感染工作记录薄门诊临床用

1、XXXXXX医院医院感染管理工作督查记录簿 部门：2017年 目录一、前言············································

2、;··················································

3、;·························(1)二、医院感染监控小组名单及职责······················

4、;··················································

5、;···(0)三、医院感染管理工作记录1月份医院感染管理工作记录··········································&

6、#183;········································(0)2月份医院感染管理工作记录······

7、83;·················································

8、83;··························(0)3月份医院感染管理工作记录·····················

9、;··················································

10、;············(0)第一季度手卫生管理质量持续改进小结··································

11、83;······························(0)第一季度科室医院感染与风险管理················

12、83;·················································

13、83;······(0)第一季度医院感染管理小组活动记录········································&#

14、183;····························(0)4月份医院感染管理工作记录··················

15、3;·················································

16、3;·············(0)5月份医院感染管理工作记录··································

17、·················································(0)6月份

18、医院感染管理工作记录················································&#

19、183;··································(0)第二季度手卫生管理质量持续改进小结············

20、··················································

21、···(0)第二季度科室医院感染与风险管理············································

22、·····························(0)第二季度医院感染管理小组活动记录··················

23、;··················································

24、;·(0)7月份医院感染管理工作记录··············································&

25、#183;···································(0)8月份医院感染管理工作记录···········

26、83;·················································

27、83;····················(0)9月份医院感染管理工作记录···························

28、;··················································

29、;·····(0)第三季度手卫生管理质量持续改进小结·········································

30、83;·······················(0)第三季度科室医院感染与风险管理·······················

31、83;·················································(0)

32、第三季度医院感染管理小组活动记录···············································&#

33、183;·····················(0)10月份医院感染管理工作记录·························

34、83;·················································

35、83;·····(0)11月份医院感染管理工作记录·········································

36、3;·······································(0)12月份医院感染管理工作记录········

37、;··················································

38、;·······················(0)第四季度手卫生管理质量持续改进小结·······················

39、83;·········································(0)第四季度科室医院感染与风险管理·····

40、83;·················································

41、83;·················(0)第四季度医院感染管理小组活动记录·····························&#

42、183;·······································(0)四、医疗质量检查存在的问题及知识考试情况······

43、83;··············································(0)五、突发公共卫生事件应急演练及医院感

44、染暴发应急预案演练··························(0)六、2017年现患率调查····················

45、··················································

46、······················(0) 前言医院感染是伴随医学科技进步而发展的一种特殊感染形式，是当前世界各国医院面临的重要公共卫生问题之一，也是医院现代管理的重要内容和医疗质量持续改进的热点、难点问题。近年来由于多重因素影响，国内外医院感染重大事件时有报道，不仅严重制约了医疗质量的提升，干扰了医院和谐发展，也给患者就医安全和疾病康复构成重大威胁。因此，医院感染问题

47、正日益引起各级卫生行政部门和医院管理者的高度重视。根据医院等级评审的统一部署，按照三级精神病医院评审标准（2011年版）实施细则医院感染管理与持续改进要求，为进一步完善我院医院感染管理的各项工作，我院制定了医院感染管理工作督查记录薄，请各部门按要求认真填写。要求如下：一、每月由监控医生或监控护士向科主任、科护士长汇报本病区医院感染管理小组工作开展情况，总结取得的成绩，分析存在问题，并注意查找原因，制定院感管理持续改进措施并加以落实。于次月初在科内会议进行集中反馈。二、科主任、科护士长须检查评估工作质量，并签署意见后签名。三、医院感染管理科及上级检查发现的问题也应及时记录。四、培训人员包括：新医

48、生，进修医生、病区医务人员及工勤人员，可根据本部门实际，组织学习医院感染、传染病、抗菌素合理应用等知识。 XXXXXX医院医院感染管理委员会本部门2017年度医院感染监控小组名单及职责时 间组长（科主任）小组成员副组长（科护士长）监控医生（区主任）监控护士（区护士长）注：人员变动时应做好交接班工作，及时记录更换人员名单感染监控小组职责各科室建立医院感染管理小组，由科主任、护士长及本科室兼职监控医生（区主任）、护士（区护长）组成，在科主任领导下开展工作。其主要职责及工作内容是：1、 在医院感染管理科专职人员的业务指导下，负责本科室医院感染监控工作。2、 监督检查本科室医务人员严格执行无菌操作技术

49、并检查无菌物品使用日期、无菌包名称、灭菌指示卡、消毒日期等。3、 督促检查本科室各种消毒隔离制度的落实情况、研究存在问题，并及时采取有效控制措施。4、 负责医院感染的诊断把关，负责督促主管医师及时填报医院感染病例登记表、医院感染病例登记本，定期分析本病区医院感染动态，做好资料收集和上报工作。5、 指导本科室合理使用抗菌药物，依据药敏结果指导用药，防止抗菌药物的滥用。6、 可疑或发现医院感染暴发流行时，主动查找原因及时向医院感染管理科汇报，主动配合医院感染专职人员进行医院感染暴发的流行病学调查，并采取有效控制措施。7、 负责本科室预防和控制医院感染的宣教培训工作。8、 严格消毒剂的使用管理，并做

50、好相应记录。9、 负责本科室紫外线强度监测及环境微生物监测报告的收集留档工作。10、 建立医院感染管理记录本，及时记录本科室感染控制方面的问题、整改措施以及会议内容，针对医院感染管理工作中出现的问题，采取有效控制措施等。11、 配合医院感染专职人员做好医院感染目标性监测工作及其他临时工作。医院感染兼职医师（区主任）职责1、 在科主任领导下，负责本病区感染管理工作。2、 负责对本病区工作人员进行医院感染知识的培训及宣教工作。3、 发现医院感染病例或可疑医院感染病例时，及时采样做细菌培养、药敏实验和其他必要的辅助检查，协助主管医生完成感染病例的诊断。4、 执行医院感染病例监测报告制度，发现医院感染病例，督促主管医生及时在医生工作站填写医院感染病例登记表，24小时内网上报医院感染管理科，并填写医院感染病例登记本。5、 负责监督本病区工作人员消毒隔离制度及无菌技术操作的落实情况，发现问题及时提出改进措施。6、 监督本病区工作人员医疗废物分类存放情况，严禁生活废物与医疗废物混放，防止利器刺伤。7、 发生医院感染流行趋势或暴发流行时，立即向科主任及医院感染管理科汇报，积极协助专职人员开展流行病学调查，查找感染原因，采取有效控制措施。8、 协助医院感染专职人员开展医院感染专题研究工作。9、 配合医院感染专职人员做好医院感染目标性监测工作及其他临时工作。医院感染兼职护师（区护长）职