太原市类风湿病医院二甲复审制度_二甲医院信息制度
太原市类风湿病医院二甲复审制度由刀豆文库小编整理，希望给你工作、学习、生活带来方便，猜你可能喜欢“二甲医院信息制度”。
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
