前言隨著醫(yī)藥衛(wèi)生體制改革，促進我院管理理念更新，使我院推行標準化、規(guī)范化、精細化管理，提高我院管理水平，建立正常工作秩序，改善服務態(tài)度，提高醫(yī)療護理質量，防止醫(yī)療差錯事故，使我院工作適應社會主義建設的要求，在總結《醫(yī)院工作制度與人員崗位職責等規(guī)定匯編》的基礎上，結合我院的實際情況，重新修訂了《醫(yī)院工作制度及人員崗位職責》。本書共收錄醫(yī)院工作制度項，人員崗位職責項，十五項核心制度是要求醫(yī)務人員必須熟練掌握，同時各部門根據(jù)本制度和職責的原則要求，認真貫徹執(zhí)行。太原市類風濕病醫(yī)院二O一一年九月目錄上篇太原市類風濕病醫(yī)院工作制度行政管理工作制度········································································1一、院領導干部深入科室制度·································································1二、會議制度···············································································1三、院長查房制度···········································································2四、請示報告制度···········································································2五、總值班制度·········································································2六、衛(wèi)生工作制度···········································································3七、病歷管理制度···········································································3八、醫(yī)院統(tǒng)計制度···········································································4九、醫(yī)院圖書館/室管理制度···································································4十、進修工作管理制度·······································································4十一、患者入院、出院工作管理制度····························································5十二、住院處工作制度.······································································5十三、掛號工作度···········································································6十四、職工上崗前教育制度…·································································6十五、在崗職工規(guī)范化培訓制度·······························································6十六、請假考勤制度·········································································6十七、社會監(jiān)督制度·········································································7十八、醫(yī)德教育和醫(yī)德考核制度·······························································7十九、檔案管理制度·········································································7二十、信息部門管理制度·····································································8二十一、醫(yī)院應急管理制度···································································8二十二、衛(wèi)生技術人力資源管理制度···························································9二十三、醫(yī)院標識管理制度···································································9二十四、消防與安全管理制度································································10二十五、投訴處理管理制度··································································10二十六、信息公示制度······································································11二十七、員工意外傷害（含感染、化學、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、醫(yī)院院務公開制度··································································12醫(yī)院各委員會工作制度·································································一、院務委員會工作制度···································································二、醫(yī)院醫(yī)療質量管理委員會工作制度························································三、醫(yī)院護理質量委員會工作制度···························································四、醫(yī)院學術委員會工作制度·······························································五、醫(yī)療技術管理委員會工作制度···························································六、醫(yī)院感染管理委員會工作制度···························································七、藥物與治療學委員會工作制度···························································八、臨床用血管理委員會工作制度···························································九、醫(yī)院病案管理委員會工作制度···························································十、醫(yī)學倫理委員會工作制度工作制度························································十一、醫(yī)院醫(yī)療事故鑒定委員會工作制度·····················································十二、醫(yī)院安全委員會工作制度···························································十三、實驗室生物安全管理委員會工作制度····················································十四、醫(yī)療器械臨床使用安全管理委員會工作制度················································十五、醫(yī)院后勤管理委員會工作制度···························································十六、信息安全管理委員會工作制度···························································醫(yī)療管理制度············································································12一、搶救室工作制度········································································12二、門診工作制度··········································································12三、處方制度··············································································13四、病歷書寫制度··········································································14五、查房制度··············································································16六、醫(yī)囑制度··············································································16七、醫(yī)療質量管理制度······································································17八、查對制度··············································································18九、會診制度··············································································22十、轉院轉科制度··········································································22十一、雙向轉診制度········································································22十二、病例討論制度········································································24十三、值班與交接班制度····································································25十四、手術室管理制度······································································26十五、麻醉科工作制度······································································26十六、重大醫(yī)療過失行為和醫(yī)療事故報告制度··················································27十七、醫(yī)療技術管理制度····································································27十八、臨床檢驗危急值報告與應用制度························································28十九、臨床實驗（檢驗、病理）標本采集、儲存運送制度········································28二十、患者評估管理制度····································································29二十一、手術（有創(chuàng)操作）分級管理制度························································30二十二、危重患者進行高風險診療操作的資格許可授權制度······································31二十三、首診負責制度······································································31二十四、約束器具使用制度··································································32二十五、急危重患者搶救及報告制度··························································32二十六、住院病歷環(huán)節(jié)質量與時限基本要求····················································32二十七、病房小藥柜管理制度································································34二十八、中醫(yī)科工作制度····································································35二十九、針灸室工作制度····································································35三十、醫(yī)學工程/醫(yī)療器械科（組）工作制度······················································35護理管理工作制度·······································································36一、護理部工作制度········································································36二、病房管理制度··········································································36三、早會制度··············································································37四、交接班制度············································································37五、夜班督導工作制度······································································38六、執(zhí)行醫(yī)囑制度··········································································38七、分級護理制度··········································································39八、護理會診制度··········································································41九、病房藥品管理制度······································································41十、病房消毒隔離制度······································································42十一、皮膚壓力傷登記報告制度······························································43十二、導管滑脫登記報告制度（中心靜脈插管、氣管插管等）·······································.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、探視、陪伴管理制度···································································45十七、注射室工作制度······································································45十八、治療室工作制度······································································46十九、換藥室工作制度······································································46二十、患者入院、出院、轉院、轉科護理工作制度·················································46二十一、物資、器材管理制度·································································47二十二、病人外出檢查制度··································································48二十三、護理查房制度······································································49二十四、護理查對制度······································································49二十五、護理人員技能定期評估制度··························································51二十六、護理新技術準入制度································································51二十七、護理制度、操作常規(guī)變更批準制度·····················································52二十八、護理人員繼續(xù)教育制度······························································52二十九、護理應急管理預案··································································53三十、護理差錯、事故登記報告制度···························································58三十一、病房醫(yī)囑計算機錄入管理制度························································59三十二、護理文書書寫基本規(guī)范與質量監(jiān)管制度················································59三十三、特殊科室管理制度··································································62三十四、手部衛(wèi)生規(guī)范與質量監(jiān)管制度························································68醫(yī)院感染管理制度·······································································69醫(yī)院感染監(jiān)測管理制度·································································69醫(yī)院感染消毒隔離制度·································································70消毒藥械管理制度·····································································70一次性使用無菌醫(yī)療用品管理制度·······················································71醫(yī)療廢物管理制度·····································································71醫(yī)院感染的分級防護管理制度···························································71預防重點部位醫(yī)院感染制度·····························································72醫(yī)院感染管理委員會工作制度···························································73藥劑部門工作制度·······································································73醫(yī)院藥事管理委員會工作制度···························································74臨床用藥管理制度·····································································74藥劑科工作制度·······································································75調(diào)劑室工作制度·······································································75制劑室工作制度·······································································76靜脈用藥配置中心（室）工作制度·························································77臨床藥師工作制度·····································································78藥房值班工作制度·····································································79藥庫工作制度·········································································80藥品采購工作制度·····································································80藥品驗收和保管制度·······························································81藥品質量監(jiān)控制度·································································81住院患者自備藥品制度·····························································83麻醉藥品、一類精神藥品管理制度····················································83第二類精神藥品管理制度···························································85醫(yī)技科室工作制度·······································································85一、檢驗科工作制度········································································85二、輸血科/血庫工作制度····································································86三、中心實驗室管理制度····································································87四、臨床檢驗危急值報告制度································································89五、醫(yī)學影像科（室）工作制度································································90六、特殊檢查室工作制······································································90七、理療科工作制度········································································91八、針灸室工作制度········································································91財務與物價工作制度·····································································92一、財務部門工作制度······································································92二、經(jīng)費審批及報銷制度····································································92三、醫(yī)療收費制度··········································································93四、財產(chǎn)物資管理制度······································································93五、票據(jù)管理制度··········································································94六、固定資產(chǎn)管理制度······································································94七、門診收費處工作制度····································································94八、住院處收費工作制度····································································95九、住院患者退費管理制度··································································95十、財務會計檔案管理制度··································································95十一、儀器設備、耗材妥購制度·······························································96十二、物價工作管理制度····································································96十三、醫(yī)療服務價格公示制度································································97十四、醫(yī)療服務項目的病例記錄和費用核查制度················································97十五、住院患者“每日情”制度································································97十六、績效工資分配管理制度································································97十七、內(nèi)部審計工作制度····································································98下篇太原市類風濕病醫(yī)院人員崗位職責管理工作人員職責······································································100院長職責············································································100行政副院長職責······································································100辦公室主任職責······································································100醫(yī)務科/處主任職責····································································101醫(yī)用圖書管理員職責··································································101病案管理員職責······································································101醫(yī)療統(tǒng)計人員職責····································································102人事（或人力資源管理）科科長職責······················································102總務科科長職責······································································102醫(yī)學裝備管理部門主任職責····························································103信息管理部門負責人職責··························································103十一、醫(yī)療保險管理部門負責人職責·························································103醫(yī)療工作人員職責······································································104一、臨床科主任職責·······································································104二、臨床主任醫(yī)師職責·····································································105三、臨床主治醫(yī)師職責·····································································105四、總住院醫(yī)師職責·······································································105五、臨床住院醫(yī)師職責·····································································106六、門診部主任職責·······································································106七、麻醉科主任職責·······································································107八、麻醉科主任醫(yī)師職責···································································107九、麻醉科主治醫(yī)師職責···································································107十、麻醉科醫(yī)師職責·······································································107護理部工作人員職責····································································108一、護理部主任職責·······································································108二、護理部副主任職責·····································································108三、護士長職責···········································································109四、主任（副主任）護師職責·································································109五、主管護師職責·········································································110六、護師職責·············································································110七、護士職責·············································································110八、護理員職責···········································································111九、門診護士長職責·······································································111十、門診護士職責········································································111十一、手術室護士長職責···································································112十二、手術室護士職責·····································································112十三、消毒供應中心（室）護士長職責·························································112十四、消毒供應中心（室）護士職責···························································113藥學工作人員職責······································································113藥劑科主任職責······································································113藥劑科各室、組負責人職責·····························································114主任(中、西)藥師職責··································································114主管（中、西）藥師職責·································································114藥劑師（中藥師）職責··································································114藥劑士（中藥藥劑士）職責······························································115臨床藥師職責·······································································115調(diào)劑人員職責········································································115制劑人員職責········································································116藥品采購人員職責····································································116藥品驗收保管人員職責····························································116藥學信息咨詢服務人員職責························································116醫(yī)技工作人員職責······································································117醫(yī)學影像/放射科主任職責······························································117醫(yī)學影像/放射科主任醫(yī)師職責··················