医院制度汇编大全2

XXX 中心医院制度汇编
XX 中心医院院长办公室编写
2019 年 9 月修订
目 录
第一篇 病人服务篇
第一章 临床管理 ......................................................................................................................................1
LC—001：门诊工作制度 ...................................................................................................................2
LC—002：门诊管理制度 ...................................................................................................................3
LC—003：门诊预检分诊制度 ...........................................................................................................4
LC—004：专家、专科门诊工作制度 ...............................................................................................5
LC—005：急诊工作制度 ...................................................................................................................6
LC—006：急诊预检分诊工作制度 ...................................................................................................7
LC—007：抢救室工作制度 ...............................................................................................................8
LC—008：急诊留观制度 ...................................................................................................................9
LC—009：急诊绿色通道管理制度 .................................................................................................10
LC—010：院前急救与急诊科交接制度 .........................................................................................12
LC—011：入院制度 .........................................................................................................................13
LC—012：患者病情评估制度 .........................................................................................................14
LC—013：首诊医师负责制 .............................................................................................................16
LC—014：三级医师负责制 .............................................................................................................17
LC—015：查房制度 .........................................................................................................................18
LC—016：医嘱制度 .........................................................................................................................20
LC—017：处方制度 .........................................................................................................................21
LC—018：会诊制度 .........................................................................................................................24
LC—019：病例讨论制度 .................................................................................................................27
LC—020：值班、交接班制度 .........................................................................................................29
LC—021：查对制度 .........................................................................................................................31
LC—022：转科制度 .........................................................................................................................35
LC—023：转院制度 .........................................................................................................................36
LC—024：患者出院、随访及复诊预约制度 .................................................................................37
LC—025：围手术期管理制度 .........................................................................................................38
LC—026：手术分级管理办法 .........................................................................................................41
LC—027：手术部位识别标示制度 .................................................................................................44
LC—028：手术安全核查制度 .........................................................................................................45
LC—029：手术风险评估制度 .........................................................................................................46
LC—030：急症手术管理制度 .........................................................................................................47
LC—031：介入诊疗技术临床应用管理制度 .................................................................................48
LC—032：人工关节技术临床应用管理制度 .................................................................................50
LC—033：医疗技术临床应用管理制度 .........................................................................................51
LC—034：新技术准入及临床应用管理制度 .................................................................................54
LC—035：高风险诊疗操作的资格许可授权制度 .........................................................................58
LC—036：医疗技术风险管理制度 .................................................................................................59
LC—037：危重患者抢救制度 .........................................................................................................60
LC—038：危重患者协调管理制度 .................................................................................................61
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LC—039：科室人员紧急替代制度 .................................................................................................62
LC—040：重大手术报告审批制度 .................................................................................................63
LC—041：非计划再次手术上报及监管制度 .................................................................................64
LC—042：临床输血管理制度 .........................................................................................................65
LC—043：安全输血操作规程 .........................................................................................................67
LC—044：陪检制度 .........................................................................................................................69
LC—045：临床检验标本采集、储存、运送制度 .........................................................................70
LC—046：临床“危急值”报告管理制度 .....................................................................................72
LC—047：医疗安全（不良）事件报告制度 .................................................................................78
LC—048：重大医疗过失行为和医疗事故报告制度 .....................................................................80
LC—049：关于缩短患者平均住院日的管理规定 .........................................................................82
LC—050：单病种质量管理制度 .....................................................................................................84
LC—051：临床路径管理工作制度 .................................................................................................85
LC—052：床位调配及跨病区收治患者管理制度 .........................................................................87
LC—053：双向转诊管理制度 .........................................................................................................89
LC—054：医疗证明管理制度 .........................................................................................................91
LC—055：麻醉科质量与安全管理制度 .........................................................................................92
LC—056：麻醉医师资格分级授权管理制度 .................................................................................93
LC—057：麻醉科术前术后访视和讨论制度 .................................................................................94
LC—058：麻醉恢复室管理制度 .....................................................................................................95
LC—059：急诊科管理制度 .............................................................................................................96
LC—060：重症医学科（ICU）管理制度 ......................................................................................97
LC—061：重症医学科（ICU）的收治范围 ..................................................................................99
LC—062：重症医学科（ICU）患者实施危重程度评分制度 ....................................................100
LC—063：器官移植工作制度 .......................................................................................................101
LC—064：活体亲属肾移植实施规范 ...........................................................................................104
LC—065：器官移植术后随访制度 ...............................................................................................105
LC—066：器官移植保密制度 .......................................................................................................106
LC—067：放射治疗工作制度 .......................................................................................................107
LC—068：放射诊疗质量保证制度 ...............................................................................................108
LC—069：放射诊疗工作人员健康监护制度 ...............................................................................110
LC—070：放射防护安全管理制度 ...............................................................................................111
LC—071：突发性核事故与辐射事故速报制度 ...........................................................................112
LC—072：护理质量管理委员会工作制度 ...................................................................................113
LC—073：护理质量持续改进管理办法 .......................................................................................114
LC—074：护士长夜值班制度 .......................................................................................................116
LC—075：护理人员执业准入制度 ...............................................................................................117
LC—076：护理专项技术操作资格准入管理办法 .......................................................................120
LC—077：护理人员紧急及弹性调配办法 ...................................................................................121
LC—078：分级护理制度 ...............................................................................................................122
LC—079：危重患者护理质量管理制度 .......................................................................................124
LC—080：护理单元抢救车管理办法 ...........................................................................................125
LC—081：护理查房、病例讨论制度 ...........................................................................................126
LC—082：护理会诊制度 ...............................................................................................................127