system
Hospital staff should be neatly dressed and not allowed to wear work clothes to enter public places such as canteens, libraries, conference rooms and administrative offices.
Strict implementation of disinfection and isolation system and aseptic technical operation procedures. Wash your hands before and after treatment and nursing, inject one needle, one tube and one use, change dressing and one use and one disinfection, brush the bed in the morning, put a towel on the bedside table, and soak and disinfect the thermometer before and after use.
The qualified rate of disinfection and sterilization of conventional instruments is%, and the soaking with sterile holding forceps meets the requirements. Disinfectant should be replaced once a week, and sterile holding forceps should be replaced once a week, indicating the replacement date, name and concentration of disinfectant.
Sterile articles shall be marked with sterilization date, with sterilization indication tape, and the sterilization period shall be days.
The concentration of iodine tincture and alcohol used for disinfection should be marked and changed daily. The disinfection bottle should be covered and disinfected once a week, and the opening time and usage of sterile solution should be indicated.
The disinfection cabinet is clean and dry, and the disinfectant in the cabinet is replaced once a week, indicating the replacement time, the name and concentration of the disinfectant. The refrigerator is disinfected and maintained once a week, and the items are placed in an orderly manner without expired items.
The treatment room and dressing room are divided into bacteria area and aseptic area. Sterile items are placed separately from contaminated items, and dirt is separated from garbage.
The ward is ventilated every day, the ground is dragged twice a day, cleaned once a week and the air is disinfected once a week. The treatment room, delivery room, operating room, dressing room and intensive care unit are disinfected twice a day, and air bacteria culture and monitoring are carried out twice a month. Ultraviolet disinfection should have time registration and intensity monitoring. If the monitoring is unqualified, corresponding measures should be taken in time, and it will be replaced after more than one hour.
Disinfect the toilet after each use, cover the disinfection pool and keep the effective concentration of disinfectant with signs.
Patients with special infections such as anaerobic bacteria and Pseudomonas aeruginosa should be strictly isolated, and the instruments, clothes and rooms used should be strictly treated at last, and the dressing should be burned.
All disposable medical and health products must be soaked and disinfected before being destroyed and treated harmlessly.
The dirty clothes changed by medical staff and patients should be put into the garbage truck and cleaned and disinfected separately; The list of discharged, transferred and dead patients should be handled at the end.
Radiology requires the use of disposable mouthwash cups.
Outpatient laboratory sheets must be disinfected before they can be issued.
The outpatient department should set up an infectious disease isolation clinic. Once patients with infectious diseases are found or suspected, they should be immediately isolated on the spot and reported according to the infectious disease reporting procedure.
Supervision and inspection
Set up a disinfection and isolation quality control team, with the head nurse as the team leader and the relevant nurses as the team members, and work under the guidance of the hospital infection management leading group to assist the hospital infection management personnel to train the medical staff in disinfection, sterilization and isolation techniques, control the infection, and record the activities.
The head nurse concurrently serves as the hospital infection monitoring nurse, completes the specified disinfection and sterilization detection work under the leadership of the hospital infection management full-time staff, and makes records as required.
The disinfection and isolation system of all subjects should be put on the wall, and a unified "Disinfection and Isolation Quality Inspection Scoring Form" should be formulated, and the head nurse should organize a comprehensive inspection once a month. Have the key contents and time records of the head nurse's weekly inspection; There are analysis and improvement measures for infection factors and weak links in spot check and monitoring, and there is a "hospital infection monitoring quality control feedback form".
Clinical departments shall conduct hygiene monitoring once a month, with no less than four specimens each time. Among them, there must be air, hand and disinfectant surface monitoring items that exceed the standard, and there must be a report that meets the standard after rectification. County epidemic prevention stations should carry out health monitoring every year, and those that fail to meet the standards must be rectified to meet the standards.
Strictly implement disinfection and isolation preventive measures, report hospital infection or epidemic situation to hospital infection management personnel and dean in time, and assist in investigation, analysis and formulation of effective control schemes. Those who conceal or fail to report shall be investigated for the responsibility of relevant personnel.
Second, the grading nursing system
system
Doctors prescribe nursing orders according to the patient's condition, and nurses implement graded nursing according to the orders.
Intensive care: patients who are critically ill and need to be rescued at any time.
1. Emergency medicines and equipment are available to ensure emergency use.
2. Assign a special person to be on duty day and night, closely observe the changes of illness, and make effective emergency treatment and cooperation.
(3) Formulate and implement the nursing plan, and make special nursing records in a timely, detailed, accurate, complete and standardized manner.
Four, do a good job of basic nursing and family comfort, no nursing complications.
Primary care: critically ill patients, patients who need to be observed after major surgery, etc.
Prepare first-aid articles according to the needs of the illness and ensure their use.
Second, meet the needs of patients and do a good job in physical, psychological and social care.
(3) According to the condition, formulate and implement the nursing plan, and the nursing records are complete, accurate and standardized.
Patrol the patient once every ~ minutes, closely observe the change of illness, drug reaction and effect, monitor body temperature, pulse, respiration and blood pressure, report the change of illness to the doctor in time, and actively participate in the rescue.
5. Do basic nursing, no nursing complications.
Secondary care: patients who are seriously ill and cannot take care of themselves completely.
1. Stay in bed and do appropriate activities according to the patient's condition.
Patrol every ~ hours, and pay attention to the condition and the effect after special treatment.
Third, do a good job in basic nursing, help turn over, strengthen oral and skin care, and prevent complications.
Give necessary care in life, such as washing face, wiping body, delivering meals, delivering toilets, etc.
Tertiary care: patients with mild illness or in recovery period.
A responsible nurse conscientiously performs her duties.
Second, strictly implement the disease care routine and complete the treatment and nursing on time.
Take temperature, pulse and breath ~ times a day, often patrol the condition and deal with the change of the condition in time.
Supervise patients to abide by hospital regulations, ensure rest and pay attention to patients' diet.
Supervision and inspection
The head nurse is responsible for formulating the unified "Criterion for Inspection and Evaluation of Intensive Care and First-class Nursing Quality" in the whole hospital. The head nurse shall check the implementation of nursing measures for critically ill patients once a month and ~ times a week, and record them in the Head Nurse's Manual as the basis for the assessment of the work quality of head nurses and nurses.
The head nurse is responsible for formulating the unified Quality Inspection Standard for First-aid Articles in the whole hospital and doing a good job of handover. If the rescue opportunity is delayed due to nursing mistakes, resulting in adverse consequences, it shall be handled with reference to the Measures for the Administration of Medical Errors and Accidents.
The nurse in charge can accurately answer the bed number, name, sex, diagnosis, diet type, main illness and treatment of critically ill patients. Such as bedsore, stomatitis, scald, fall, etc. If found, it should be handled according to the standard of medical errors and accidents.
Critically ill and intensive care patients have nursing plans and intensive care records, which shall be implemented according to the requirements of Fujian Province Nursing Document Writing Standard.
Third, the ward management system
system
The head nurse is responsible for ward management, and the chief of medical department actively assists.
Regularly publicize and explain health knowledge to patients, and do a good job in patients' ideological and life management.
Keep the ward clean, comfortable, quiet and safe, avoid noise, and walk lightly, close the door lightly, operate lightly and talk lightly.
Unified ward furnishings, indoor items and beds should be placed neatly and fixedly, and they should not be moved at will without the consent of the head nurse.
Keep the ward clean and tidy, pay attention to ventilation, and clean it at least twice a day and once a week.
Medical staff must wear clean clothes and masks when necessary. Smoking is strictly prohibited in the ward.
The patient's clothes and appliances are allocated to the patient for management according to the base number, and they are counted and recycled when leaving the hospital.
The head nurse is fully responsible for keeping the property and equipment of the ward, establishing accounts and counting them regularly. If it is lost, find out the reason in time and deal with it according to the regulations. When managers are transferred, handover procedures should be completed.
During the rounds, non-hospitalized patients and guests are not allowed to enter the ward. Doctors don't answer personal calls during rounds, and patients are not allowed to leave the ward without permission.
Supervision and inspection
Set up a nursing quality control team to check the implementation of ward management system regularly or irregularly, and keep records. Ward quality control team checks the implementation of ward management system once a week, and records special circumstances at any time as an important basis for head nurses' year-end work performance.
The head nurse conducts a special inspection on the implementation of the sexually transmitted diseases management system in the hospital every quarter, writes a comprehensive written analysis and evaluation on the implementation of the nursing group in each ward, and comprehensively reports the situation in the hospital.
Formulate a unified ward management system in the whole hospital, implement a quantitative scoring table, and implement a hundred-point scoring system. Those who get excellent wards in the quarterly inspection of the hospital should be rewarded, and those who fail to pass the inspection should be dealt with according to the relevant regulations of the hospital.
Fourth, check the system.
system
Check the doctor's advice system:
A copy of the doctor's advice must indicate the date, time and signature of the original and copy of the doctor's advice. After copying the doctor's advice, it must be checked before execution, and every BANCHA is correct. The head nurse takes part in a comprehensive examination once a week.
2. Temporary immediate execution of the doctor's advice, must be checked by two people. And record the execution time and the signature of the executor.
When rescuing a patient, the doctor gives a verbal order, and the executor must repeat it and then execute it. And urge doctors to make it up in time.
Drug, injection and infusion inspection system:
First, the "three checks and seven pairs" must be strictly implemented before taking medicine, injection and infusion.
Three examinations: preoperative, intraoperative and postoperative examinations;
Seven pairs: bed number, name, drug name, concentration, dosage, time and usage.
2. Before preparing the drug, check the quality of the drug, pay attention to whether there is deterioration, whether there are cracks in ampoules and injection bottles, and if the expiration date and batch number do not meet the requirements or the label is unclear, they shall not be used.
3. After dispensing, it must be checked by a second person before execution.
4. For allergic drugs, ask if there is any allergic history before taking the drug. When using poisonous, hemp, restricted and dramatic drugs, it should be checked repeatedly, and the ampoule should be properly kept after use so that it can be checked correctly when necessary. When giving a variety of drugs, we should pay attention to whether there are compatibility taboos.
When patients raise questions during five doses of drugs and injections, they should be found in time before implementation.
Supervision and inspection
The director of nursing department must establish the following register and strictly implement it.
Check the registration book according to the doctor's advice;
2. Blood samples and blood samples;
Registration of nursing errors and accidents.
The nursing quality control team will check the implementation of the inspection system in our hospital once a week. Special circumstances should be recorded at any time, which will serve as an important basis for assessing the performance of head nurses at the end of the year.
Formulate a unified nursing ward round system and a quantitative scoring table, implement a scoring system of 100, conduct a hospital inspection every quarter, and reward excellent wards. Can not meet the requirements, with reference to the relevant provisions of the hospital.
Five, nursing conference system
system
Once a month, presided over by the head nurse and attended by nurses in the whole hospital, convey instructions from superiors, summarize the arrangement work, analyze and improve nursing quality, unify nursing standards, organize nurses to learn, exchange work experience, and praise good deeds among nursing staff. Introduce the development direction of new business, new technology and nursing work, carry out academic exchanges and business activities, carry out quality education for nurses and commend advanced nurses.
Supervision and inspection
There is a meeting schedule.
Establish a perfect head nurse's regular meeting record book to record the meeting time, participants and main contents.
Attend various meetings on time and keep records. If you are not late, leave early, or ask for leave, you should arrange the meeting on your behalf, convey the contents of the meeting in time, and conscientiously implement the tasks. If the work quality is affected and adverse consequences are caused due to the absence without reason or the failure to timely convey and implement the work tasks, the responsibility shall be investigated and linked to the year-end assessment.
Sixth, the forum system of work and rest.
system
Holiday symposium is held once a month, convened by the head nurse or her designated senior nurse, or by the management doctor.
Apart from publicizing the hospital system and health education to patients, holiday seminars focus on listening to patients' opinions and suggestions on medical treatment, nursing, diet, service attitude and management. It is necessary to implement the opinions of patients and their families on specific people and things, and improve and improve the quality of work accordingly.
Patients' representatives should be informed before the meeting to collect opinions and suggestions.
Clinical departments should establish a work and rest symposium record book, and each record must be signed by the patient representative.
If patients' opinions and suggestions can be improved and adopted, they should immediately coordinate with relevant departments and personnel to solve them. If it cannot be improved and adopted temporarily for some reason, it should be explained to the patient and the patient's understanding should be obtained.
Relevant departments or personnel should reply within three working days after receiving the opinions sent by the clinical department, and give written feedback on the handling situation to the clinical department. The clinical department is responsible for giving feedback to the patient representatives at the next symposium.
Medical personnel shall not make things difficult for patients and take revenge on patients in any way because of their opinions.
Supervision and inspection
This system is implemented by the head nurse, and the head nurse and relevant functional departments are responsible for inspection and supervision.
The head nurse and other functional personnel should check the implementation of the rest work forum system in time, and apply to the hospital leaders for holding inter-departmental and departmental coordination meetings when necessary.
According to the opinions and suggestions of clinical departments and related departments and personnel on patients, the head nurse puts forward suggestions on rewards and punishments to hospital leaders.
It is required that the off-duty meeting records and written materials between clinical departments and other departments on handling patients' opinions and suggestions should be accurately dated, signed by relevant personnel and kept for future reference.
Seven, nursing ward round system
system
Nursing rounds include administrative rounds, professional rounds and teaching rounds;
Nursing administrative rounds: focus on ward management, post responsibility system, implementation of rules and regulations, service attitude and implementation of nursing work plan;
Two nursing rounds including teaching rounds:
Check the development of basic nursing, specialized nursing, new business and new technology, discuss intensive care or choose instructive cases, analyze and evaluate the diagnosis, treatment and nursing effect of patients and their mutual influence, sum up experience, find out the gap and make a new nursing plan.
The head nurse makes rounds twice a month, once for administrative rounds and once for business rounds, and keeps records and data of rounds so as to sum up experience.
Supervision and inspection
The head nurse must have a fixed schedule of rounds every month;
Establish a head nurse's work manual, focusing on weekly rounds, new business and new technology development, and intensive care case rounds. Record it once a week, and keep special circumstances in mind at any time. The end of the year will serve as an important basis for assessing the performance of head nurses.
Formulate a unified quantitative scoring table for the implementation of nursing administration and business ward round system in the whole hospital, implement a hundred-point scoring system, and reward and punish accordingly.
Eight, the nurse on duty, succession system
system
The hospital implements the hourly duty system. .
The personnel on duty should strictly follow the doctor's advice, obey the arrangement, stick to their posts and perform their duties to ensure that all treatment and nursing work is carried out accurately and timely. Nurses are not allowed to change shifts without the consent of the medical section chief.
Patrol patients in strict accordance with the requirements of graded nursing, deal with their condition changes within the scope of their duties and report to the doctor on duty. Report major problems to the business vice president in time.
Before the succession, the personnel on duty must complete the records of all the work of the class and the disposal of used items. In case of special circumstances, the unfinished work must be explained in detail to the next shift, and the successor can do a good job before leaving.
Written handover should be written according to the requirements of Fujian medical record writing standard. Oral and bedside handover contents include the implementation of the doctor's orders of the class, the completion of various treatments, whether the critically ill patients such as coma, paralysis and first-class care have bedsores, basic nursing, various catheter fixation and drainage, etc.
For the quantity and efficiency of standing, precious, highly toxic, hemp, limited, drama drugs, rescue articles, equipment, instruments, etc. The successor shall be responsible for the problems found in the face-to-face handover. If an error or accident occurs due to unclear handover, or the goods are lost after handover, the successor shall be responsible.
Supervision and inspection
The system is supervised and implemented by the head nurse every day. When there are violations, the head nurse will make records and ask the parties to sign and keep the inspection records. The head nurse checks the shift change and on-the-job situation of nursing staff every month.
Nurses who are late, leave early or leave their posts for more than minutes and accumulated more than times in one year shall be treated as absenteeism days. Those who work shifts without the consent of the head nurse will be treated as absenteeism days. A person on duty who handles affairs unrelated to work and answers personal calls for more than minutes at a time can be regarded as getting off work.
Failing to patrol the patients according to the regulations, failing to complete the work on duty without special reasons, and delaying the treatment of patients, once found, will be recorded as a reference for year-end assessment.
Nine, nursing document writing system
system
The nursing staff of each class earnestly implemented it according to the writing norms and requirements of nursing documents. Copying doctor's advice and various nursing records should use blue-black ink pen, and shall not be altered at will. If there is any mistake, it should be crossed out and signed to show responsibility.
All documents must be put in a certain place and put back in their original place immediately after use. The whole document must not be scattered.
No documents shall be taken out or torn up without approval.
All medical care records shall be properly kept according to the principle of medical protection system, and shall not be given to patients, family members or irrelevant personnel for reading at will.
The medical records of discharged patients should be tidied up according to the regulations. After the chief physician fills in the summary of hospitalization, it will be recycled and kept by the medical record room within the specified time.
Ward nurse handover report should be carefully written as required, and kept for one year for future reference after use.
Supervision and inspection
Strengthen the education of nurses' legal awareness, pre-job education of new nurses and standardized education of nursing document writing, and clarify the responsibility of nurses for nursing document writing.
The head nurse randomly checks the nursing records every week, puts forward and corrects the problems in time, urges and ensures that the nursing records are filed in time as required, and the management of nursing records writing by the head nurse serves as the basis for the head nurse's year-end performance appraisal.
According to the unified scoring table of Nursing Medical Records in the whole province, the head nurse checks the nursing medical records once every quarter, writes a comprehensive written report, and reports it at the hospital meeting. Unqualified medical records are linked to departmental bonuses.
X. diet management system
system
The patient's diet is determined by the doctor according to the condition. After the doctor gives the doctor's advice, the nurse should inform the patient's family members in time, make a good diet sign, and publicize the clinical significance of treating diet to the patient and their family members.
For fasting patients, eye-catching signs should be set on food cards and at the end of the bed, and the reasons and time limit for fasting should be informed to patients or their families.
Help patients who can't take care of themselves.
Nursing staff should be concerned about patients' diet, strengthen patrol, and encourage patients with loss of appetite to eat properly to increase nutrition.
Supervision and inspection
The head nurse establishes a weekly inspection system, which is mainly recorded on the head nurse checklist, and the year-end is used as the basis for assessing the performance of the head nurse.
Eleven, nurse night rounds system
system
The head nurse makes rounds every night.
Carefully check the implementation of the post responsibility system and the nursing work of each department, and record the major problems in detail in the ward round record book.
When you find good people and deeds, you should praise and encourage them in time. If someone has a weak sense of responsibility, poor labor discipline, can't stick to his post, or has an accident, the head nurse should help educate and make up for it.
If there are problems that department nurses can't solve, they should help solve them.
If there is a large-scale rescue, you should go to the scene to assist the hospital leaders to organize and guide and participate in the rescue.
Night rounds should be reported orally to the medical section chief in time.
Supervision and inspection
The head nurse is responsible for the night rounds of continuous quality control of the nursing quality in the whole hospital, including the monthly rounds schedule, key inspection contents and the original records of the head nurse rounds.
The head nurse's night rounds must be carried out as required, and the problems found in the rounds should be carefully checked and recorded. If nursing defects are found, they should be signed by the nurse on duty.
The head nurse will make a written report on the inspection summary every month and inform the whole hospital of the problems existing in the inspection. Those who fail to meet the quality standards or individual nurses violate hospital rules and regulations will be dealt with according to the circumstances.
Twelve. Visiting and accompanying system
system
When patients are admitted to the hospital, nurses should introduce the visiting system in detail, and medical staff should explain those who cannot visit because of illness.
Visiting patients should enter the ward with a visiting card issued by the doorman at the specified time, and no more than two people at a time. Return the visiting card to the doorman when leaving, and the family members of critically ill patients can visit the patients at any time with the critically ill notice.
Patients with respiratory infections and other epidemic diseases, alcoholics and preschool children are not allowed to enter the ward, and visitors are not allowed to bring pets into the ward.
When the patient is sick and needs to be accompanied, the doctor decides and the head nurse issues a companion card. If it is not necessary, the card will be taken back.
During rounds and treatment, the accompanying personnel should take the initiative to leave the ward. For those who refuse to leave, the medical staff should persuade them to leave.
Visiting and accompanying personnel shall abide by the ward system, keep the ward clean and quiet, and shall not smoke, drink, make a loud noise or sit in the hospital bed, visit the ward or read the medical records, take the patient out of the hospital without permission, talk about the contents that are harmful to the patient's health and treatment, and invite doctors outside the hospital to make diagnosis and take medicine on their own.
Visiting and accompanying personnel should take good care of public property, save water and electricity, and do not use alcohol stoves, electric stoves, electric cups, chargers and other electrical appliances in the ward, and be responsible for compensation for lost and damaged items.
In order to ensure that the electronic instruments and equipment in the hospital are not disturbed, no one is allowed to use mobile communication tools in some areas.
All hospital staff should consciously abide by and maintain the system of visiting and accompanying, and must not bring people into the ward to visit or take outpatients into the ward for treatment.
Supervision and inspection
The escort system is implemented by the nurse on duty during the day and is supervised by the head nurse at any time.
Medical staff should publicize the system of visiting patients and their families at any time.
Thirteen, nursing health education system
system
Patient education: including health education and discharge guidance for patients.
In clinical nurse, that nurse in charge will assess the patients' health status in accordance with the method of nursing procedure, systematically collect data, conduct targeted education according to the needs and understanding ability of patients and their families, and explain the knowledge about diseases, diet, nutrition, medication guidance, exercise and rest, so as to make them cooperate with medical care well and reduce the recurrence and complications of diseases.
Discharge guidance: nurses provide patients with preventive and nursing methods to prevent disease recurrence after discharge, as well as precautions for the use of some auxiliary devices, and indicate the follow-up time when necessary.
Group education: Make use of the waiting time of outpatient service and the rest time of ward staff to carry out group education, explain health knowledge, prevention of common diseases, frequently-occurring diseases and seasonal infectious diseases, family planning and simple first aid knowledge, and give oral explanations or cooperate with videos, slides and models to carry out publicity and education.
Character education: use blackboard newspaper, publicity column, popular science pamphlet, pictures and health education prescription to carry out health publicity and education.
Supervision and inspection
The nurse in charge completed the health education within a few hours after the patient was admitted to the hospital. The head nurse checks the health education of nurses in each ward once a month, and checks the signatures of patients or their families in the column of "Health Education and Discharge Guidance" in the ward admission evaluation form to understand the feedback information of patients' understanding of health knowledge, which can be used as the basis for evaluating the work behavior of nurses in charge.
Hold a working holiday symposium once a month, and record the contents of health education in the "Working Holiday Symposium Record Book" as a monthly quality inspection item.
The blackboard newspaper of written education is changed once a month, and its main contents, forms and records are recorded in the Record Book of Health Science Education.