5. Report on the work of the Medical Service

# Report # Introduction Seeking truth from facts, accurate facts, reasonable analysis and proper details are the keys to writing a good situation report. The following is the work report of the medical department, welcome to read!

1. Report on the work of the Medical Department

In 20xx years, under the direct leadership of hospital leaders, in line with the concept of quality first and patient first, we paid close attention to the standardization of medical system, thoroughly studied and implemented the Law of People's Republic of China (PRC) on Medical Practitioners, the Regulations on the Management of Medical Institutions, the Regulations on the Handling of Medical Accidents, and the Basic Specification for Medical Record Writing, and combined with the actual situation of our hospital, we took practical and effective measures to strengthen medical quality management. Pay attention to the quality training and professional ethics education of medical staff, further emancipate the mind, update ideas, improve service efficiency, effectively promote medical treatment, teaching and scientific research, and make contributions to the reform and development of hospitals. The quality of medical care is the fundamental problem for the survival and development of hospitals. Paying close attention to medical quality management and improving the quality of medical services in an all-round way is the primary task of the medical department. The improvement of medical quality and medical safety has achieved remarkable results.

(1) Basic medical quality: According to the Detailed Rules for the Implementation of Medical Quality Management Regulations, the implementation of medical core rules and regulations, such as medical record writing system, request reporting system, checking system, third-level doctor rounds system, consultation system, case discussion system, operation grading system and responsibility system of first-visit departments, was supervised and inspected. According to the principle of combining education, guidance and criticism, the method of combining regular supervision, spot check and centralized inspection is adopted to improve the quality of basic medical care and link up the quality of medical care.

(2) Quality of medical record writing: In strict accordance with the requirements of the Basic Specification for Medical Record Writing, we put forward further standard requirements for the writing of inpatient medical records, course records and related materials, carefully organized study, and conducted 1-2 quality supervision and inspection every month, with clear rewards and punishments, rewarding the excellent and punishing the poor, which greatly improved the consciousness and quality of medical record writing of clinicians. Each department can turn over the medical records in time, and can write the current medical records in strict accordance with the Basic Rules for Medical Records Writing. Outpatient infusion observation medical records can basically be completed as required. The quality of prescription has also been improved to varying degrees. Prescriptions were randomly selected for 5 days every month, with an average pass rate of 86. 2%。 The basic registration of outpatient and inpatient departments can also be carried out as required, which basically meets the requirements of quality standards.

(3) Medical quality of medical technology departments: strengthen technical training of medical technicians and improve service quality, attach importance to monitoring the coincidence rate and accuracy of test results, and constantly add new items to meet clinical needs. Pay attention to communication with front-line clinical departments, actively participate in interstitial evaluation and indoor quality evaluation activities, achieve excellent results, and successfully pass the inspection and acceptance of provincial clinical inspection center. The radiology department standardized the morning meeting reading system and error correction system, which effectively prevented the occurrence of medical disputes.

(IV) Outpatient medical quality After the hospital decomposes the economic indicators, the sense of responsibility, risk awareness and competition awareness of outpatient doctors are obviously improved, and they can strictly abide by the responsibility system of first diagnosis and first diagnosis, and carefully register and write outpatient prescriptions. The results of prescription quality inspection for five consecutive months show that the qualified rate of outpatient prescription writing reaches 86. 2%, outpatient visits and economic income have also increased significantly.

(5) Medical safety work: the prevention and treatment plan of medical accidents was formulated, and the training of professional ethics and professional technical ability of medical staff was strengthened, especially the study of the Regulations on Handling Medical Accidents. 1 1 month holds a special lecture on the prevention and treatment of medical accidents, educating the medical staff and teaching them how to effectively prevent medical disputes and protect the legitimate rights and interests of patients, medical institutions and their medical staff.

In a word, although the Medical Department has made some achievements in the work of 20xx, it still needs further efforts to make greater contributions to the medical reform and construction of our hospital in the new year.

2. Report on the work of the Medical Service

In the first half of xx, under the correct leadership of the hospital committee, the medical department took patients as the center, took the overall improvement of medical quality as the theme, aimed at establishing the doctor-patient relationship, strictly grasped the implementation of medical standardization and core system, prevented and controlled medical hidden dangers from the source, innovated thinking, and changed ideas, so that all the work in the department could be carried out efficiently and orderly. Continuously improving medical quality is the driving force to promote the development of hospitals. Strict medical quality management and comprehensive improvement of medical service quality are the important tasks of the medical department. In xx, the medical department has always taken "Evaluation Standards and Implementation Rules of General Hospitals in xx Province" and "Two Good and One Satisfied" as the standards. According to the established plan at the beginning of the year, it has been deepened from three aspects: the implementation of core system, the quality management of medical records and the self-construction of departments.

1, the completion of various work indicators in the first half of the year (as of May 30, xx)

(1) 420 open beds

(2) Hospital bed utilization rate: 1 1 1.3%

(3) Total outpatient visits in the whole year: 199 1 1.

(4) Number of inpatients: 1054 1.

(5) Average stay time: 7 days.

(6) The actual number of beds in the hospital: 69,875.

(7) First-class product rate of medical records: 99%

(8) Prescription qualification rate

(9) The coincidence rate of admission diagnosis

The coincidence rate of diagnosis before and after operation was (10)

(1 1)ct positive rate

(12) success rate of emergency rescue

(13) Grade A healing rate of aseptic operation incision.

(14) Infection rate of aseptic operation incision

(15) Accuracy of pathological diagnosis

(16) component transfusion ratio

(17) Average preoperative hospitalization days of patients undergoing elective surgery.

2. Strict management and promotion of system implementation.

In 2009, the Medical Department continued to strengthen the implementation and implementation of the thirteen core systems, especially since functional departments participated in the handover and rounds of departments in the whole hospital. The Medical Department went further into departments and participated in the handover of departments, three-level rounds of rounds and group rounds every day, which gave us a more comprehensive understanding of the actual situation of the departments and made us more humanized on the basis of strengthening the implementation of the system. Facing the key inspectors of critically ill patients in various departments, all departments are required to report relevant information in time. After filing, the medical department should go to the department to understand the patient's condition and consult the medical records in time, then make specific arrangements for the consultation of the whole hospital or department, organize the consultation personnel and time, participate in the whole consultation process, and ensure the quality of consultation, thus saving time and energy for the department to concentrate on treating patients and collecting consultation data, effectively improving the success rate of treating critically ill patients and reducing the disability rate and mortality rate.

3. Report on the work of the Medical Service

Under the direct leadership of hospital leaders, with the concept of "quality first, patients first", we should pay close attention to the standardization of medical system, thoroughly study and implement the Law of People's Republic of China (PRC) on Medical Practitioners, the Regulations on the Management of Medical Institutions, the Regulations on the Handling of Medical Accidents, and the Basic Specification for Medical Record Writing, and take practical and effective measures to strengthen medical quality management in combination with the actual situation of our hospital. First, medical quality and medical safety.

The quality of medical care is the fundamental problem for the survival and development of hospitals. Paying close attention to medical quality management and improving the quality of medical services in an all-round way is the primary task of the medical department. The improvement of medical quality and medical safety has achieved remarkable results.

(1) Basic medical quality: According to the requirements of hospital quality management, the three-level medical quality control system was improved, the Medical Quality Control Scheme was formulated, and the Medical Quality Inspection and Assessment Standard was revised, which helped and urged all departments to establish eight books on medical quality control. Supervise and inspect the implementation of medical core rules and regulations such as medical record writing system, request report system, check system, three-level doctor rounds system, consultation system, case discussion system, operation grading system, and responsibility system of first-visit departments. According to the principle of combining education with criticism, the method of combining regular supervision and spot check with centralized inspection was adopted to strictly control the quality of basic medical care and link medical care, and the medical quality of our hospital was obviously improved.

(2) Quality of medical record writing: In strict accordance with the requirements of the Basic Specification for Medical Record Writing, we put forward further standard requirements for the writing of inpatient medical records, course records and related materials, carefully organized study, and conducted 1-2 quality supervision and inspection every month, with clear rewards and punishments, rewarding the excellent and punishing the poor, which greatly improved the consciousness and quality of medical record writing of clinicians. The number of inpatients in 20xx is 2670, which is 0.03% lower than that in 2004. 2,670 medical records were filed, 2,553 were Grade A medical records, and the rate of Grade A medical records was 95.6%. There are 2670 qualified medical records, and the qualified rate is 100%. Each department can turn over the medical records in time, and can write the current medical records in strict accordance with the Basic Rules for Medical Records Writing. Outpatient infusion observation medical records can basically be completed as required. The quality of prescription has also been improved to varying degrees. Prescriptions were randomly selected for five days every month, and the average pass rate of1-1was 86.2%. The basic registration of outpatient and inpatient departments can also be carried out as required, which basically meets the requirements of quality standards.

(3) Medical quality of medical technology departments: strengthen technical training of medical technicians and improve service quality, attach importance to monitoring the coincidence rate and accuracy of test results, and constantly add new items to meet clinical needs. Among them, the laboratory has newly developed the detection items of hepatitis A antibody, hepatitis C antibody and treponema pallidum this year, which meets the needs of clinical blood transfusion safety. Pay attention to communication with front-line clinical departments, actively participate in interstitial evaluation and indoor quality evaluation activities, achieve excellent results, and successfully pass the inspection and acceptance of provincial clinical inspection center. The radiology department standardized the system of reading films in the morning meeting and the system of blocking and correcting errors, which effectively prevented the occurrence of medical disputes.

(4) Outpatient medical quality: After the hospital breaks down the economic indicators, the sense of responsibility, risk awareness and competition awareness of outpatient doctors are obviously improved, and they can strictly abide by the responsibility system of first consultation and first consultation, and carefully register and write outpatient prescriptions. The results of prescription quality inspection for five consecutive months show that the qualified rate of outpatient prescription writing has reached 86.2%, and the number of outpatient visits and economic income have also increased significantly.

(5) Medical safety work: From May to July this year, several medical disputes occurred in our hospital, and the medical department coordinated and resolved them in time to minimize hospital losses. Subsequently, in view of the continuous occurrence of many medical disputes in this hospital, the Medical Department carefully analyzed the situation, formulated a plan for the prevention and treatment of medical accidents, and strengthened the training of medical staff's professional ethics and professional technical ability, especially the study of the Regulations on the Handling of Medical Accidents. In July and August, a series of emergency training was held to strengthen the professional skills training of medical staff. 10 also held the prevention and treatment of medical accidents. Combined with typical cases around or in our hospital, this paper analyzes how to educate medical staff to effectively prevent medical disputes and protect the legitimate rights and interests of patients, medical institutions and their medical staff. 1 1 At the end of the month, the medical staff of the whole hospital were also organized to study the medical professional laws and regulations such as the Law on Medical Practitioners, the Regulations on the Management of Medical Institutions, the Measures for the Management of Nurses, and the Regulations on the Handling of Medical Accidents, which set off a hot lake of learning, understanding and abiding by the law in the whole hospital. Through our efforts, the frequent occurrence of medical disputes has been effectively curbed.

Second, science and education work.

Continuing medical education

1. Incorporate continuing education into the work plan of our hospital and attach importance to the training and education of staff inside and outside the hospital. This year, our hospital sent five people to tertiary hospitals inside and outside the province for further study and sent nearly 20 short-term classes. Several doctors who returned to the hospital after further study were able to quickly apply the new knowledge and technology they had learned to the clinic and actively carry out their work, which played a great role in improving the level of medical technology in our hospital.

2. This year, nearly 10 people in our college participated in various adult college entrance examinations and education for academic transformation.

3. Actively write papers, publish 6 papers throughout the year, and exchange more than 10 papers in the Municipal Medical Association.

4. Two academic training courses were held and achieved complete success. A training course on the basic theory of traditional Chinese medicine was held, and more than 60 Chinese medicine doctors from all towns and villages in the county participated in the training; 165438+1in late October, our hospital also hosted the 20xx annual meeting and academic exchange meeting of Shiyan Rehabilitation Medical Association, a municipal continuing medical education project, and more than 90 people attended the meeting.

(B) Three basics training and teaching work

This year, the Medical Department and the Nursing Department jointly held more than ten academic lectures, carried out a series of first-aid knowledge training and first-aid skill examination, and then conducted a closed-book examination on first-aid knowledge, which was a complete success, and greatly improved the theoretical knowledge and skills of most young medical staff. The nursing department also carried out large-scale nursing operation training in a timely manner, which enabled the majority of nursing workers to master skilled operation skills. In addition, our hospital has strengthened the management of senior interns, and further carried out discipline education and requirements for interns, so that senior interns and nurses feel that they can really learn their own places during their internship in our hospital. This year * * * received 25 advanced students from township hospitals and hospitals in other counties, and 58 interns from Shiyan Medical and Health School.

(3) Scientific research work

This year, our hospital declared three scientific research projects, among which the project of acupuncture plus liquid tension therapy for cervical spondylosis of vertebral artery type passed the provincial appraisal, and the two scientific research projects of carotid artery injection for cerebral infarction and Poyu capsule for thrombotic diseases were formally established, which created a precedent for scientific research in our hospital.

Three. Publicity and health education

1. Make use of news media such as Yunxian TV Station and Yunyang Communication to expand hospital brand promotion, and do special topics and news in Yunyang TV Station's Healthy Sight and Yunyang News respectively. 16, at Shiyan TV Station.

2. Carry out various forms of health education: each ward and clinic will issue two publicity columns. More than 20 prescriptions for health education of common diseases were printed and distributed to patients in wards and clinics free of charge, and health education guidance was carried out in combination with TV media, which was welcomed by the masses.

Fourth, free clinic activities and physical examination work.

1, organized experienced medical staff to go to poor and remote villages for free clinic for local people for ***9 times, cooperated with county health bureau and Red Cross to carry out free clinic activities in Yunyang Road and Yunyang Square respectively, * * * treated patients 150 times, and distributed health education prescriptions, which was well received by the people.

2. This year, about 1 144 employees of enterprises, institutions and life insurance companies were organized for physical examination, which facilitated the physical examination needs of the broad masses of the people and was well received by the people, and achieved social and economic benefits.

Although the Medical Department has made some achievements in the work of 20xx, it still needs further efforts to make greater contributions to the medical reform and construction of our hospital in the new year.

4. Report on the work of the Medical Service

Under the leadership of the Dean, we thoroughly studied and implemented the Law on Medical Practitioners, Regulations on the Management of Medical Institutions, Regulations on the Handling of Medical Accidents, Medical Record Writing Standards, Prescription Management Measures and other laws and regulations, and combined with the actual situation of our hospital, we took practical and effective measures to strengthen medical quality management, pay attention to the quality training of medical personnel and professional ethics education, further emancipate our minds, update our concepts and improve service efficiency. Strengthen medical quality management, improve the three-level medical quality control system according to the requirements of hospital quality management, and formulate a continuous improvement plan for medical quality. Strengthen the quality management, evaluation and supervision of clinical departments, medical technology departments and pharmaceutical departments, and put forward suggestions for improvement. Establish and improve medical quality, medical records, pharmaceutical affairs, infection, blood transfusion and other management organizations and their working systems, clarify responsibilities, organize regular activities to carry out work, and comprehensively improve the quality of medical services.

Do a good job in medical education. Implement the credit system for continuing education, organize business personnel to learn laws and knowledge such as Several Opinions of the Ministry of Health on Strengthening Continuing Medical Education, Measures for the Declaration and Identification of Continuing Medical Education Projects, Measures for the Granting and Management of Continuing Medical Education Credits, and Measures for the Assessment and Management of Continuing Medical Education Credits, and carry out skills training such as self-study, special lectures, rounds and on-the-job training. In the first half of this year, 65,438+02 business and legal studies were organized. And arrange 1 written examination, so that the popularization rate of continuing education in the whole hospital can reach over 95%. Through learning, business personnel have consolidated basic knowledge, basic theory and basic skills, learned new knowledge and progress of medical technology at home and abroad, broadened their horizons and further improved their professional level.

In terms of system construction, all departments are required to study and implement it seriously. In particular, the implementation of the core systems, such as the first-visit responsibility system, the three-level doctor rounds system, the consultation system, the death case discussion system, the difficult case discussion system, the medical record writing standard and other systems, and supervise and inspect the implementation.

In terms of echelon construction and personnel training, the Medical Department actively cooperated with the leaders of the hospital and sent eight health technicians who were in their prime of life and had both ability and political integrity to the superior hospital for further study or short-term study and training.

Go to community service stations regularly, strengthen management, supervise and inspect the completion of community health files and six major tasks, improve the level of diagnosis and treatment and the management level of community health services, and make primary health care penetrate into residents' lives.

Strengthen disease control and issue birth medical certificates, death certificates and diagnosis certificates in strict accordance with regulations. The direct reporting of infectious diseases and deaths on the internet is helpful to the standardized management of hospitals.

The monitoring of hospital infection was strengthened, the implementation of the system was improved, the hospital infection was monitored, and the use of antibacterial drugs was also monitored and managed, which filled the blank of hospital infection monitoring.

In the first half of the year, all the work planned at the beginning of the year and arranged by the hospital leaders were well completed. In the future work, we will continue to maintain a good work style, blaze new trails, work hard and serve patients wholeheartedly.

5. Report on the work of the Medical Service

In the first half of 20xx, according to the instructions of hospital leaders and the standards and requirements of tertiary hospitals, the staff of our department carried out various tasks of medical quality and safety management, which are as follows: 1. Medical quality management.

(A) Process management

In-depth clinical practice, through on-site discovery of problems and holding coordination meetings, various processes between departments and within departments are sorted out to achieve the goal of continuous improvement. In the first half of the year, 14 coordination meetings were held, involving more than 10 departments, to sort out the procedures such as preoperative medication specification, emergency operating room management in obstetric delivery room, consultation management outside the hospital, neonatal supervision management, clinical massive blood transfusion treatment scheme and process, outpatient gynecology, obstetrics, medical guide desk, toll collection office, blood transfusion management, second-line doctors in obstetrics and gynecology, obstetrics, induced labor, and treatment management of dead infants.

(B) to strengthen the management of the core system

1. management of referral consultation system: in the first half of 20xx, the medical department organized 26 out-of-hospital consultations, 5 out-of-hospital consultations, expanded in-hospital consultations 10, and the whole city 1 time. Manage 22 referral patients.

2. Pay close attention to the "three basics and three strictness" assessment. With the attention and support of hospital leaders, in July of 20xx, we organized the "three basics" theoretical examination for all medical, technical and pharmaceutical personnel, and actively organized medical staff to participate in the national maternal and child health skills competition, which is currently in the preparatory stage.

3. Clinical pathway, appointment service and critical value management have been normalized. In the first half of the year, the total number of discharged patients was 1 1603, with 3997 cases, and the total admission rate was 34.4% (the standard was 20%). The total number of appointments was 63,423, and the total appointment rate was 35% (40% of the standard). Our department will check the implementation of various systems in clinical and medical departments every month, and communicate with individuals and departments in time when problems are found, which will be included in the performance appraisal.

4. Adhere to the system of monthly on-site assessment and quarterly medical quality meeting, analyze and summarize medical quality problems, especially cases of potential safety hazards, medical complaints and medical disputes, timely organize discussions between departments and systems, find out the reasons, and incorporate the results into performance appraisal and evaluation.

5, strengthen business knowledge training, improve the level of diagnosis and treatment. Take all employees, subsystems, departments, etc. Carry out continuing education and training for professional and technical personnel, combine learning with examination, pay attention to learning effect, and organize business study for 7 times in the first half of this year.

6. Difficult case discussion: In the first half of 20xx, our department organized five difficult case discussions, mainly for cases with complaints and disputes. The medical department often participated in the discussion of difficult cases in the department, especially those with dispute tendency, so as to know the situation in time and deal with the problems better.

Second, strengthen medical safety awareness, attach importance to laws and regulations, and properly handle medical disputes.

1. According to the actual situation of our hospital, various forms of safety training for all staff were carried out, and two lectures on medical safety and medical quality were organized in the first half of the year. One of them invited Wei Ying, deputy director of the Medical Affairs Department of the Municipal Health Bureau, to deeply interpret the Regulations on the Handling and Prevention of Medical Disputes in Jiangxi Province, which strengthened the legal awareness of medical staff in our hospital and improved their ability to handle medical disputes.

2. Further strengthen the management of adverse event reports, and mobilize all staff to actively discover and report potential safety hazards in medical care, security and other links. In the first half of 20xx, the Medical Department received 9 adverse event reports. Reward related departments of reported adverse events in accordance with the Measures for the Administration of Adverse Events, and coordinate with relevant departments for rectification in time according to the contents of the report, so as to nip all kinds of unsafe factors in the cradle.

3. Handling of medical complaints and disputes:

1) complaints: in the first half of 20xx, the medical department * * * received complaints 10, of which 7 were directly complained to the medical department and 3 were transferred by the complaints department. Every time I received a complaint, our department responded positively, and learned about the situation from patients and departments at the first time, and convened relevant departments to discuss and analyze, found deficiencies, put forward rectification, and gave the complainant an oral or written reply.

2) Disputes: Of the 6 medical disputes in the first half of 20xx, 3 have been solved (① Xie Hongmei's inevitable miscarriage and twin death, ② Zhao Yi's tubal pregnancy rupture, ③ Li Qiulian's Mao Mao's humeral fracture), and 3 medical disputes to be solved (① Peng Xiaorong's placental abruption, which has been medically identified, ② Aiping's bladder rupture in gynecology, which is under legal procedures, and ③ the stillbirth in Meigong, which is currently awaiting autopsy results.

When encountering complaints and disputes, the Medical Department always goes to the first site to learn about the situation, and organizes relevant departments and personnel to discuss the medical records, some of which are discussed many times; According to the situation, convene different forms of communication and resolution meetings, sometimes a complaint or dispute needs dozens of communication. With the promulgation of "Regulations on Dispute Settlement in Jiangxi Province" and "Clear Solutions", contacts with medical commissions, medical appraisal institutes, lawyers, courts, judicial departments and personnel have become more frequent. After the dispute is resolved, it is also an important task of the medical department to organize academic Committee discussion, identify and divide the responsibilities of existing problems, and optimize the system and process in the next cycle.

Three, the implementation of health support for agriculture, counterpart support work

In 20xx, the counterpart support work in our hospital was Lianhua Fanglou Health Center and Chishan Central Health Center, and our hospital carried out various forms of counterpart support work. Lianhua Fanglou Health Center has two middle-level or above doctors stationed in the obstetrics and gynecology department of the aided hospital, giving a professional lecture once a month, attending outpatient clinics or organizing rounds every day, and regularly hosting discussions on difficult cases. Every Saturday, an obstetrician and a pediatrician were sent to Chishan Central Health Center for ward rounds and professional guidance, which was well received by the aided hospitals. My support hospital is Chishan Hospital in Shangli County.

Four. Infectious disease management plan for the second half of the fifth year

Our department will continue to go deep into the clinic, strengthen the on-site assessment, find out the shortcomings of the department and rectify the weak links in combination with the standards and various rules and regulations of the Measures for the Administration of Dean's Administrative Warding, so as to ensure safety by quality and promote quality by safety.