决的问题，应及时向领导汇报，请求指示，以便及时、准确、有效的办理公文。

2．填写《催办登记表（单）》。为了备查，催办应予登记，其登记方法有：簿式登记，即文秘人员分送公文时，同时填写一张催办单，注明承办要求（如“请于×月×日办毕），随公文一起交给承办人；催办卡登记，即填写一式二联的催办卡，一联附在公文前发给承办单位，另一联催办部门（人）留存备查；电脑登记，即将催办事项输入电脑，同时填写一份催办单，随公文发给承办单位，催办时限一到，电脑会自动显示当天需催办的公文。

3．建立反馈机制。建立目标并具体落实为其提出的要求和标准，以灵敏及时的反馈机制迅速将反映监督对象的实际情况反馈回文书处理部门或有关领导，比较反馈的信息，找出存在的问题和差距，请示有关领导或会同有关方面经协商形成解决问题的办法，指导或帮助承办或执行公文精神的部门解决问题，完成公文的办理工作。

4．注销办结公文。催办人员应在《催办登记表》登记栏中简要注明公文办理的方式、公文办毕的时间等情况。《催办登记表》的参考格式如下：

第三篇：催办、督办制度

催办、督办制度

为提高我处办事效率，保证办事质量，把我处的重点工作落实到位，根据有关行政管理规定，结合我处实际，制定本制度。

第一条 催办、督办范围：

1.上级组织部署和批办的重要工作；农业部文件确定的重要工作；

2.上级组织会议和文件确定我处办理的重要工作；

3、上级领导批办的重要事宜；

4.处党委会议、处长办公会议决定的重要工作； 5.以处党委、处文件形式规定的重要工作。6.处领导批办的重要事宜； 7.我处重要的阶段性工作； 8.其他需要催办、督办的工作。

第二条 催办、督办由党委办公室、办公室牵头实施。第三条 党委办公室、办公室应当对落实难度较大的列入催办、督办的，采取跟踪督查、实地督查、联合督查和协调督查等方式进行督查落实。

第四条 各承办科（室、段）应当保证在规定的时限内按要求完成工作任务，对落实过程中出现的问题，应当及时反馈党委办公室或办公室，党委办公室或办公室应当立即呈报相关领导。第五条 凡列入催办、督办的重大决策和重要工作部署，实行领导和承办单位责任制，一级对一级负责。主管领导应负责对涉及分管科（室、段）被列入催办、督办的重点工作提出明确的落实质量、时限要求，跟踪问效，发现问题及时指导解决。

第六条 对情况复杂、落实难度较大的重要工作，处领导要亲自抓落实，不搞层层批办。分管领导难以协调解决的，应及时提交处党委会议或处长办公会议进行协调落实。

第七条 实行工作落实情况通报制度。不定期召开工作情况通报会议，通报一个时期我处确定的重要工作的落实情况和协调解决落实过程中遇到的问题，分析和研究落实办法。

第四篇：医院二甲复审核心制度

二甲复审核心制度1.1.2 主要承担常见病、多发病、部分疑难病的诊疗工作，兼顾预防、保健、康复功能，可提供 24 小时急危重症诊疗服务。1.1.2.1 【C】主要承担常见病、多发 1.有承担本辖区常见病、多发病、部分疑难疾病诊疗的设施设备、技术梯队与病、部分疑难病的诊疗工 处置能力。作。可提供 24 小时急诊 a.有设施设备、技术梯队及处置能力，详询医务处诊疗服务。（★）2.急诊部门独立设置，承担本区域急危重症的诊疗。1Y a.急诊部独立设置 b.可以承担本区域急危重症的治疗 3.预防、保健、康复独立设置。a.没有独立设置

4.根据病源，与三级综合医院距离较远或危重病人转诊困难的二级医院的重症 医学床位数可占医院总床位的 2。a.成立的重症医学科病床数为10张 5.医学影像可提供 24 小时急诊诊疗服务。a.可以提供24小时急诊诊疗服务 【B】符合“C”，并 1.重症医学床位占医院总床位的＞3。a.没有达到 2.且符合重症评估标准的患者≥30。a.没有达到 3.医学影像（含 CT、超声）可提供 24 小时急诊诊疗服务。a.可以提供24小时急诊诊疗服务 【A】符合“B”，并 1.重症医学科床位占医院总床位的≥5。a.没有达到 2.且符合重症评估标准的患者≥40。a.没有达到1.4.3.2 【C】编制各类应急预案。（★）1.根据灾害易损性分析的结果制订各种专项预案，明确应对不同突发公共事件2 的标准操作程序。a.已成立了应对不同突发公共事件的预案 b．对不同突发事件有相关标准操作程序 23.院发（2008）18号文件 2.制订医院应对各类突发事件的总体预案和部门预案，明确在应急状态下各个 部门的责任和各级各类人员的职责以及应急反应行动的程序。a.制定了处理各类事件的总体预案 b.对各类突发事件有相关领导组及人员职责、应急行动程序。3.有节假日及夜间应急相关工作预案，配备充分的应急处理资源，包括人员、应急物资、应急通讯工具等。a.有相关预案（已下载）b．具有人员、应急物资、应急通讯工具 【B】符合“C”，并 编制医院应急预案手册，方便员工随时查阅，各部门各级各类人员知晓本部门 和本岗位相关职责与流程。a.没有医院应急预案手册 ？？？ 【A】符合“B”，并 定期并及时修订总体预案和专项预案，持续完善。a.没有修订预案1.6.4 根据政府指令，接受城市三级医院对口支援的医院，达到二级医院标准，应将“达标工作”任务作为院长目标责任制与医院工作计划，有实施方案，专人负责。

1.6.4.1 【C】政府指令的受援的二级医

1、受援的二级医院，应将“达标工作”任务作为院长目标责任制与医院院，应将“达标工作”任务 工作计划，有实施具体的方案。作为院长目标责任制与医 a.有实施的具体方案。（咨询王园媛，省立医院，对口支援）院工作计划，有实施方

2、有专人负责，对口支援工作，保证达标工作进行。案，专人负责。（★）a.有专人负责 详询医务处3 Y

3、相关人员熟悉实施方案的相关内容。a.有相关内容。【B】符合“C”，并 用当年案例证实在以下二方面能有提升：（1）承担县域内居民的常见病、多发病、危急和部分疑难重症的诊治任务，解决影响群众生产生活的重大疾病能力有一定提升。没有（2）开展 24 小时连续性急诊科院内急救服务，组织建立本县域内医疗急救服 务网络，承担日常院前急救救治任务的能力有一定提升。没有 【A】符合“B”，并 1.有数据及相关案例证实受援方案取得预定目标。？？？？ 2.数据指标显示在严重外伤（颅腔、胸腔、腹腔内大出血，与其它威胁生命需 要紧急手术抢救）、急性心肌梗死（仅 STEMI）、急性脑卒中等急危重症病人诊 治效率及处理结果取得显著进步，其能力在本区域具有明显优势。？？？？2.3.4.2 【C】对急性创伤、急 农药中毒、1.医院对急性创伤、农药中毒、急诊分娩、急性心肌梗死、急性脑卒中、急性诊分娩、急 急性心肌梗死、颅脑损伤、高危妊娠孕产妇与高危新生儿等重点病种的急诊服务流程与服务时性脑卒中、急性颅脑损伤、限有明文规定，并且在技术、设施方面提供支持。高危妊娠孕产妇等重点病 a.有对上述急症的急诊服务流程，技术、设施提供支持（已下载）见补充材料种的急诊服务流程与服务 2.急诊服务体系中相关部门（包括急诊科、各专业科室、各医技检查科室、药时限有明文规定，能落实到 剂科以及挂号与收费等）责任明确，各司其职，确保患者能够获得连贯、及时、位。（★）有效的救治。4 a.各相关部门责任明确，能够确保患者获得及时有效的救治 3.急诊服务流程体系相关责任部门人员知晓履职要求。a.有具体急诊服务流程体系（已下载）【B】符合“C”，并 1.用关键质量指标与服务时限来管理与协调各个相关科室的服务。a.没有关键质量指标与服务时限 2.有培训与教育，措施落实到位。a.没有培训与教育 3.职能部门知晓与履行监管责任，对存在问题与缺陷有改进措施。a.没有改进措施 【A】符合“B”，并 危重症患者来源与救治能力在本区域具有优势明显。a.有优势2.6.1.1 【C】患者及其近亲属、授权委托人 1.有保障患者合法权益的相关制度并得到落实。对病情、诊断、医疗措施和医 a.有相关制度。（有关尊重患者隐私权、民族习惯和宗教信仰的有关规定）疗风险等具有知情选择的权 b.落实。（病案中的知情同意书）利。医院有相关制度保证医务 2.医务人员尊重患者的知情选择权利，对患者进行病情、诊断、医疗措施和医人员履行告知义务。（★）疗风险告知的同时，能提供不同的诊疗方案。5 Y a.能够提供不同的诊疗方案。病案中体现（不同病种各异通知各科要有不用的诊疗方案记 录）3.医务人员熟知并尊重患者的合法权益。a.完全了解。（07.六安市立医院维护医患双方合法权益相关知识培训纲要）【B】符合“C”，并 1.患者或近亲属、授权委托人对医务人员的告知情况能充分理解并在病历中体 现。a.患者能充分理解。（在病案中充分体现）（知情同意书要有患者的意见不能仅有签字。）

2.职能部门对上述工作进行督导、检查、总结、反馈，有改进措施。a.有监督改进措施。（病案检查中体现）【A】符合“B”，并 持续改进有成效。（01）2.7.1 贯彻落实《医院投诉管理办法（试行）》，实行“首诉负责制”，设立或指定专门部门统一接受、处理患者和医务人员投诉，及时处理并答复投诉人。2.7.1.1 【C】贯彻落实《医院投诉管理办法 1.设立院领导接待室并执行院长接待入日制度、意见箱、投诉电话等。（试行）》，实行“首诉负责 a.执行院长接待日制度。（六安市立医院行政管理制度——院长接待日制度）制”，设立或指定专门部门统 b.意见箱。（电梯内）一接受、处理患者和医务人员 c.投诉电话。（24小时通畅2166）投诉，及时处理并答复投诉 2.设立专门科室、专职人员接待医疗纠纷投诉，并有登记记录。人。（★）a.医务处，吴忠钰。6 Y 3.定期对员工进行医疗纠纷案例分析、医疗安全教育培训及相关法律法规培训 和考试，有奖罚措施 a.案例分析。（1.4月份）b.教育培训考试。（院长培训班）c．奖罚措施。4.有投诉管理相关制度及明确的处理流程。a.有制度和流程。（见医疗纠纷投诉接待与处理程序）5.有明确的投诉处理时限并得到严格执行。a.处理时限严格执行。（见医疗纠纷投诉接待与处理程序）【B】符合“C”，并 1.实行“首诉负责制”，科室、职能部门处置投诉的职责明确，有完善的投诉 协调处置机制。a.科室、职能部门职责。b.处置机制。（见医疗纠纷投诉接待和处理程序）2.有配置完善的录音录像设施的投诉接待室。a.有。（医务处对面会议室。）3.职能部门对上述工作进行督导、检查、总结、反馈，有改进措施。a.有改进措施。【A】符合“B”，并 1.每季召开一次专题医疗纠纷投诉事件的讨论会，各科科主任均应参加通报 会。a.有参加。（1月份，4月份，少7月份）2.职能部门对提出持续改进措施有成效评价的记录。a.没有记录3.1.2 在诊疗活动中，严格执行“查对制度”，至少同时使用姓名、年龄、床号等两项核对患者身份，确保对正确的患者实施正确的操作。3.1.2.1 【C】在诊疗活动中，严格执行 1.有标本采集、给药、输血或血制品、采集供临床检验及病理标本、发放特殊，“查对制度” 至少同时使 饮食、诊疗活动及操作前患者身份确认的制度、方法和核对程序。核对时应让用姓名、年龄两项等项目核 患者或其近亲属、授权委托人陈述患者姓名。对患者身份，确保对正确的 a.有患者身份确认制度、方法及核对程序。已下载 见补充材料（患者实施正确的操作。★）2.至少同时使用两种患者身份识别方式，如姓名、年龄、出生年月、年龄、病7 历号、床号等（禁止仅以房间或床号作为识别的唯一依据）。a.至少使用患者姓名、性别、床号3种方式识别。见以上制度。3.相关人员熟悉上述制度和流程并履行相应职责。a.抽查各科室医务人员

【B】符合“C”，并 有规章制度和或程序规范各科室在任何环境和任何地点下都必须持续地履行 查对制度，识别“患者身份”。a.患者身份识别制度及程序 见补充材料 【A】符合“B”，并 1.各科室对本科执行查对制度有监管。a.抽查各科室医务人员 2.职能部门对上述工作进行督导、检查、总结、反馈，有改进措施。a.护理部、医务处进行督导、检查、总结、反馈。b．没有改进措施3.3.3 有手术安全核查与手术风险评估制度与工作流程。3.3.3.1 【C】有手术安全核查与手术风 1.有手术安全核查与手术风险评估制度与流程。险评估制度与流程。（★）a.有 《手术安全核查制度及流程》 《手术风险评估制度与流程》8 Y 2.实施“三步安全核查”，并正确记录：《手术安全核查制度》（1）第一步：麻醉实施前：三方按《手术安全核查表》依次核对患者身份（姓 名、性别、年龄、病案号）、手术方式、知情同意情况、手术部位与标识、麻 醉安全检查、皮肤是否完整、术野皮肤准备、静脉通道建立情况、患者过敏史、抗菌药物皮试结果、术前备血情况、假体、体内植入物、影像学资料等内容。

（2）第二步：手术开始前：三方共同核查患者身份（姓名、性别、年龄）、手 术方式、手术部位与标识，并确认风险预警等内容。手术物品准备情况的核查 由手术室护士执行并向手术医师和麻醉医师报告。（3）第三步：患者离开手术室前：三方共同核查患者身份（姓名、性别、年 龄）、实际手术方式，术中用药、输血的核查，清点手术用物，确认手术标本，检查皮肤完整性、动静脉通路、引流管，确认患者去向等内容。3.手术院感风险评估表应在手术结束后填写。a.具体体现在病案中《手术风险评估表》 4.手术安全核查项目填写完整。a.查手术患者病案 【B】符合“C”，并 1.制定规章制度和工作步骤来统一程序，支持在手术室之外的内科和牙科等部 门的操作，确保正确部位，正确操作和正确病人。a.有相应实行措施（手术安全核查，风险评估制度发文含内科、门诊）2.手术核查手术风险评估执行率≥95。a.查手术病案 已达标（具体体现在病案中院感调查表）【A】符合“B”，并 职能部门对上述工作进行督导、检查、总结、反馈，有改进措施。a.术前病案检查及反馈（01.以及报送考评办扣款材料）3.4.2 医务人员在临床诊疗活动中应严格遵循手卫生相关要求。

3.4.2.1 【C】医护人员在临床诊疗活动 1.对员工提供手卫生培训。中应严格遵循手卫生相关 a.有对洗手的规范程序的培训，各医务人员熟悉该洗手程序。要求。（★）2.有手卫生相关要求（手清洁、手消毒、外科洗手操作规程等）的宣教、图示。9Y a.各科室洗手池有宣教、图示。3.手术室等重点部门外科洗手操作正确率 100。a．手术室外科洗手操作正确率100，抽查相关医务人员 【B】符合“C”，并 1.职能部门有对规范洗手进行督导、检查、总结、反馈，有改进措施。a.护理部进行督导、检查、总结、反馈 b.有改进措施 已下载 见补充材料 2.洗手正确率≥90。a.达到90抽查医务人员 【A】符合“B”，并 不断提高洗手正确率，洗手正确率≥95。a.不断提高3.6.2 建立“危急值”评价制度。3.6.2.1 【C】严格执行“危急值”报告制 1.医技部门相关人员知晓本部门“危急值”项目及内容，能够有效识别和确认度与流程。（★）“危急值”。a.抽查医技科相关人员（通知各科）10 Y 2.接获危急值报告的医护人员应完整、准确记录患者识别信息、危急值内容、和报告者的信息，按流程复核确认无误后，及时向经治或值班医师报告，并做 好记录。a.查各科记录（通知各科）3.医师接获危急值报告后应及时追踪、处置并记录。a.查科室病案（通知各科）【B】符合“C”，并 信息系统能自动识别、提示危急值，相关科室能够通过网络及时向临床科室发 出危急值报告，并有语音或醒目的文字提示。a.与检验科联系确定，可以自动识别 【A】符合“B”，并 有网络监控功能，保障危急值报告、处置及时、有效。a.各科有监控、报告处理（详见各科室报告流程）3.9.1 有主动报告医疗安全（不良）事件与隐患缺陷的制度与可执行的工作流程，并让医务人员充分知晓。3.9.1.1 【C】有主动报告医疗安全（不 1.有医疗安全（不良）事件的报告制度与流程，多种途经便于医务人员报告。良）事件的制度与工作流 a.报告制度《医疗安全不良事件报告制度》文档程。（★）b.报告流程（08，《医疗安全管理》、各临床科室专门成立医疗安全管理小组，发11 Y 生医疗不良事件首先科室调处，医院专家委员会每季度对医疗安全不良事件讨论及 分析，有防患预案）2.有对员工进行不良事件报告制度的教育和培训。a.有培训通知，课件，培训，考核 3.每百张开放床位年报告≥10 件。

a.有 报告表下发各科室 未收集 【B】符合“C”，并 1.有指定部门统一收集、核查、分析医疗安全（不良）事件，采取防范措施。a.医务处 b.不良事件收集、分析、处理、防范措施 2.有指定部门向相关机构上报医疗安全（不良）事件。a.医务处 3.每百张开放床位年报告≥15 件。a.有报告 但数量不足 4.医护人员对不良事件报告制度的知晓率≥95。a.有培训、考试

【A】符合“B”，并 1.建立院内网络医疗安全（不良）事件直报系统及数据库。a.无 2.每百张开放床位年报告≥20 件。a.无 3.改进安全（不良）事件报告系统的敏感性，有效降低漏报率。a.无3.9.2 有激励措施，鼓励医务人员通过“医疗安全（不良）事件报告系统”开展网上报告工作。3.9.2.1 【C】有激励措施鼓励医务人员 1.建立有医务人员主动报告的激励机制。对不良事件呈报实行非惩罚制度。参加“医疗安全（不良）事 a.有主动报告激励制度，08 《医疗安全不良事件报告制度》件报告系统”网上自愿报告 2.严格执行卫生部《医疗质量安全事件报告暂行规定》的规定。

第五篇：太原市类风湿病医院二甲复审制度

前言

随着医药卫生体制改革，促进我院管理理念更新，使我院推行标准化、规范化、精细化管理，提高我院管理水平，建立正常工作秩序，改善服务态度，提高医疗护理质量，防止医疗差错事故，使我院工作适应社会主义建设的要求，在总结《医院工作制度与人员岗位职责等规定汇编》的基础上，结合我院的实际情况，重新修订了《医院工作制度及人员岗位职责》。

本书共收录医院工作制度

项，人员岗位职责

项，十五项核心制度是要求医务人员必须熟练掌握，同时各部门根据本制度和职责的原则要求，认真贯彻执行。

太原市类风湿病医院 二O一一年九月

目录

上篇

太原市类风湿病医院工作制度

行政管理工作制度········································································1

一、院领导干部深入科室制度·································································1

二、会议制度···············································································1

三、院长查房制度···········································································2

四、请示报告制度···········································································2

五、总值班制度·········································································2

六、卫生工作制度···········································································3

七、病历管理制度···········································································3

八、医院统计制度···········································································4

九、医院图书馆/室管理制度···································································4

十、进修工作管理制度·······································································4

十一、患者入院、出院工作管理制度····························································5

十二、住院处工作制度.······································································5

十三、挂号工作度···········································································6

十四、职工上岗前教育制度…·································································6

十五、在岗职工规范化培训制度·······························································6

十六、请假考勤制度·········································································6

十七、社会监督制度·········································································7

十八、医德教育和医德考核制度·······························································7

十九、档案管理制度·········································································7

二十、信息部门管理制度·····································································8 二

十一、医院应急管理制度···································································8 二

十二、卫生技术人力资源管理制度···························································9 二

十三、医院标识管理制度···································································9 二

十四、消防与安全管理制度································································10 二

十五、投诉处理管理制度··································································10 二

十六、信息公示制度······································································11 二

十七、员工意外伤害（含感染、化学、放射等）管理制度··········································11 二

十八、患者知情同意告知制度······························································11 二

十九、医院院务公开制度··································································12 医院各委员会工作制度·································································

一、院务委员会工作制度···································································

二、医院医疗质量管理委员会工作制度························································

三、医院护理质量委员会工作制度···························································

四、医院学术委员会工作制度·······························································

五、医疗技术管理委员会工作制度···························································

六、医院感染管理委员会工作制度···························································

七、药物与治疗学委员会工作制度···························································

八、临床用血管理委员会工作制度···························································

九、医院病案管理委员会工作制度···························································

十、医学伦理委员会工作制度工作制度························································

十一、医院医疗事故鉴定委员会工作制度·····················································

十二、医院安全委员会工作制度···························································

十三、实验室生物安全管理委员会工作制度····················································

十四、医疗器械临床使用安全管理委员会工作制度················································

十五、医院后勤管理委员会工作制度···························································

十六、信息安全管理委员会工作制度···························································

医疗管理制度············································································12

一、抢救室工作制度········································································12

二、门诊工作制度··········································································12

三、处方制度··············································································13

四、病历书写制度··········································································14

五、查房制度··············································································16

六、医嘱制度··············································································16

七、医疗质量管理制度······································································17

八、查对制度··············································································18

九、会诊制度··············································································22

十、转院转科制度··········································································22

十一、双向转诊制度········································································22

十二、病例讨论制度········································································24

十三、值班与交接班制度····································································25

十四、手术室管理制度······································································26

十五、麻醉科工作制度······································································26

十六、重大医疗过失行为和医疗事故报告制度··················································27

十七、医疗技术管理制度····································································27

十八、临床检验危急值报告与应用制度························································28

十九、临床实验（检验、病理）标本采集、储存运送制度········································28

二十、患者评估管理制度····································································29 二

十一、手术（有创操作）分级管理制度························································30 二

十二、危重患者进行高风险诊疗操作的资格许可授权制度······································31 二

十三、首诊负责制度······································································31 二

十四、约束器具使用制度··································································32 二

十五、急危重患者抢救及报告制度··························································32 二

十六、住院病历环节质量与时限基本要求····················································32 二

十七、病房小药柜管理制度································································34 二

十八、中医科工作制度····································································35 二

十九、针灸室工作制度····································································35 三

十、医学工程/医疗器械科（组）工作制度······················································35 护理管理工作制度·······································································36

一、护理部工作制度········································································36

二、病房管理制度··········································································36

三、早会制度··············································································37

四、交接班制度············································································37

五、夜班督导工作制度······································································38

六、执行医嘱制度··········································································38

七、分级护理制度··········································································39

八、护理会诊制度··········································································41

九、病房药品管理制度······································································41

十、病房消毒隔离制度······································································42

十一、皮肤压力伤登记报告制度······························································43

十二、导管滑脱登记报告制度（中心静脉插管、气管插管等）·······································.43

十三、病房安全制度········································································43

十四、患者膳食管理制度····································································44

十五、健康教育制度········································································44

十六、探视、陪伴管理制度···································································45

十七、注射室工作制度······································································45

十八、治疗室工作制度······································································46

十九、换药室工作制度······································································46

二十、患者入院、出院、转院、转科护理工作制度·················································46 二

十一、物资、器材管理制度·································································47 二

十二、病人外出检查制度··································································48 二

十三、护理查房制度······································································49 二

十四、护理查对制度······································································49 二

十五、护理人员技能定期评估制度··························································51 二

十六、护理新技术准入制度································································51 二

十七、护理制度、操作常规变更批准制度·····················································52 二

十八、护理人员继续教育制度······························································52 二

十九、护理应急管理预案··································································53 三

十、护理差错、事故登记报告制度···························································58 三

十一、病房医嘱计算机录入管理制度························································59 三

十二、护理文书书写基本规范与质量监管制度················································59 三

十三、特殊科室管理制度··································································62 三

十四、手部卫生规范与质量监管制度························································68 医院感染管理制度·······································································69

一、医院感染监测管理制度·································································69

二、医院感染消毒隔离制度·································································70

三、消毒药械管理制度·····································································70 四、一次性使用无菌医疗用品管理制度·······················································71

五、医疗废物管理制度·····································································71

六、医院感染的分级防护管理制度···························································71

七、预防重点部位医院感染制度·····························································72

八、医院感染管理委员会工作制度···························································73 药剂部门工作制度·······································································73

一、医院药事管理委员会工作制度···························································74

二、临床用药管理制度·····································································74

三、药剂科工作制度·······································································75

四、调剂室工作制度·······································································75

五、制剂室工作制度·······································································76

六、静脉用药配置中心（室）工作制度·························································77

七、临床药师工作制度·····································································78

八、药房值班工作制度·····································································79

九、药库工作制度·········································································80

十、药品采购工作制度·····································································80

十一、药品验收和保管制度·······························································81

十二、药品质量监控制度·································································81

十三、住院患者自备药品制度·····························································83

十四、麻醉药品、一类精神药品管理制度····················································83

十五、第二类精神药品管理制度···························································85 医技科室工作制度·······································································85

一、检验科工作制度········································································85

二、输血科/血库工作制度····································································86

三、中心实验室管理制度····································································87

四、临床检验危急值报告制度································································89

五、医学影像科（室）工作制度································································90

六、特殊检查室工作制······································································90

七、理疗科工作制度········································································91

八、针灸室工作制度········································································91 财务与物价工作制度·····································································92

一、财务部门工作制度······································································92

二、经费审批及报销制度····································································92

三、医疗收费制度··········································································93

四、财产物资管理制度······································································93

五、票据管理制度··········································································94

六、固定资产管理制度······································································94

七、门诊收费处工作制度····································································94

八、住院处收费工作制度····································································95

九、住院患者退费管理制度··································································95

十、财务会计档案管理制度··································································95

十一、仪器设备、耗材妥购制度·······························································96

十二、物价工作管理制度····································································96

十三、医疗服务价格公示制度································································97

十四、医疗服务项目的病例记录和费用核查制度················································97

十五、住院患者“每日情”制度································································97

十六、绩效工资分配管理制度································································97

十七、内部审计工作制度····································································98

下 篇

太原市类风湿病医院人员岗位职责

管理工作人员职责······································································100

一、院长职责············································································100

二、行政副院长职责······································································100

三、办公室主任职责······································································100

四、医务科/处主任职责····································································101

五、医用图书管理员职责··································································101

六、病案管理员职责······································································101

七、医疗统计人员职责····································································102

八、人事（或人力资源管理）科科长职责······················································102

九、总务科科长职责······································································102

十、医学装备管理部门主任职责····························································103

十一、信息管理部门负责人职责··························································103

十一、医疗保险管理部门负责人职责·························································103 医疗工作人员职责······································································104

一、临床科主任职责·······································································104

二、临床主任医师职责·····································································105

三、临床主治医师职责·····································································105

四、总住院医师职责·······································································105

五、临床住院医师职责·····································································106

六、门诊部主任职责·······································································106

七、麻醉科主任职责·······································································107

八、麻醉科主任医师职责···································································107

九、麻醉科主治医师职责···································································107

十、麻醉科医师职责·······································································107 护理部工作人员职责····································································108

一、护理部主任职责·······································································108

二、护理部副主任职责·····································································108

三、护士长职责···········································································109

四、主任（副主任）护师职责·································································109

五、主管护师职责·········································································110

六、护师职责·············································································110

七、护士职责·············································································110

八、护理员职责···········································································111

九、门诊护士长职责·······································································111 十、门诊护士职责········································································111

十一、手术室护士长职责···································································112

十二、手术室护士职责·····································································112

十三、消毒供应中心（室）护士长职责·························································112

十四、消毒供应中心（室）护士职责···························································113 药学工作人员职责······································································113

一、药剂科主任职责······································································113

二、药剂科各室、组负责人职责·····························································114

三、主任(中、西)药师职责··································································114

四、主管（中、西）药师职责·································································114

五、药剂师（中药师）职责··································································114

六、药剂士（中药药剂士）职责······························································115

七、临床药师职责 ·······································································115

八、调剂人员职责········································································115

九、制剂人员职责········································································116

十、药品采购人员职责····································································116

十一、药品验收保管人员职责····························································116

十二、药学信息咨询服务人员职责························································116 医技工作人员职责······································································117

一、医学影像/放射科主任职责······························································117

二、医学影像/放射科主任医师职责··························································117

三、医学影像/放射科主治医师职责··························································117

四、医学影像/放射科医师职责······························································118

五、医学影像/放射科技师职责······························································118

六、医学影像/放射科技士、技术员职责·······················································118

七、物理治疗科主任职责··································································118

八、理疗科主治医师职责··································································119

九、理疗科医师职责······································································119

十、理疗科技师、技士、见习员职责··························································119

十一、医院感染管理部门主任/负责人职责··················································119

十二、检验科主任职责··································································120

十三、主任（副主任）检验师职责··························································121

十四、主管检验师职责··································································122

十五、检验师职责······································································122

十六、检验士职责······································································122

十七、临床检验医师职责································································123

十八、检验科质量主管职责······························································123

十九、检验科技术主管职责······························································123 财务工作人员职责······································································124

一、财务部门负责人职责··································································124

二、财务部门会计职责····································································125

三、财务部门出纳职责····································································125

四、财务部门成本及奖金核算人员职责······················································125

五、住院处、门急诊收费处收费员职责·······················································126

六、住院、门急诊收费处审核人员职责·······················································126

七、价人员职责···········································································126