JCI临床麻醉管理规程

2025-10-19 999+ 84KB 10 页海报

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1、标准 (Standard):

ASC.4 A qualified individual conducts a preanesthesia assessment and

preinduction assessment.

ASC.5 Each patient’s anesthesia care is planned and documented, and the

anesthesia and technique used are documented in the patient’s record.

ASC.5.1 The risks, benefits, and alternatives related to anesthesia are

discussed with the patient, his or her family, or those who make decisions for

the patient.

ASC.6 Each patient’s physiological status during anesthesia and surgery is

monitored according to professional practiceguidelines and documented in the

patient’s record.

每例麻醉的操作与麻醉评估都须获得认证过的专业人员来执行、实施麻醉前都须制定

麻醉方案、麻醉相关事宜与家属沟通、以及每位患者的麻醉与手术时的生理状态监测都需

依照专业标准执行，并记录在病历中。

2、目的 (Purpose)

1).A preanesthesia assessment is performed for each patient.

2).A separate preinduction assessment is performed to reevaluate patients

immediately before the induction of anesthesia.

3).The two assessments are performed by an individual(s) qualified to do so

and documented in the patient record.

4).The anesthesia care of each patient is planned and documented in the

patient's record.

5).The anesthesia agent, dose (when applicable), and anesthetic technique are

documented in the patient’s anesthesia record.

6).The anesthesiologist and/or nurse anesthetist and anesthesia assistants

are identified in the patient’s anesthesia record.

7).The patient, family, and/or decision makers are educated on the risks,

benefits, and alternatives of anesthesia.

8).The patient, family, and/or decision makers are educated about

postoperative analgesia.

9).The anesthesiologist or another qualified individual provides and

documents the education.

10).The frequency and type of monitoring during anesthesia and surgery are

based on the patient’s preanesthesia status, the anesthesia used, and the

surgical procedure performed.

11).Monitoring of the patient’s physiological status is consistent with

professional practice.

12).The results of monitoring are documented in the patient’s record.

保障病患的权益及医疗安全，每一个麻醉手术病人都须获得医院授权的医务人员在麻

醉前进行麻醉评估、制定麻醉方案、医患沟通，麻醉和手术中实施标准化操作与监测，以

及术后随访评价。内容包括以下：

2.1 麻醉前进行两次评估（麻醉前评估、诱导前评估）

2.2 制定麻醉计划、医患沟通、卫教、签署知情同意书

2.3 麻醉与手术期间的监测方式与频率需根据患者的麻醉前生理状态、麻醉与手术方式

的需要而定

2.4 麻醉操作与监测符合专业标准

2.5 麻醉方式和信息、围麻醉期使用的药物及剂量、发生的事件及处置均记录在病历中

2.6 监测的结果记录在病历中

2.7 病人复苏期的管理按照麻醉恢复室的标准规程执行

2.8 离开手术室的术后病人须在 24 小时内进行随访

2.9 每例麻醉做品质管理评价

3、范围（Scope）

3.1 适用范围：所有需接受各种麻醉以进行相关手术及检查的病人

3.2 流程范围：所有需接受各种麻醉以进行相关手术及检查的病人，从麻醉前评估开始，

止于术后随访

4、权责 (Responsibility)

4.1 管理权责：

4.1.1 本流程是由麻醉科主任负责：

* 政策的撰写文件化

* 提出政策更新的建议

* 确保执行与文件一致性

4.1.2 说明本政策的制定、修改、废止提出意见，经部门会议讨论，呈主任核准后公

告实施

4.1.3 本政策由麻醉科主任每 3 年12 月的部门会议进行报告说明，讨论是否更新修改

4.1.4 绩效衡量机制：品质管理负责人应该针对本政策控制点，定期在部门会议报告，

做提醒，以确保贯彻落实

4.2 政策相关人员职责

单位名称人员权责

麻醉科医师制定政策及执行麻醉政策

麻醉科麻醉科护士协助并执行麻醉政策

恢复室医护人员协助并执行麻醉政策

5、参考文献 (References)

5.1《JCI医院评审标准》第五版 ASC16，2014 年

5.2 卫生部《三级综合医院评审标准》2011 年

6、政策（Policy）

ME1).A preanesthesia assessment is performed for each patient.

ME2).A separate preinduction assessment is performed to reevaluate patients

immediately before the induction of anesthesia.

ME3).The two assessments are performed by an individual(s) qualified to do so

and documented in the patient record.

ME4).The anesthesia care of each patient is planned and documented in the

patient's record.

ME5).The anesthesia agent, dose (when applicable), and anesthetic technique

are documented in the patient’s anesthesia record.

ME6).The anesthesiologist and/or nurse anesthetist and anesthesia assistants

are identified in the patient’s anesthesia record.

ME7).The patient, family, and/or decision makers are educated on the risks,

benefits, and alternatives of anesthesia.

ME8).The patient, family, and/or decision makers are educated about

postoperative analgesia.

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摘要：

1、标准(Standard):ASC.4Aqualifiedindividualconductsapreanesthesiaassessmentandpreinductionassessment.ASC.5Eachpatient’sanesthesiacareisplannedanddocumented,andtheanesthesiaandtechniqueusedaredocumentedinthepatient’srecord.ASC.5.1Therisks,benefits,andalternativesrelatedtoanesthesiaarediscussedwiththepat...

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