2011 Shanxi Province Nurse Core System

The best answer (1) Checking system

1. Doctor's order checking system

1) The doctor's order can only be executed after two people have checked it and it is correct. Doctor’s orders must be checked once a day.

2) The copied medical order must indicate the date, time and signature, and must be checked by another person. Both the person who copies the medical order and the person who checks it must sign.

3) Temporarily executed medical orders must be verified by a second person before they can be executed, and the execution time should be recorded and signed by the executor.

4) When rescuing a patient, the doctor issues an oral medical order, and the executor must repeat it loudly and then execute it. After the rescue is completed, the doctor must reissue the medical order and sign it. The ampoule should be kept for re-checking after the rescue.

5) Questionable medical orders must be clarified before they can be executed and copied.

2. Checking and checking system for taking medicines, injections and infusions

1) "Three checks and seven checks" must be strictly implemented before taking medicines, injections and infusions. Three inspections: inspection after dispensing the medicine; inspection before taking the medicine, injection, and treatment; inspection after injection and treatment. Seven pairs: bed number, name, drug name, dose, concentration, time, and usage.

2) Before preparing medicines, check the quality of the medicines. Pay attention to whether the liquids and tablets have deteriorated; whether there are cracks in the ampoules and injection bottles; whether the sealed aluminum caps are loose; whether the infusion bags are leaking; Is there any turbidity or floc in the medicinal solution? Expired medicines, if their expiry dates and batch numbers do not meet the requirements or their labels are unclear, they must not be used.

3) After dispensing the medicine, it must be checked by a second person before execution.

4) For allergenic drugs, you should ask whether you have any allergic history before administration; when using poisons, anesthetics, and psychotropic drugs, strictly implement the "Regulations on the Management of Narcotic Drugs and Class I Psychotropic Drugs in Medical Institutions" (Wei Medical [2005] Document No. 438). The nurse should check repeatedly and return the ampoules to the pharmacy promptly after use; when giving multiple drugs, pay attention to whether there are any incompatibility. At the same time, the nursing department should standardize and improve the operating instructions for skin testing drugs and the drug compatibility list according to the drug instructions.

5) When dispensing medicine or injecting, if the patient raises any questions, he should check it in time and make sure it is correct before execution.

6) After adding medicine to the infusion bottle, the name of the medicine and dosage should be written on the label, and the ampoule should be left behind. It can only be used after being checked by another person.

7) Strictly implement the bedside double check system.

3. Surgical patient checking system

1) When receiving a patient in the operating room, the department, hospital number, bed number, name, wristband, gender, and age should be checked , diagnosis, operation name and site (left and right) and its logo, preoperative medication, eight results before blood transfusion, whether the drug allergy test results are consistent with the operation notice, and the drugs and items (such as CT, X-ray films) brought with the operation order ). Assess the patient's overall condition and skin condition, and ask about allergies.

2) The surgical nurse checks whether the prepared surgical instruments are complete and whether the categories, specifications and quality of various supplies meet the requirements. Whether the patient's position is correct to expose the surgical field as much as possible and prevent falling from the bed and pressure ulcers.

3) The operating staff should check the department, hospital number, bed number, name, wrist band, gender, age, diagnosis, surgical site, anesthesia method and medication, blood matching report, etc. before the operation. When the hand-washing nurse opens the sterile bag, check whether the chemical index card in the bag meets the standards. For body cavity or deep tissue surgery, the hand-washing nurse and circulating nurse must strictly check before the operation and before suturing after the operation. The number of instruments, large gauze pads, gauze, suture needles, etc. will be recorded and signed by the circulating nurse immediately on the surgical care record sheet. The number of instruments and items in the bag before and after surgery matches, and only after verification is correct can the surgeon be notified to close the surgical incision to prevent foreign objects from being left in the body cavity.

4) Biopsy specimens removed during surgery should be checked by a handwashing nurse and the operator, a specimen registration system should be established, and a designated person should be responsible for sending pathological specimens for inspection.

4. Blood transfusion checking system Based on the requirements of the Ministry of Health's "Clinical Blood Transfusion Technical Specifications", a blood drawing cross-matching checking system, a blood collection checking system, and a blood transfusion checking system have been formulated.

1) Blood drawing cross-matching and blood checking system

① Carefully check the cross-matching blood list, patient blood type test sheet, patient bed number, name, gender, age, disease Area code, hospitalization number.

②. There must be two nurses when drawing blood (when one nurse is on duty, the doctor on duty should assist), one person draws blood, and the other checks, and then executes after checking.

③. After drawing blood (crossing), a barcode must be affixed to the test tube, and the ward (number), bed number, and patient’s name must be written on it. The handwriting must be clear and correct to facilitate verification.

④. Blood samples should be drawn in sufficient amount as required, and should not be drawn from the veins of limbs that are being rehydrated.

⑤. If you have any questions about the test form and patient identity when drawing blood, you should recheck it with the doctor in charge and the senior responsible nurse on duty. You cannot directly modify the wrong test form and wrong label, and you should fill it out again. Correct test forms and labels.

2) Blood collection check system When you go to the blood bank to collect blood, you should carefully check the name, gender, bed number, blood bag number, blood type, blood transfusion quantity, blood expiration date on the blood bag, and the preservation of blood. The appearance must be accurate; the blood bag must be retrieved in a treatment tray or clean container covered with sterile towels.

3) Blood transfusion check system ①. Patient check before blood transfusion: 2 medical staff must check the patient’s bed number, name, hospitalization number, blood type, and blood volume on the cross-matching report, and verify The name, serial number, blood type of the blood donor and the patient’s cross-compatibility test results. Check whether the name, number, and blood type on the label on the blood bag match the blood matching report form. If they match, proceed to the next step.

②. Check the supplies before blood transfusion: Check the date of collection of the blood bag, whether there is extravasation in the blood bag, the appearance quality of the blood, and confirm that there is no hemolysis, clots, or deterioration before use. Check whether the blood transfusion set and needle used are within the validity period. After blood is taken out from the blood bank, do not shake it, do not heat it, do not put it in the refrigerator for quick freezing, and do not leave it at room temperature for too long.

③ During blood transfusion, two medical staff (carrying medical records and cross-matching blood orders) will go to the patient's bedside to check the bed number, ask the patient's name, check the bedside card, and ask about the blood type. to identify the recipient.

④. Use intravenous saline to flush the blood transfusion channel before and after blood transfusion. When continuously transfusing blood from different donors, after the previous bag of blood is exhausted, flush the blood transfusion set with intravenous saline, and then Continue to infuse additional blood bags. During blood transfusion, closely monitor the patient for transfusion reactions.

⑤. After completing the blood transfusion operation, check the doctor's order again, including the patient's bed number, name, blood type, blood matching order, blood bag label's blood type, blood number, blood donor's name, and blood collection date, and confirm that they are correct. sign. Attach the record sheet (cross-match report sheet) to the medical record and return the blood bag to the transfusion department (blood bank) for at least one day.

5. Diet check system

1) After checking the doctor's order every day, based on the diet list, check the patient's bedside diet sign, bed number, and diet species and educate patients about the clinical significance of therapeutic diets.

2) Before distributing meals, check whether the meal list matches the type of meal.

3) Check again at the patient’s bedside before starting a meal.

4) For fasting patients, eye-catching signs should be placed on the diet and at the end of the bed, and the patient or family should be informed of the original time limit for fasting.

5) For patients who have food restrictions due to their illness, the food sent by their family members must be inspected by medical staff before they can be eaten

(2) Shift handover system

< p>1. Personnel on duty should strictly abide by the nursing management system, obey the arrangements of the head nurse, stick to their posts, perform their duties, and ensure that all treatment and nursing work is carried out accurately and timely.

2. Before the shift is handed over, the nurse in charge should check the implementation of medical orders and the nursing records of critically ill patients, focus on inspecting critical and new patients, and arrange nursing work during the shift.

3. Each shift must be handed over on time. The successor must arrive at the department 15 minutes in advance, read the nursing records, and do not accept the handover items (the number of patients is inaccurate, the condition is unclear, the bed is unclean, The patient's skin is unclean, the pipelines are blocked, various treatments are not completed, and the number of items does not match and is not handed over).

4. The person on duty must complete all the records of the shift and all the work of the shift before handing over, handle the items, and make preparations for the successor, such as sterilized dressings, test tubes, etc. Specimen bottles, syringes, standing instruments, clothing, etc. to facilitate the successor's work. In case of special circumstances, detailed explanations must be made and the work must be done well together with the successor before leaving.

5. When the shift is handed over in the morning, the night shift nurse will report the condition. All staff should listen carefully and carefully. After the night shift is handed over, the head nurse will lead the day and night shift nurses to inspect the ward together and hand over the condition and ward bedside. management situation.

6. The handover content includes:

①The total number of patients, the number of discharges, transfers, transfers, deliveries, operations, deaths, as well as the number of new admissions, patients, rescue patients, and general There may be special examinations and treatment before and after surgery, abnormal behavior, suicidal tendencies, illness/changes in relationships and mental state.

②The implementation of medical orders, critical care records, collection of various examination specimens and completion of various treatments, and unfinished work should be clearly explained to the successor.

③ Check whether coma, paralysis and other critically ill patients have pressure ulcers, as well as the completion of basic care, various catheters and patency.

④ The full names of valuables, poisons, anesthetics, psychotropic drugs and rescue drugs, instruments, quantity and technical status, etc.

7. The person taking over the shift will inspect the ward to see whether it meets the requirements of cleanliness, orderliness, quietness and the actual status of various tasks.

8. Except for detailed handovers, all other shifts should patrol the wards together and conduct bedside handovers.

9. If you find that the condition, treatment, equipment, and items are unclear during shift handover, you should inquire immediately. If any problems are discovered during the shift, the successor shall be responsible; if after the shift is unclear, an error occurs or items are lost, the successor shall be responsible.

10. The shift report (nursing record) should be written neatly, clearly, and with highlighted key points. The content of nursing records is objective, true, timely, accurate, comprehensive, concise, coherent, and uses medical terminology. When a training nurse or internship nurse writes a nursing record, the teaching nurse is responsible for revising and signing it.

(3) In the hierarchical nursing system, doctors issue medical orders based on the patient's condition. The levels are divided into special care and first, second and third-level care, and are marked (first-level care is red, second-level care is blue, and third-level care does not need to be marked).

1. Special care

1) Applicable objects: patients who are in critical condition and need to be observed at any time; patients who need absolute bed rest.

2) Nursing content:

① Arrange dedicated nursing care and closely observe changes in eyes and vital signs.

② Develop a nursing plan, strictly implement various diagnosis, treatment and nursing measures, and fill in the nursing records of critically ill patients item by item in a timely and accurate manner.

③ Prepare the medicines and supplies needed for first aid.

④ Provide basic care, strictly prevent complications, and ensure patient safety.

2. First-level care

1) Applicable objects: Those who are seriously or critically ill, need strict bed rest, and cannot take care of themselves.

2) Nursing content:

① Closely observe changes in the condition. Generally, the patient is inspected every 15 to 30 minutes, and body temperature, pulse, respiration, blood pressure, etc. are measured regularly according to the needs of the condition; the reaction and effect after medication are observed.

② Strictly implement various diagnosis, treatment and nursing measures, and fill in nursing records promptly and accurately.

③ Strengthen basic nursing care, strictly prevent complications, and meet the physical and mental needs of patients.

3. Secondary care

1) Applicable objects: patients with severe malaria and unable to take care of themselves in part of their lives.

2) Nursing content:

①Visit the patient once every 1-2 hours to observe the condition.

② Follow the corresponding routine care.

③Give necessary life care and psychological support to meet the patient's physical and mental needs.

4. Third-level nursing care

1) Applicable objects: patients with mild illness who can basically take care of themselves.

2) Nursing content:

①Visit patients every shift and observe their condition.

② Follow the corresponding routine care.

③ Provide health care guidance, urge patients to abide by hospital rules, and meet patients' physical and mental needs.

(4) Nursing defects and dispute registration and reporting system

1. In nursing activities, medical and health management laws, administrative regulations, departmental rules and diagnosis and treatment nursing standards and routines must be strictly observed. Comply with professional ethics in nursing care.

2. Each nursing unit has a plan to prevent and handle nursing defects and disputes to prevent defects and accidents from occurring.

3. Each nursing unit should establish a nursing defect registration book and register the nursing defects in the ward in a timely and factual manner.

4. When nursing defects or accidents occur, they must be reported in a timely manner and proactively take rescue or rescue measures to minimize or eliminate the adverse consequences caused by the defects or accidents.

5. After a defect or accident occurs, relevant records, specimens, test results, and the drugs and equipment that caused the defect or accident should be properly kept and shall not be altered or destroyed without authorization.

6. Reporting time after nursing defects occur: Whenever a defect occurs, the person concerned should immediately report it to the doctor on duty, department head nurse, district head nurse and department leader. The ward head nurse will report to the head nurse on the same day. Report to the head nurse of the department and submit a written report to the Nursing Department.

7. Each department should carefully fill in the nursing defect report form, and the individual should register the process, causes and consequences of the defect, as well as his/her understanding of the defect. The head nurse should promptly investigate and study the deficiencies and organize discussions within the department. The head nurse will submit the discussion results to the department head nurse. The department head nurse should submit the handling opinions and reports to the nursing department within one week.

8. For nursing defects that occur, organize the Nursing Defects Appraisal Committee to discuss the incident and submit handling opinions; when the defects cause adverse effects, relevant follow-up work should be done.

9. After a defect occurs, the head nurse should carefully analyze the causes, influencing factors and management of the defect, formulate improvement measures in a timely manner, track the implementation of the improvement measures, and conduct regular inspections of the ward Analyze and discuss the nursing safety situation and formulate relevant preventive measures for weak links in the work.

10. If a department or individual in which a nursing defect or accident occurs fails to report as required and intentionally conceals it, and is later discovered by the leader or others, he or she must be dealt with according to the seriousness of the case.

11. The management of nursing accidents shall be carried out in accordance with the "Regulations on the Handling of Medical Accidents".

(5) Nursing rounds system

1. Nursing administrative rounds

1), presided over by the director of the nursing department, head nurse of the department, and nursing department officer Participate more than once a month, with special topics, focusing on checking the quality of nursing management work, job responsibility system, implementation of rules and regulations, service attitude, implementation of nursing work plan and nursing teaching.

2) The director of the nursing department regularly visits the ward or door to check on the implementation of the duties of the head nurse of the emergency department and the district head nurse.

3) Nursing rounds: presided over by the head nurse of the department and attended by the head nurses of each ward. Once a month, key cross-checks are conducted on the quality of nursing management work, service attitude and nursing work in each ward of the undergraduate department. Plan implementation and nursing teaching status.

2. Nursing business rounds refer to the three-level ward rounding system of doctors. The superior nurses conduct nursing rounds on the lower-level nurses’ care of patients. 1). The main objects of nursing rounds: newly admitted critically ill patients, hospitalized During this period, the condition changes or verbal/written notification of serious/critical illness occurs.

Patients whose pressure ulcer score exceeds the standard, patients who are brought out of the hospital with stage II or above pressure ulcers, patients who develop pressure ulcers in the hospital, whose diagnosis is not clear and whose nursing effect is poor, and patients who are at high risk of potential safety accidents (such as falls, bed falls, wandering, suicide, etc.) .

2) Specific methods:

① The head nurse, nursing team leader or specialist nurse of the department (district) organizes checks on new people, serious patients or patients before and after major operations every morning house.

② The junior responsible nurse reports to the head nurse or superior nurse on the situation, nursing measures and implementation effects of the patients in charge.

③The superior nurse proposes nursing measures based on the patient's condition and nursing problems, and the subordinate nurse records the objective situation in the nursing record, and notes "Head Nurse's Ward Round", "Senior Responsible Nurse X X Ward rounds" etc.

④ During the ward round, the lower-level nurse can request a nursing consultation from the higher-level nurse according to the needs of the patient's condition.

⑤The director of the nursing department should regularly participate in nursing rounds and provide guiding opinions on the nursing work of the department.

3. Nursing teaching ward rounds 1), Nursing skills ward rounds: observe the technical operation demonstrations of experienced nurses, standardize basic or specialist nursing operation procedures, clinical application skills, etc., through demonstrations, In the form of video recording, on-site operation, etc., nurses at different levels can become teachers, and the participants are nurses and nursing students. High-quality nursing case display and health education implementation methods, etc., achieve the role of teaching demonstration and teaching, helping and leading.

2) Clinical case teaching: nursing teaching activities organized by senior responsible nurses or above in the ward or teaching teachers. Select typical cases and propose the purpose of ward rounds and the achieved teaching objectives. Apply the method of nursing procedures to help nurses master the thinking method of applying nursing procedures and further understand the theory of new professional knowledge through the study and discussion of collecting data, identifying nursing problems, formulating nursing plans, implementing nursing measures, and feedback on nursing effects. , can discover noteworthy issues and methods in clinical nursing work, standardize the nursing process in the process of teaching and learning, understand new theories, and grasp new developments.

3) Clinical teaching ward rounds: organized by the teaching teacher, and attended by nurses and student nurses. The focus is on the basic knowledge and theory of nursing, and the content and form of ward rounds are determined according to the needs of student nurses. Focusing on the key points and difficulties of intern nursing students in clinical work, in accordance with the "Nursing Teaching Ward Rounds Standards", clinical teaching rounds are conducted 1 to 2 times a month, such as operation demonstrations, case reviews, case discussions, etc.

(6) Nursing consultation system

1. Specialist nursing consultation

1) Personnel with senior responsible nurses or above have consultation qualifications.

2) When encountering nursing problems that cannot be solved by this specialty, the ward or department should organize cross-ward and multi-specialty nursing consultations. The nursing department is responsible for coordination when necessary.

3) The nursing consultation is hosted by a specialist nurse or head nurse. Relevant professional nurses and relevant nursing staff in the ward participate in the consultation, conduct serious discussions, propose solutions to problems or conduct investigations.

4) Consultation must be prepared in advance. The responsible department should organize relevant materials, make written summaries as much as possible, and send them to those participating in the consultation in advance to prepare for speeches.

5) During the discussion, the senior responsible nurse will be responsible for introducing and answering questions about the condition, diagnosis, treatment and care. Participants will fully discuss the nursing issues and put forward consultation opinions and suggestions.

6). At the end of the consultation, the specialist nurse or ward head nurse will summarize, record the consultation process and results, organize the clinical implementation, and observe the nursing effect. Special research projects can be established for problems that are difficult to solve at the moment.

2. Nursing consultation for difficult cases

1) When a difficult case is admitted to the ward, an application should be submitted in time, and the head nurse of the department will organize a nursing consultation. The main content is to correctly assess patients, discover correct nursing problems and judge the outcome of the disease, propose effective nursing measures and issues to pay attention to, conduct nursing consultations at any time according to clinical needs, and record them in the nursing consultation sheet as required.

2) For special cases or typical cases, the nursing department can be responsible for organizing hospital-wide nursing consultations. Full preparations should be made before the consultation, and written consultation opinions should be provided at the end of the consultation.

(7) Critically ill patient rescue system

1. Requirements: Maintain a serious, serious, positive and orderly work attitude, and race against time to rescue patients. Achieve the five implementations of ideas, organization, medicines, equipment and technology.

2. Only those who are in critical condition and require rescue can enter the intensive care unit or rescue room.

3. All rescue items, equipment and medicines must be complete, kept by designated personnel, positioned and stored quantitatively. All rescue facilities are in emergency mode and clearly marked. They are not allowed to be moved or loaned out at will. Nurses must check items once a day and hand them over during each shift to ensure that the accounts are consistent.

4. Staff must be proficient in the performance and use of various instruments and instruments and various rescue operation techniques, closely observe the condition, and accurately and timely record the dosage, method and patient status.

5. When the patient's life is in danger, before the doctor arrives, the nurse should take the best possible rescue measures according to the condition, such as timely oxygen administration, sputum suction, blood pressure measurement, establishment of intravenous access, artificial respiration and Heart compressions.

6. Rescue personnel must have a clear division of labor, cooperate closely, obey orders, stick to their posts, and strictly implement various rules and regulations and rescue procedures for various diseases.

7. Closely observe changes in the condition during the rescue process. Critical patients should be rescued on the spot and can only be moved after their condition stabilizes.

8. Carry out medical instructions promptly and correctly. When the doctor gives an oral medical order, the nurse should repeat it. After the rescue, the ampoules of the drugs used must be temporarily retained and discarded after two people check and record them. The doctor should be reminded to immediately make up the medical order according to the facts.

9. The changes in condition, rescue process, various medications, etc. should be recorded in detail, timely and accurately. If the patient fails to write the medical record in time due to rescuing the patient, the relevant personnel should make up the medical records within 6 hours after the rescue. Note it and mark it.

10. Contact the patient’s family or unit promptly.

11. After the rescue, make a summary of the rescue records and clean and disinfect the drugs and equipment, replenish the rescue vehicle with drugs and items in a timely manner, and keep the rescue equipment in standby mode.

2. Reporting system for handling blood transfusions and infusion reactions

(1) Handling and reporting system for infusion reactions When an infusion patient is suspicious or an infusion reaction occurs, report it to the doctor on duty in a timely manner and actively Cooperate with symptomatic treatment, such as keeping warm for those with chills, ice for those with high fever, inhaling oxygen when necessary, and administering drugs as directed by the doctor. At the same time, do the following inspections:

1. Stop the infusion immediately and start new treatment. Use an infusion set, switch to intravenous drip of normal saline to maintain intravenous access, and notify the doctor on duty.

2. Cooperate with the doctor on duty to provide symptomatic treatment and rescue.

3. Collect specimens and draw blood for culture.

4. Check the quality of the liquid, whether there are cracks in the infusion bottle, and whether the bottle cap is loose; write down the name, dosage, manufacturer, and batch number of the liquid, infusion set, and syringe used, and use disinfectant wipes and glue to Wrap the infusion bottle (bag) and the infusion set in a bag and store it in the refrigerator. Contact the laboratory department of the pharmacy department to fill in the adverse drug reaction report form. Drugs are transferred from the Pharmacy Department to relevant departments for sampling inspection, and infusion sets and other equipment should be subject to relevant bacteriological testing by the bacteriology room of the Laboratory Department.

5. All the above items should be filled in the infusion reaction report form, reported to the nursing department within 24 hours, and nursing records and shift handover work should be done well.

6. Accurately record changes in condition and treatment measures.

(2) Reporting and handling system for blood transfusion reactions. During the blood transfusion process, the blood transfusion should be slow first and then fast, and then the infusion speed should be adjusted according to the condition and age, and the recipient should be closely observed for adverse reactions of the transfusion. If any abnormality occurs, The situation should be dealt with promptly.

1. Slow down or stop the blood transfusion, and use a new infusion tube to inject normal saline intravenously to maintain the intravenous channel.

2. Immediately notify the doctor on duty and the staff on duty in the blood transfusion department, report to the medical office and nursing department, conduct timely inspection, treatment and rescue, find out the reasons, and make records.

3. If the blood transfusion reaction is suspected to be hemolytic or bacterial contamination, the blood transfusion should be stopped immediately, a new dropper should be used to inject intravenous saline to maintain the intravenous access, and the superior physician should be reported promptly. During active treatment and rescue, At the same time, do the following checks: ① Check the blood application form, blood bag label, and cross-matching test record.

② Check blood routine, urine routine and urine hemoglobin as soon as possible. If bacterial contamination is suspected, in addition to the above treatment, blood bacterial culture should be done.

③ Wrap the blood bag and transfusion tube and send it to the blood bank for bacteriological testing.

④ Keep nursing records accurately.

Three. Nursing Complaint Handling System

1. Any patient or family member who is dissatisfied with nursing work due to service attitude, service quality, own reasons or skills in medical nursing work shall be reported in writing or verbally Opinions reflected to the Nursing Department or transferred back to the Nursing Department by relevant departments are nursing complaints.

2. The nursing department has dedicated personnel to receive nursing complaints, listen carefully to the complainants' opinions, give patients the opportunity to express their views, patiently appease the complainants, and keep records of complaints.

3. Personnel who receive complaints should be patient and meticulous, and explain things carefully to avoid causing new conflicts.

4. The Nursing Department has a special record book for nursing complaints to record the causes, analysis and handling of complaints, and corrective measures.

5. After receiving nursing complaints, the nursing department will provide timely feedback, investigate and verify, and inform the head nurse of the relevant department. The department should carefully analyze the reasons for the incident, sum up experience, learn lessons, and propose corrective measures.

6. After the complaint is verified, the Nursing Department can deal with the party concerned accordingly according to the severity of the incident.

7. The Nursing Department summarizes, analyzes and formulates corresponding measures at the hospital-wide head nurse meeting every month.

Four. Procedures for handling disputes and accidents

Strictly implement the regulations of the "Regulations on Handling Medical Accidents" (State Council No. 351).

1. When a dispute or accident occurs, nursing staff should actively participate in rescue and care. At the same time, report to the department director and head nurse in a timely manner and strive to coordinate and solve the problem within the department. If it is ineffective, report to the medical office and nursing department.

2. Ways to deal with medical disputes or accidents: ① In-hospital mediation.

②When it is invalid, both doctors and patients have the right to apply for medical appraisal by a higher-level institution.

③ Judicial proceedings.

3. Emergency medical record sealing procedures: ① After the patient’s family makes an application, the nursing staff should promptly report to the department director and head nurse, and also report to the medical office and relevant hospital-level departments. If it occurs on a holiday or at night, directly notify the hospital's medical and nursing staff.

② When all documents are complete, the medical records will be sealed in the presence of the hospital’s full-time management personnel (medical record room personnel), medical attendants, and the patient’s family members (photocopies may be sealed).

③ In special circumstances, medical staff need to send the original medical records to the medical record room. Nursing staff cannot directly hand over the medical records to the patient or family members.

4. Things that nurses should do before sealing medical records: ① Improve nursing records, requiring nursing records to be complete, accurate, and timely; nursing records are comprehensive and consistent with medical records, such as the patient’s time of death and changes in condition Time, disease diagnosis, and all raw data in patient care.

② Check whether the temperature sheet and medical order records are complete, including whether the doctor's oral medical orders are recorded in a timely manner.

③After the medical records are sealed, they will be kept by full-time personnel designated by the medical office.

5. Medical records can be copied: outpatient (emergency) medical records and admission records in inpatient medical records, temperature sheets, medical orders, laboratory test orders (test reports), medical imaging examination data, special examinations (treatments) ) Consent form, operation consent form, operation and anesthesia record sheet, medical record report, nursing record, and discharge record.

Five. Medical waste classification management system

1. Medical staff in clinical departments must strictly implement medical waste management in accordance with the "Medical Waste Management Regulations", "Medical Waste Management Measures for Medical Institutions" and relevant supporting documents.

2. The head nurse is responsible for the training, guidance, supervision and management of medical waste management knowledge for medical staff in the department.

3. The head nurse should strengthen the management of medical waste in the department to prevent leakage, loss, and trading of medical waste.

4. During the classification and collection of medical waste, medical staff should strengthen self-protection to prevent occupational exposure.

5. Clinical departments should provide necessary occupational protection measures for personnel engaged in classifying and collecting medical waste.

6. The color of medical waste packaging bags (boxes) is yellow, and the color of domestic waste packaging bags is black.

7. Before containing medical waste, the medical waste packaging bags (boxes) should be carefully inspected to ensure that there is no damage or leakage. Small amounts of pharmaceutical waste may be mixed with infectious waste, but this should be noted on the label.

8. There are warning signs on the outer surface of each packaging bag (box) containing medical waste. When the contained medical waste reaches 3/4 of the package or container, the clinical hygienist will seal it using an effective sealing method to ensure that the seal is tight and tight, and then a warning label, For Chinese labels of different categories of medical waste, fill in the content of the Chinese label: department, shift handover date, category of medical waste, and signature of the person handling it.

9. When the outer surface of the packaging bag (box) is contaminated by infectious waste, the contaminated area should be disinfected or a layer of packaging bags should be added.

10. Medical waste generated by isolated patients with infectious diseases or patients with suspected infectious diseases should be double-packaged and sealed in time.

11. The temporary storage point for medical waste in the department has a schematic diagram or text description of the classification collection method.

12. After the handover of medical waste is completed every day, department staff will clean and disinfect the temporary storage area of ??medical waste.

13. Department staff shall perform medical waste handover and weighing procedures with the health class receiving personnel according to the prescribed time, and register and |