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目录一、廉洁行医制度······························································3二、请示报告制度······························································3三、急诊科工作制度···························································4四、急诊科预检分诊制度·····················································5五、急诊抢救室工作制度·····················································6六、急诊留观制度······························································6七、急诊出诊抢救制度························································7八、涉及法律问题伤病员处理办法·········································8九、急诊科突发公共卫生事件处置预案···································8十、急诊观察室工作制度·····················································9十一、救护车使用制度······················································10十二、危重病人救治绿色通道制度·······································10十三、病历书写制度··························································11十四、处方书写制度·························································12十五、医嘱制度·······························································14十六、差错、事故登记报告处理制度····································14十七、医疗缺陷管理制度···················································161.医疗缺陷管理制度·····················································162.医疗缺陷范围说明·····················································183.医疗缺陷登记、报告、处理制度···································20十八、出、入院制度·························································21十九、知情告知谈话制度···················································22二十、病人知情同意签字制度·············································23二十一、医务人员履行告知义务制度····································25二十二、无菌操作制度······················································26二十三、消毒药械管理制度················································27二十四、合理使用抗生素制度·············································28二十五、医务人员职业防护工作制度····································31二十六、药品不良反应报告制度··········································32二十七、首诊负责制度······················································34******妇产医院急性心肌梗死质量控制评价流程·····················36******妇产医院心力衰竭质量控制评价流程···························37******妇产医院肺炎质量控制评价流程·································38******妇产医院脑梗死质量控制评价流程······························39******妇产医院发生输血反应处理流程·································41******妇产医院医嘱执行工作流程·······································42******妇产医院医疗不良事件报告、处理流程························43一、廉洁行医制度1、遵守医德规范，救死扶伤，实行社会主义人道主义，尽职尽责，全心全意为病人服务，任何时候不准以冷、硬、推、拖的态度对待病人。2、坚持原则，不以医谋私，不开人情处方、人情病假或病情不相符合的诊断书或假报告。3、严格执行医疗护理常规，按病情选用恰当药物和必要检查，不得小病大治，开大处方，乱检查，增加病人或单位经济负担。4、不收受和索取病人或家属的红包与礼物，不接受病人宴请，如无法谢绝，可通过组织妥善处理。5、根据医院管理条例，严格控制乱用滥检等损害病人利益的行为，不得以患者名义为自己或熟人开“搭车”药，做“搭车”检查。不得为拉关系，把自费项目改为公费项目，或少收费，不收费。6、遵守药品管理法和医院规章制度，不私自向病人销售药物或推销非医疗性商品。7、未经批准不得在外兼职或利用业余时间在院外行医，谋求私利。8、爱护医院仪器设备、药品及其它公共财物，不浪费、不侵吞、不损坏，不以公物做人情。9、遵守劳动纪律和医院各项规章制度，坚守岗位，不擅自离岗或上班办私事。二、请示报告制度凡有下列情况，必须及时逐级向有关部门及院领导请示报告。1、遇有严重工伤、重大交通事故、大批中毒、法定传染病及突发公共卫生事件，必须动员全院力量抢救的病员时。2、凡有重大手术，重要脏器切除、截肢、首次开展的新手术、新疗法、新技术应用时。3、紧急手术而病员的单位领导和家属不在时。4、发生医疗事故或严重差错时。丢失或损坏贵重器材和贵重药品，发现成批药品失效或变质时。5、收治涉及法律和政治问题及有自杀迹象的病人时。6、重大经济开支报批时。7、增补、修改医院规章制度、技术操作常规时。8、工作人员因公出差、院外会诊、接受院外任务时。9、参加院外进修学习、接受来院业务进修人员时。三、急诊科工作制度1、医院应设置急诊科，实行24小时开放随时应诊，节假日照常接诊。根据医院的功能任务，设置相应内部工作部门，医院并能为急诊患者提供药房、检验、医学影像等及时连贯的服务。2、医院应由业务副院长负责与协调医院急诊工作，加强对急危重症患者的管理，提高急危重症患者抢救成功率。提高急诊科能力，做到专业设置、人员配备合理，医务人员相对固定，值班医师胜任急诊抢救工作。3、急诊科应配有经急诊专业培训的专职医师、护士，固定人员不少于60％，各临床科室应选派有临床工作3年以上的医师参加急诊工作，轮换时间不少6个月。实习期医师与护士不得单独值急诊班。进修医师至少应经科主任批准方可参加值班。4、医疗、护理管理部门应加强急诊工作的监督管理，定期召开联席会议，开展协调工作。5、急诊科一入院一手术“绿色通道”畅通，急诊会诊迅速到位。对急诊病员应以高度的责任心和同情心及时、严肃、敏捷地进行救治，严密观察病情变化，做好各项记录。疑难、危重病员应即请上级医师诊视或急会诊。6、对危重不宜搬动的病员，应在急诊室就地组织抢救，待病情稳定后再护送病房。对立即须行手术的病员应及时送手术室施行手术。急诊医师应向病房或手术医师直接交班。7、急诊室各类抢救药品及器材要准备完善，保证随时可用。由专人管理，放置固定位置，便于使用，经常检查，及时补充、更新、修理和消毒。8、急诊室工作人员必须坚守岗位，做好交接班，严格执行急诊各项规章制度和技术操作规程。要建立各种危重病员抢救技术操作程序和突发公共卫生事件应急预案。9、急诊室应设立留院观察病床，病员由急诊医师和护士负责诊治护理，认真写好病历，开好医嘱。密切观察病情变化，及时有效地采取诊治措施。留院观察时间一般不超过三天(72小时)。10、要建立突发公共卫生事件应急预案，遇重大抢救，需立即报请科主任和院领导亲临参加指挥。凡涉及法律、纠纷的患者和无名氏者，在积极救治的同时，及时向有关部门报告。11、急诊病人不受地域与医院等级的限制，对需要转院的急诊病人须事先与转去医院联系，取得同意后，方得转院。四、急诊科预检分诊制度1、预检分诊处护士必须熟悉业务，责任心强。2、预检护士必须坚守岗位，临时因故离开时必须由护士长安排能胜任的护士代替。3、预检护士应热情接待每一位前来就诊的患者，简要了解病情，重点观察体征，进行必要的初步检查，尽量予以合理的分诊。遇有分诊困难时，可请有关医生协助，及时做好分诊登记。4、根据“重病优先”的原则，优行安排病情危重患者诊治，危急病人先抢救后挂号。5、对危重患者，一边予以紧急处理，一边及时通知有关医护人员进行抢救。6、遇有严重工伤事故或成批伤病员时，应立即通知科主任及医务科或院总值班，组织抢救工作。对涉及刑事、民事纠纷的伤病员，应及时向有关部门报告。7、掌握急诊范围，做好解释工作，对婴幼儿及老年患者酌情予以照顾。五、急诊抢救室工作制度1、抢救室专为抢救病员设置，其他任何J睛况不得占用，设有危重症抢救流程图。2、一切抢救药品、物品、器械、敷料均须放在指定位置，并有明显标记，不准任意挪用或外借。3、药品、器械用后均需及时清理、消毒，消耗部分应及时补充，放回原处，以备再用。4、每班核对一次物品，班班交接，做到帐物相符。5、无菌物品须注明灭菌日期，超过一周时重新灭菌。6、每周须彻底清扫、消毒一次，室内禁止吸烟。7、抢救时抢救人员要按岗定位，遵照各种疾病的抢救常规程序，进行工作。8、每次病员抢救完毕后，主持者要及时做现场评论和初步总结。六、急诊留观制度1、留观察对象：1)病情需要住院，但无床位且一时不能转出，病情允许留院观察。2)不能立即确诊，离院后病情有可能突显变化者。3)某些病症如：高热、哮喘、腹痛、高血压等经治疗病情未稳定者。4)其他特殊情况，如：已明确诊断但经短期治疗能恢复者，但传染病、精神病患者不予留观察。2、留院观察病人应建立留观察记录，及时记录病情变化、检查、治疗、护理等情况。留观记录在急诊科保管一般保管一年。3、观察室内环境要清洁、安静；被服要随时更换；值班护士要及时巡视病房，按医嘱进行诊疗护理；严密观察病情，及时发现病人病情变化，及时处理和报告医生并做好记录，及时排除输液故障。4、留院观察时间一般为24小时一7天，特殊情况除外。5、危重病人，值班医生应及时向病人家属交代病情，取得家属的理解并下达病危通知书，请家属签字，如处理上有困难或家属有意见时，应及时向科主任汇报。6、值班医师下班前应巡视一遍病人，写好交班记录，并在床旁交接班。7、对可以离院的病人，值班医师应视情况予以带药并详细交代注意事项，在急诊病历和留观记录上做好记录。七、急诊出诊抢救制度1、急诊科安排好每日的出诊人员，值班人员要坚守岗位，随时待命，保证随叫随到。急诊电话确保24小时通畅。2、当接到出诊电话时，应问清出诊地点、姓名及基本情