醫(yī)院護理管理制度

目錄

護理管理制度...................................................................................................................................1

護理部工作制度.......................................................................................................................1

臨床科室護理工作制度...........................................................................................................2

A特級護理.......................................................................................................................2

B一級護理.......................................................................................................................2

C二級護理.......................................................................................................................3

D三級護理.......................................................................................................................3

分級護理制度...........................................................................................................................4

查對制度...................................................................................................................................6

1.醫(yī)屬查對制度................................................................................................................6

2.服藥、注射、輸液查對制度........................................................................................6

3.輸血查對制度................................................................................................................7

4.飲食查對制度................................................................................................................7

5.手術(shù)病人查對制度........................................................................................................8

6.供應室查對制度............................................................................................................8

護理人員排班制度...................................................................................................................8

（一）排班原則...............................................................................................................8

（二）排班的有關(guān)規(guī)定...................................................................................................8

值班與交接班制度...................................................................................................................9

執(zhí)行醫(yī)囑制度.........................................................................................................................11

搶救工作制度.........................................................................................................................12

消毒隔離制度.........................................................................................................................12

護理信息統(tǒng)計制度.................................................................................................................13

護理文件管理.........................................................................................................................14

護理文書書寫制度.................................................................................................................14

關(guān)于對護理文書實施質(zhì)量檢控的規(guī)定.................................................................................15

醫(yī)療文件質(zhì)量控制制度.........................................................................................................16

護理病例討論制度.........................................................................................................17

護理質(zhì)量管理制度.................................................................................................................17

護理質(zhì)量考評制度.................................................................................................................18

護理差錯事故報告、管理制度.............................................................................................18

差錯、事故防范措施.....................................................................................................18

差錯、事故登記報告制度.............................................................................................19

差錯、事故處理制度.....................................................................................................19

護理差錯事故高危防范要點.........................................................................................20

護理安全管理制度.................................................................................................................21

護理事故、意外的預防.........................................................................................................22

護理過失行為處理制度.........................................................................................................23

護理投訴管理制度.................................................................................................................24

護理投訴處理制度.................................................................................................................25

重大護理過失行為及事故爭議報告制度.............................................................................26

附件：臨床突發(fā)事件處理預案.............................................................................27

護士職業(yè)安全管理制度.........................................................................................................27

物品、藥品、器材管理制度.................................................................................................29

1.一般管理制度..............................................................................................................29

2.被服管理制度..............................................................................................................29

3.器材管理制度..............................................................................................................29

4.小藥柜管理制度..........................................................................................................30

護理查房制度.........................................................................................................................30

1.行政查房......................................................................................................................30

2.業(yè)務查房......................................................................................................................31

3.教學查房......................................................................................................................31

4.夜查房..........................................................................................................................32

護士長夜查房制度.................................................................................................................32

護士崗前教育制度.................................................................................................................33

臨床護理教學制度.................................................................................................................34

各級護理繼續(xù)教育制度.........................................................................................................35

繼續(xù)教育學分規(guī)定.................................................................................................................36

青年護士輪轉(zhuǎn)制度.................................................................................................................36

護理業(yè)務學習制度.................................................................................................................37

護理人員考核制度.................................................................................................................37

進修實習護士管理制度.........................................................................................................37

健康宣教制度.........................................................................................................................39

病人健康教育制度.........................................................................................................39

飲食管理制度.........................................................................................................................40

飲食管理制度.........................................................................................................................40

病房管理制度.........................................................................................................................41

附件：住院規(guī)則.............................................................................................................41

住院病人護送制度.................................................................................................................42

各項檢查及標本送檢制度.....................................................................................................43

護理員管理制度.....................................................................................................................43

普通病房探視陪護制度.........................................................................................................43

附：入出院須知.............................................................................................................44

出入院護理服務制度.............................................................................................................44

1.入院病人護理服務程序..............................................................................................44

2.出院病人護理服務程序..............................................................................................45

急診病人護理服務制度.........................................................................................................45

門診病人護理服務程序.........................................................................................................46

轉(zhuǎn)院病人護理服務程序.........................................................................................................46

普通病房管理制度.................................................................................................................47

普通病房管理要求.................................................................................................................47

搶救室工作制度.....................................................................................................................50

治療室工作制度.....................................................................................................................50

門診護理工作制度.................................................................................................................51

門診注射室護理工作制度.............................................................................................51

門診輸液室護理工作制度.............................................................................................521

門診換藥室護理工作制度.............................................................................................52

換藥室工作制度.....................................................................................................................53

外科門診小手術(shù)室工作制度.........................................................................................53

婦產(chǎn)科門診治療室工作制度.........................................................................................54

腹瀉病門診工作制度.....................................................................................................54

急診室工作制度.....................................................................................................................55

急診室工作制度.............................................................................................................55

附件：急診范圍.....................................................................................................55

搶救室工作制度.............................................................................................................56

觀察室工作制度.............................................................................................................57

急診科分診管理制度.....................................................................................................57

急診科搶救室管理制度.................................................................................................58

急診科觀察室管理制度.................................................................................................58

急診清創(chuàng)室管理要制度.................................................................................................58

手術(shù)室工作制度.....................................................................................................................59

手術(shù)室工作制度.............................................................................................................59

手術(shù)室工作制度.....................................................................................................................60

入室制度.........................................................................................................................61

參觀手術(shù)制度.................................................................................................................61

接送病人制度.................................................................................................................62

手術(shù)體位安置制度.........................................................................................................62

手術(shù)清點制度.................................................................................................................62

標本管理制度.................................................................................................................63

輸血查對制度.................................................................................................................63

手術(shù)室消毒隔離制度.....................................................................................................64

手術(shù)間消毒制度.............................................................................................................64

手術(shù)室安全管理制度.....................................................................................................65

手術(shù)器械物品消毒及滅菌管理制度.............................................................................65

手術(shù)室清潔、消毒隔離制度.........................................................................................66

手術(shù)室查對清點制度.....................................................................................................67

手術(shù)室貴重儀器保管制度.............................................................................................67

手術(shù)室防止差錯事故制度.............................................................................................67

手術(shù)室參觀規(guī)則.............................................................................................................68

手術(shù)室傳染病病人處理制度（HAA陽性）...............................................................68

手術(shù)室病人接送規(guī)則.....................................................................................................69

供應室工作制度.....................................................................................................................69

供應室工作制度.............................................................................................................69

供應室工作制度.............................................................................................................70

供應室護士長職責.........................................................................................................72

供應室護士職責.............................................................................................................73

供應室工作制度.............................................................................................................73

1.供應室回收工作制度..........................................................................................73

2.供應室洗滌工作制度..........................................................................................74

3.供應室包裝制度..................................................................................................74

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4.供應室敷料制作工作制度..................................................................................75

5.供應室滅菌制度..................................................................................................75

6.供應室物品存放制度..........................................................................................76

7.供應室質(zhì)量監(jiān)控制度..........................................................................................76

8.供應室藥品物品器材管理制度..........................................................................77

回收室工作制度.............................................................................................................78

洗滌間工作制度.............................................................................................................78

包裝間工作制度.............................................................................................................78

消毒滅菌工作制度.........................................................................................................79

無菌物品存放室工作制度.............................................................................................79

供應室物品交接班制度.................................................................................................80

供應室物品器械查對制度.............................................................................................80

供應室下收下送制度.....................................................................................................80

供應室質(zhì)量監(jiān)測制度.....................................................................................................81

供應室消毒隔離制度.....................................................................................................81

供應室物品管理制度.....................................................................................................82

供應室一次性物品使用管理制度.................................................................................83

供應室保潔制度.............................................................................................................83

供應室賠償制度.............................................................................................................83

供應室管理制度.............................................................................................................84

供應室下收下送制度.....................................................................................................85

供應室查對制度.............................................................................................................86

供應室監(jiān)測工作制度.....................................................................................................86

消毒隔離制度.................................................................................................................87

消毒供應室醫(yī)院感染管理制度.....................................................................................87

產(chǎn)房工作制度.........................................................................................................................88

制度.................................................................................................................................88

監(jiān)督檢查.........................................................................................................................89

出生醫(yī)學證明領(lǐng)發(fā)管理制度.........................................................................................90

待產(chǎn)室工作制度.............................................................................................................91

分娩室制度.....................................................................................................................92

新生兒室工作制度.................................................................................................................93

血透室工作制度.....................................................................................................................93

護理安全預案.................................................................................................................................94

預防病人墜床或跌倒.............................................................................................................94

防燙傷預案.............................................................................................................................95

預防輸入含霉菌液體和輸液反應、輸血反應的措施.........................................................96

護理工作表格.................................................................................................................................98

護理持續(xù)質(zhì)量改進（CQI）計劃表......................................................................................98

護理持續(xù)質(zhì)量改進（CQI）結(jié)果報告表..............................................................................99針頭處理流程圖...................................................................................................................100護理差錯隱患排查記錄匯總單...........................................................................................101患者意外傷害事件報告.......................................................................................................102病區(qū)——預防病員跌傷、墜床報告登記表.......................................................................1033

萬寧市中醫(yī)院護理差錯、事故登記報告1........................................................................105萬寧市中醫(yī)院護理差錯、事故登記報告表2....................................................................106醫(yī)院護理差錯、事故登記報告表.......................................................................................108護理業(yè)務查房記錄...............................................................................................................109護理投訴登記表...................................................................................................................110理質(zhì)量自控檢查反饋表.......................................................................................................111萬寧市中醫(yī)院——導管護理登記表...................................................................................112護理操作規(guī)范...............................................................................................................................113

呼吸機操作流程...................................................................................................................115

呼吸機與自主呼吸的對抗...........................................................................................116呼吸機的撤離指征.......................................................................................................118使用機械通氣的患者根據(jù)血氣結(jié)果調(diào)節(jié)呼吸機參數(shù)...............................................118心電圖機操作流程（暫定）...............................................................................................119心電監(jiān)護儀操作流程（暫定）...........................................................................................121?？谱o理操作程序...............................................................................................................123

動脈血標本采集評分操作實務...................................................................................123胃腸減壓術(shù)評分操作實務...........................................................................................124胸膜腔閉式引流護理評分操作實務...........................................................................125膀胱沖洗術(shù)評分操作實務...........................................................................................126三基技能操作.......................................................................................................................127

無菌技術(shù).......................................................................................................................127

1.無菌持物鉗及無菌容器的使用........................................................................127

2.無菌溶液............................................................................................................128

3.打開一次性無菌包............................................................................................129

4.鋪無菌盤............................................................................................................130

5.戴、脫無菌手套................................................................................................131

附：無菌技術(shù)操作原則.......................................................................................132

鋪床...............................................................................................................................133

1.備用床................................................................................................................133

2.麻醉床................................................................................................................134

3.臥有病人床更換床單........................................................................................135

口腔護理.......................................................................................................................136床上擦浴.......................................................................................................................137床上洗頭.......................................................................................................................138鼻飼.............................................................................................................................139氧氣吸入.......................................................................................................................140霧化吸入.......................................................................................................................141生命體征測量...............................................................................................................142

1.體溫、脈搏、呼吸測量....................................................................................142

2.測血壓................................................................................................................143

口服給藥.......................................................................................................................144

附：口服用藥注意事項.......................................................................................145

注射法...........................................................................................................................146

1.皮內(nèi)、皮下、肌肉注射法................................................................................146

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2.靜脈注射法........................................................................................................147靜脈輸液.......................................................................................................................148灌腸.............................................................................................................................150

1.保留灌腸............................................................................................................150

2.不保留灌腸（大量、小量）............................................................................151

3.肛管排氣法........................................................................................................152搬運病人.......................................................................................................................153

1.輪椅運送法........................................................................................................153

2.平車運送法........................................................................................................154