医院科室管理制度

2025-10-21 999+ 138.5KB 39 页海报

目   录
科室质量管理小组工作制度.............................................................................................................1
（一）人员组成.........................................................................................................................1
（二）科室质管小组职责.........................................................................................................1
（三）业务科室主任职责.........................................................................................................1
（四）质管员职责.....................................................................................................................2
内科工作职责.....................................................................................................................................3
临床科主任职责.........................................................................................................................3
临床主任医师职责.....................................................................................................................3
临床主治医师职责.....................................................................................................................4
总住院医师职责.........................................................................................................................4
临床住院医师（士）职责.........................................................................................................5
普通门诊医师岗位职责.............................................................................................................6
专科（专病）门诊人员岗位职责............................................................................................6
专家门诊人员岗位职责.............................................................................................................7
急诊科医师职责.........................................................................................................................8
外科工作职责.....................................................................................................................................9
临床科主任职责.........................................................................................................................9
临床主任医师职责.....................................................................................................................9
临床主治医师职责...................................................................................................................10
总住院医师职责.......................................................................................................................11
临床住院医师（士）职责.......................................................................................................11
普通门诊医师岗位职责...........................................................................................................12
专科（专病）门诊人员岗位职责..........................................................................................13
专家门诊人员岗位职责...........................................................................................................13
急诊科医师职责.......................................................................................................................14
中医科工作制度...............................................................................................................................15
抢救室工作制度...............................................................................................................................16
预防保健科工作制度.......................................................................................................................17
防治（保）科工作制度...................................................................................................................18
家庭病床科工作制度.......................................................................................................................19
儿童保健科工作制度.......................................................................................................................20
（一）考勤制度.......................................................................................................................20
（二）首诊首科负责制度.......................................................................................................20
（三）休假与补休制度...........................................................................................................20
（四）外出进修、学习、会议制度......................................................................................20
（五）学习制度.......................................................................................................................21
（六）请假制度.......................................................................................................................21
（七）重大事项讲座及通报制度..........................................................................................21
（八）奖惩制度.......................................................................................................................21
重症监护病房管理制度...................................................................................................................23

放疗科工作制度...............................................................................................................................24
高压氧室管理制度...........................................................................................................................26
1.总则........................................................................................................................................26
2.进舱须知................................................................................................................................26
3.氧舱消毒隔离制度................................................................................................................27
4.供氧间管理规则....................................................................................................................27
5.氧舱应急情况处理规则........................................................................................................28
理疗科（室）工作制度...................................................................................................................30
血透室工作制度...............................................................................................................................31
麻醉科工作制度...............................................................................................................................32
1.临床麻醉工作制度................................................................................................................32
2.麻醉前访视、讨论和小结制度...........................................................................................32
3.麻醉准备室制度....................................................................................................................33
4.麻醉记录制度........................................................................................................................34
5.意外及并发症的预防和报告制度.......................................................................................35
6.麻醉后随访和总结制度........................................................................................................37
7.麻醉科工作质量考核制度...................................................................................................37
8.会诊制度................................................................................................................................38
手术室工作制度...............................................................................................................................39
（一）手术前基本准备制度..................................................................................................39
（二）手术室控制感染管理制度..........................................................................................40
（三）手术室安全管理制度..................................................................................................41
（四）手术室查对清点制度..................................................................................................42
（五）手术室交接班制度.......................................................................................................42
内窥镜中心工作制度.......................................................................................................................44
内镜室制度.......................................................................................................................44
内镜室工作制度.......................................................................................................................44
内镜室消毒隔离制度...............................................................................................................45
内窥镜室的医院感染管理制度..............................................................................................46
内镜诊疗病人登记制度...........................................................................................................47
病理科工作制度...............................................................................................................................48
病理科主任职责.......................................................................................................................49
病理科主管医师职责...............................................................................................................49
病理科医师职责.......................................................................................................................49
病理科医士、技术员职责.......................................................................................................50

科室质量管理小组工作制度

（一）人员组成

1.由各科室科主任、护士长及 1名主治医师以上人员，至少 4

人组成，其中确定一名副主任或主治医师以上人员为科室质管员。

2.科室质管小组成员根据科室人员变动情况适当调整，尽量保

持稳定。

（二）科室质管小组职责

1.负责本科室医疗质量全面工作。

2.起草科室质量计划、总结，负责组织落实医疗质量管理方案，

实施日常自查、自控和持续质量改进。

3.传达全院质量管理计划措施并组织实施。

4.维持科室正常的医疗秩序，严防医疗差错发生。

5.根据科室工作需要，完善健全科室医疗质量提高相关规定。

6.组织全科学习卫生法律法规及规章制度，强化质量意识、服

务意识。

7.树立良好科室风气，强化科室文化建设。努力营造"医疗质量，

人人有责"，"发展大计，质量第一"的氛围。

（三）业务科室主任职责

1.科主任是科室医疗质量第一责任人。

2.熟悉质量管理体系中本科室的质量职责。

3.随时进行质量管理和开展质量控制。

4.不断进行持续的质量改进工作并对质量进行跟踪。

5.做好本科室与其他相关科室的工作衔接。

6.对科室人员进行岗位能力培训。

7.参加全院每月医疗质量检查工作。

文档加载中……请稍候！
如果长时间未打开，您也可以点击刷新试试。

下载文档到电脑，查找使用更方便

立即下载

摘要：

目录科室质量管理小组工作制度.............................................................................................................1（一）人员组成.........................................................................................................................1（二）科室质管小组职责.......................................

展开>> 收起<<

医院科室管理制度.doc

共39页,预览12页

还剩页未读，继续阅读