三級(jí)綜合醫(yī)院評(píng)審標(biāo)準(zhǔn)考評(píng)辦法(國標(biāo))

1、內(nèi)部資料內(nèi)部資料注意保存注意保存2015三級(jí)綜合醫(yī)院評(píng)審標(biāo)準(zhǔn)考評(píng)辦法評(píng)審標(biāo)準(zhǔn)考評(píng)辦法湖南省衛(wèi)生廳版湖南省衛(wèi)生廳版2382七、麻醉管理與持續(xù)改進(jìn)...................................................................................91八、急診科管理與持續(xù)改進(jìn)....................................................

2、...........................99九、重癥醫(yī)學(xué)科管理與持續(xù)改進(jìn).....................................................................108十、感染性疾病管理與持續(xù)改進(jìn).....................................................................113十一、中醫(yī)管理與持續(xù)改進(jìn).......

3、......................................................................118十二、康復(fù)治療管理與持續(xù)改進(jìn).....................................................................121十三、疼痛治療管理與持續(xù)改進(jìn)...............................................

4、......................126十四、精神科疾病的管理與持續(xù)改進(jìn).............................................................128十五、藥事和藥物使用管理與持續(xù)改進(jìn).........................................................131十六、臨床檢驗(yàn)管理與持續(xù)改進(jìn)........................

5、.............................................152十七、病理管理與持續(xù)改進(jìn).............................................................................167十八、醫(yī)學(xué)影像管理與持續(xù)改進(jìn)..................................................................

6、...182十九、輸血管理與持續(xù)改進(jìn).............................................................................188二十、醫(yī)院感染管理與持續(xù)改進(jìn).....................................................................202二十一、介入診療管理與持續(xù)改進(jìn).....................

7、............................................212二十二、血液凈化管理與持續(xù)改進(jìn).................................................................219二十三、臨床營(yíng)養(yǎng)管理與持續(xù)改進(jìn).................................................................230二十四、醫(yī)用氧

8、艙管理與持續(xù)改進(jìn)（醫(yī)務(wù)科，高壓氧）.............................233二十五、放射治療管理與持續(xù)改進(jìn).................................................................238二十六、其他特殊診療管理與持續(xù)改進(jìn).........................................................244二十七、病歷（案）管理

9、與持續(xù)改進(jìn).............................................................250第五章護(hù)理管理與質(zhì)量持續(xù)改進(jìn)第五章護(hù)理管理與質(zhì)量持續(xù)改進(jìn)........................................................257一、確立護(hù)理管理組織體系....................................................

10、.........................257二、護(hù)理人力資源管理.....................................................................................262三、臨床護(hù)理質(zhì)量管理與改進(jìn).........................................................................268四、護(hù)理安

11、全管理.............................................................................................275五、特殊護(hù)理單元質(zhì)量管理與監(jiān)測(cè).................................................................278第六章第六章醫(yī)院管理醫(yī)院管理........................

12、..........................................................287一、依法執(zhí)業(yè).....................................................................................................287二、明確管理職責(zé)與決策執(zhí)行機(jī)制，實(shí)行管理問責(zé)制..........................

13、.......291三、依據(jù)醫(yī)院的功能定位，確定醫(yī)院的發(fā)展目標(biāo)和中長(zhǎng)期發(fā)展規(guī)劃.........294四、人力資源管理.............................................................................................296五、醫(yī)院信息化建設(shè)（本部分提前單獨(dú)評(píng)審）.............................................

14、303六、圖書管理（科教科、信息網(wǎng)絡(luò)科）.........................................................306七、財(cái)務(wù)與價(jià)格管理.........................................................................................307八、醫(yī)德醫(yī)風(fēng)管理...............................

15、..............................................................313九、后勤保障管理.............................................................................................316十、醫(yī)學(xué)裝備管理（設(shè)備科）......................................

16、...........................326十一、院務(wù)公開管理.........................................................................................333十二、醫(yī)院社會(huì)評(píng)價(jià)................................................................................