1、醫(yī)院制度職責(zé)目 錄第一部分 工作制度第1章 黨群系統(tǒng)第1節(jié) 黨委工作制度············································

2、·1 一、 政治理論學(xué)習(xí)制度··········································3 二、 黨員廉潔自律制度··

3、3;·······································4 三、 黨支部三會(huì)一課制度········&#

4、183;·······························4 四、 創(chuàng)先爭(zhēng)優(yōu)制度················

5、83;·························8 五、 黨員聯(lián)系群眾制度······················&#

6、183;···················8 六、 黨員教育制度····························

7、83;··············9 第二節(jié) 團(tuán)委工作制度·································

8、83;········10 一、 團(tuán)組織生活制度·······································&#

9、183;·10 二、 學(xué)習(xí)教育制度··········································11 第三節(jié) 工會(huì)工作制度··&

10、#183;·······································12 一、 工會(huì)會(huì)員管理制度········

11、;·······························13 第四節(jié) 老干部科工作制度················&#

12、183;····················14 第五節(jié) 監(jiān)察科工作制度···························

13、··········14 第六節(jié) 維權(quán)辦工作制度·····································14 第

14、七節(jié) 效能辦工作制度·····································15第2章 行政系統(tǒng)第一節(jié) 人事管理制度········

15、···································15 一、 職工請(qǐng)銷(xiāo)假制度·············

16、;···························23 二、 臨時(shí)工管理制度····················

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

18、3;···········25 四、 離崗培訓(xùn)制度····································

19、3;···26 五、 關(guān)于在職職工自費(fèi)脫產(chǎn)學(xué)習(xí)的有關(guān)規(guī)定··················28 六、 新參加工作滿(mǎn)一年（見(jiàn)習(xí)期滿(mǎn)）后轉(zhuǎn)正定級(jí)有關(guān)規(guī)定······28 七、 再分配人員管理制度···········

20、83;····························28 八 關(guān)于我院中層干部民主考評(píng)工作的實(shí)施意見(jiàn)·················

21、83;29 第三節(jié) 教育科研制度······································30 一、 進(jìn)修、實(shí)習(xí)人員管理制度······

22、83;·····························30 二、 進(jìn)修、實(shí)習(xí)生管理制度··················

23、;··················31 三、 醫(yī)務(wù)人員外出進(jìn)修制度·····························&

24、#183;······31 四、 外出參加學(xué)術(shù)活動(dòng)管理制度··································32 五、 臨床住院醫(yī)師規(guī)范化培訓(xùn)制度···

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

26、3;···················34 七、 科研工作獎(jiǎng)勵(lì)辦法····························&#

27、183;·········36 第四節(jié) 預(yù)防保健科工作制度··································37一、 健康教育工作制度·

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

29、83;··················39（1） 傳染病管理網(wǎng)絡(luò)系統(tǒng)·····························

30、·····39（2） 傳染病知識(shí)培訓(xùn)制度··································39（3） 法定傳染病及性病······&

31、#183;···························40（4） 傳染病網(wǎng)絡(luò)直報(bào)制度···················

32、3;··············40（5） 傳染病首診負(fù)責(zé)制度·································&

33、#183;41（6） 傳染病疫情報(bào)告程序··································41（7） 傳染病疫情自查制度··········&

34、#183;·······················41（8） 傳染病消毒隔離制度·······················

35、3;··········42（9） 傳染病病例登記和轉(zhuǎn)診制度····························42（10） 不明原因肺炎會(huì)診排查制度·····

36、83;······················42（11） 傳染病預(yù)檢分診制度·························

37、;·········44（12） 住院患者傳染病登記規(guī)范······························45（13） 傳染病患者密切接觸者管理制度····&#

38、183;···················45（14） 肺結(jié)核患者管理實(shí)施辦法···························&#

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

40、183;·····················46 （二） 死亡病例網(wǎng)絡(luò)直報(bào)制度·························

41、83;·····46 七、突發(fā)公共衛(wèi)生事件制度·······························47 （一）突發(fā)公共衛(wèi)生事件報(bào)告制度········

42、·······················48 （二）突發(fā)公共事件報(bào)告程序和時(shí)限························

43、;·····48 八、職工保健制度··································48 （一）醫(yī)院職工保健制度······

44、3;····························48 （二）醫(yī)院工作人員發(fā)生銳器刺傷的應(yīng)急處理原則···············48第6節(jié) 信息管理制度

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

46、83;·····················51 二、 病歷借閱制度··························

47、83;········51 三、 病歷復(fù)印制度···································51 四、 醫(yī)療登記、統(tǒng)計(jì)管理制度·

48、3;·································52 五、 圖書(shū)、期刊借閱制度··············&

49、#183;····················53 六、 電子閱覽室管理制度··························

50、3;········54 七、 讀者守則···································54第7節(jié) 財(cái)務(wù)管理制度···

51、································551、 物價(jià)收費(fèi)管理制度················

52、;···················58第八節(jié) 設(shè)備科工作制度····························

53、3;······602、 醫(yī)療儀器設(shè)備管理制度···································603、 醫(yī)療儀器安全使用制度···

54、3;·······························614、 計(jì)量管理工作制度················

55、83;··················635、 醫(yī)療儀器維修保養(yǎng)制度·····························

56、······646、 中心供氧安全管理制度···································647、 滅火設(shè)備的使用····

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

58、183;·················659、 醫(yī)用氧氣管理制度······························&

59、#183;····6510、 設(shè)備計(jì)劃管理制度···································6611、 醫(yī)療器械采購(gòu)制度·····

60、83;·····························6612、 醫(yī)療設(shè)備更新管理制度··················

61、;·················6613、 搶救設(shè)備操作管理制度······························&

62、#183;····6714、 大型醫(yī)療儀器資源共享制度·······························6815、 應(yīng)招標(biāo)目錄外的醫(yī)療耗材采購(gòu)管理制度·······&#

63、183;·············6816、 普通醫(yī)用耗材采購(gòu)管理制度·······························6817、 高值耗材和貴重藥

64、品使用管理制度··························6818、 一次性使用無(wú)菌醫(yī)療用品消毒產(chǎn)品管理制度··················6919

65、、 一次性使用無(wú)菌醫(yī)療用品管理制度·························6920、 醫(yī)療器械不良反應(yīng)報(bào)告制度···················&

66、#183;···········7021、 可疑醫(yī)療器械不良事件報(bào)告表填寫(xiě)說(shuō)明···················71第10節(jié) 總務(wù)科工作制度·············

67、······················711、 物資管理工作制度··························

68、;·········722、 用水管理工作制度···································723、 用電管理工作制度·

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

70、3;····················755、 固定資產(chǎn)管理制度···························

71、83;·······76第3章 醫(yī)療管理第一節(jié) 醫(yī)療質(zhì)量、安全管理核心制度（十三項(xiàng)）·······················79 一、 首診負(fù)責(zé)制············&#

72、183;······················79 二、 三級(jí)醫(yī)師查房制度·························

73、··········79 三、 疑難病例討論制度···································79 四、 術(shù)前病例討論制度&#

74、183;··································80 五、 死亡病例討論制度·············

75、······················806、 危重病例搶救制度··························

76、;·········807、 會(huì)診制度···································818、 查對(duì)制度···

77、;································829、 手術(shù)分級(jí)管理制度···············

78、3;···················8310、 值班與交接班制度····························&#

79、183;······8911、 臨床用血審批制度···································8912、 病歷書(shū)寫(xiě)規(guī)范與病歷管理制度···

80、;·························9013、 分級(jí)護(hù)理管理制度······················

81、83;············91第2節(jié) 醫(yī)療準(zhǔn)入制度···································92（

82、1） 新技術(shù)、新業(yè)務(wù)準(zhǔn)入管理制度····························95（2） 醫(yī)師及醫(yī)技人員職業(yè)準(zhǔn)入制度················&

83、#183;···········92（3） 有創(chuàng)操作準(zhǔn)入制度···································93第3節(jié)

84、 門(mén)、急診管理制度···································94 （一) 門(mén)診管理制度···········&#

85、183;·······················94 （二） 急診管理制度························&

86、#183;··········95 （三） 專(zhuān)家門(mén)診管理制度···································96 （四） 醫(yī)療證

87、明管理制度···································96 （五） 檢驗(yàn)報(bào)告管理制度···········

88、3;·······················97第4節(jié) 住院相關(guān)制度························

89、3;··········97 （一）入院與出院制度···································97 （二）醫(yī)囑制度·

90、;··································98 （三）轉(zhuǎn)院與轉(zhuǎn)科制度·············

91、3;····················98第5節(jié) 手術(shù)有關(guān)制度···························

92、3;······991、 手術(shù)制度··································992、 圍手術(shù)期管理制度······

93、····························1013、 手術(shù)安全核對(duì)與手術(shù)風(fēng)險(xiǎn)評(píng)估制度··················

94、83;········1054、 實(shí)施診療技術(shù)操作的有關(guān)規(guī)定·······························105第6節(jié) 醫(yī)療安全相關(guān)制度·····

95、;·····························1091、 知情同意書(shū)簽字制度··················&#

96、183;···············1092、 醫(yī)療安全管理制度································

97、··1133、 防止醫(yī)療事故發(fā)生的措施和制度·····························1144、 保護(hù)性醫(yī)療和保護(hù)患者隱私制度············&#

98、183;················1145、 實(shí)施醫(yī)療技術(shù)操作的有關(guān)規(guī)定······························1

99、156、 醫(yī)療請(qǐng)示報(bào)告制度··································115第7節(jié) 報(bào)告制度············

100、······················1161、 緊急情況及重大醫(yī)療事件報(bào)告制度························

101、83;··1162、 危重患者搶救報(bào)告制度··································1163、 死亡病例報(bào)告制度········

102、83;·························1164、 醫(yī)療糾紛、差錯(cuò)、事故報(bào)告制度·····················&

103、#183;········1165、 藥品不良反應(yīng)報(bào)告制度··································1176、 傳染病、性病報(bào)告制度··

104、;································117第8節(jié) 藥品處方管理制度···············&#

105、183;·················1171、 處方規(guī)范制度······························&#

106、183;··1172、 關(guān)于控制藥品費(fèi)用、加強(qiáng)藥品使用環(huán)節(jié)管理的規(guī)定··············1183、 處方權(quán)申請(qǐng)、審批制度··························

107、·······1194、 抗菌藥物臨床使用管理制度·································1195、 特殊藥品管理制度····

108、3;····························119第9節(jié) 其它相關(guān)制度···················

109、83;·············1201、 醫(yī)院緊急召集制度·································1202、 醫(yī)

110、院病歷管理辦法（草案）·································1213、 醫(yī)師外出會(huì)診管理制度及管理細(xì)則···········

111、3;···············1214、 外聘醫(yī)師來(lái)院或受聘外院醫(yī)師管理制度·······················1225、 醫(yī)師定期考核實(shí)施辦法·····&

112、#183;···························1226、 單病種質(zhì)量管理與控制方案···················&

113、#183;·············1227、 高年資住院醫(yī)師及主治醫(yī)師急診科輪轉(zhuǎn)制度···················1238、 臨床輸血管理制度··········

114、3;······················124第4章 門(mén)診工作制度第一節(jié) 門(mén)診工作管理制度·······················

115、83;·········183第二節(jié) 門(mén)診醫(yī)師管理辦法實(shí)施細(xì)則·································184第三節(jié) 專(zhuān)家門(mén)診管理制度··

116、;·······························184第四節(jié) 門(mén)診護(hù)理工作制度················&#

117、183;················185第五節(jié) 門(mén)診首診負(fù)責(zé)制度·······························

118、;··185第六節(jié) 門(mén)診會(huì)診轉(zhuǎn)診制度·································186第七節(jié) 門(mén)診分診護(hù)士工作制度·········

119、83;·······················186第八節(jié) 門(mén)診導(dǎo)醫(yī)工作制度························

120、·········186第九節(jié) 門(mén)診診前準(zhǔn)備制度·································187第十節(jié) 門(mén)診預(yù)約診療制度···

121、······························187第十一節(jié) 門(mén)診驗(yàn)診制度·················

122、3;···············188第十二節(jié) 門(mén)診登記統(tǒng)計(jì)制度································

123、·188第十三節(jié) 門(mén)診消毒隔離制度·································188第十四節(jié) 門(mén)診環(huán)境管理制度··········

124、3;······················188第十五節(jié) 門(mén)診醫(yī)護(hù)人員宣教工作管理制度························

125、··188第5章 護(hù)理管理制度第1節(jié) 護(hù)理行政管理·································1891、 護(hù)理部工作制度·········

126、························1892、 護(hù)理職業(yè)人員準(zhǔn)入制度·······················&#

127、183;·········1893、 護(hù)理部各種會(huì)議制度·································1894、 護(hù)理部夜班督導(dǎo)制度··&#

128、183;······························1905、 護(hù)理查房制度·················&#

129、183;···············1906、 請(qǐng)示報(bào)告制度································&#

130、183;1907、 護(hù)理人員考核制度·································1908、 護(hù)理人員獎(jiǎng)懲制度···········

131、3;·····················1919、 護(hù)理人員緊急替代制度··························

132、·······19210、 護(hù)理質(zhì)量管理制度·································19211、 護(hù)理新技術(shù)、新業(yè)務(wù)準(zhǔn)入制度····&

133、#183;·······················19312、 護(hù)理投訴管理制度·······················

134、3;·········19413、 工休座談會(huì)制度·································19414、 護(hù)理缺陷登記報(bào)告制度··

135、83;······························19515、 臨床護(hù)理教學(xué)管理制度················

136、3;················19516、 新護(hù)士崗前培訓(xùn)制度·······························

137、··19617、 護(hù)士規(guī)范化培訓(xùn)教育制度·······························19618、 在職護(hù)士繼續(xù)教育制度···········&

138、#183;·····················197第2節(jié) 護(hù)理業(yè)務(wù)技術(shù)管理·························

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

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

141、3;············2004、 護(hù)理工作制度·································2015、 交接班制度·

142、;································2016、 分級(jí)護(hù)理制度················

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

144、83;··2028、 危重患者搶救制度·································2039、 執(zhí)行醫(yī)囑制度··········&

145、#183;······················20310、 查對(duì)制度·························&#

146、183;·······20411、 接待患者入院、出院、轉(zhuǎn)科制度····························20512、 飲食管理制度········

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

148、83;·········20614、 護(hù)理病例討論制度·································20615、 護(hù)理會(huì)診制度···

149、;······························20616、 各項(xiàng)護(hù)理操作前告知制度·················

150、;················20617、 病房藥品管理制度·······························&#

151、183;·20718、 藥品管理制度·································207第3節(jié) 各室管理制度···········

152、······················211 一、護(hù)辦室工作制度··························

153、;·······211 二、治療室工作制度·································211 三、注射室工作制度·····

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

155、183;············212 五、換藥室工作制度·································212第6章 醫(yī)院感染管理

156、制度第1節(jié) 醫(yī)院感染知識(shí)培訓(xùn)制度·································231第2節(jié) 醫(yī)院感染臨床病例監(jiān)測(cè)制度···········&

157、#183;···················231第3節(jié) 醫(yī)院感染流行、暴發(fā)的報(bào)告與控制制度·······················232第4節(jié) 消毒、滅菌效果監(jiān)測(cè)制度&

158、#183;································232第5節(jié) 重要部位醫(yī)院感染預(yù)防控制措施·············

159、3;··············232第6節(jié) 清潔、消毒、隔離制度·······························233第7節(jié) 醫(yī)務(wù)人員

160、手衛(wèi)生制度·································234第8節(jié) 醫(yī)務(wù)人員職業(yè)暴露防護(hù)制度·············

161、··················234第9節(jié) 消毒藥械、一次性使用醫(yī)療用品管理制度·····················235第10節(jié) 醫(yī)療廢物管理制度····&

162、#183;····························235第11節(jié) 參與抗菌藥物臨床應(yīng)用管理制度·················

163、83;·········236第12節(jié) 醫(yī)務(wù)人員利器傷報(bào)告及處理制度··························236第13節(jié) 醫(yī)務(wù)人員HIV、HBV、HCV 職業(yè)暴露報(bào)告及處理制度·····

164、····236第14節(jié) 突發(fā)事件的報(bào)告與處理制度······························237第15節(jié) 職業(yè)暴露的處理流程··········

165、;·······················237第16節(jié) 醫(yī)務(wù)人員職業(yè)防護(hù)措施························

166、;·········238第17節(jié) 醫(yī)療廢物泄露、流失、擴(kuò)散應(yīng)急預(yù)案························238第18節(jié) 醫(yī)院感染流行、暴發(fā)應(yīng)急預(yù)案·········&#

167、183;···················238第19節(jié) 耐藥菌或特殊病原體感染監(jiān)測(cè)上報(bào)制度·····················239第20節(jié) 無(wú)菌技術(shù)操作原則··

168、83;······························239第21節(jié) 重點(diǎn)部門(mén)的醫(yī)院感染管理制度················

169、···········2401、 ICU醫(yī)院感染管理制度·································2402、 透析室醫(yī)院感染管理制度&#

170、183;································2413、 內(nèi)窺鏡室醫(yī)院感染管理制度··············&#

171、183;··················2414、 檢驗(yàn)科醫(yī)院感染管理制度····························

172、83;····2425、 口腔科醫(yī)院感染管理制度·································2426、 導(dǎo)管室醫(yī)院感染管理制度·······

173、;··························2437、 血液病房醫(yī)院感染管理制度·····················

174、;············2438、 消毒供應(yīng)室醫(yī)院感染管理制度·····························2449、 門(mén)診醫(yī)院醫(yī)院感染管理制度·············