急诊科留观规定.docx

these precious and worth cherishing. Second, scientific research situation, grasp the opportunities and challenges of transformation and upgrading of full completion of the Thirteen-Five development tasks, start is crucial. Focused grand blueprint, must to history of thinking views trend, put associate times forward of pulse, stepped on associate economic law of drums, find associate transformation upgrade of path, in grasp macro trend in the advance science development; to strategy of vision conspiracy to global, always tight buckle national macro policy oriented, accurate grasp County love actual, based overall caught opportunities, and PCT thought, ensure County economic social development always along right track continued forward; to precision of measures seeking breakthrough, tightly pegged focus task and bottleneck restricted, Science and identify practical and effective measures, advance breakthrough, ensuring all tasks carry out to the letter; based on scientific assessment and strict implementation, persist in combining routine supervision and centralized supervision, accurate assessment Township departments, strictly cash rewards, prompted the departments own implementation at all levels. In working to advance, to truly grasp the Guide, seize the opportunity, finding a position and play to our strengths and take the initiative, ensure that the start of the new year tree, new performance. Grasp the Guide, is to dock in policy measures to seize the initiative. Accurate grasp of the Central Government, provinces and cities to speed up the development of new policies and new initiatives with a high degree of policy acumen to capture opportunities to accelerate development. Follow-up to promote the transformation and upgrading of the five great ideas offer a great chance. Five large development philosophy is the Party Central Committee with a view to promote economic transformation and upgrading, complete the building of a well-off society in major decisions and arrangements, is the development of a profound change. County-wide at all levels should conscientiously study and implement, implement the five ideas, green development, open development, on which to share advantages, and actively explore new path of innovative and coordinated development, changing the concept of leading the transformation of development mode of development, promote the development of quality improvement. Floor supply side structural reform implementation provides an effective strategy for improving the quality of development. Supply side structural reform is future full deepening reform of plays, to according to macro policy to stability, and industry policy to associate, and micro policy to live, and reform policy to real, and social policy to backing of requirements, keen grasp Central, and provinces release out of new signal, combined County love actual accurate docking, full grasp to capacity, and to inventory, and to lever, and drop cost, and fill short Board five big focus task implementation, prompted County economic transformation upgrade, and continued upgrade. Poverty荔湾区人民医院门急诊留观病人及病历管理规定 急诊科： 根据卫生部病例书写规范及广东省医院管理考核评价标准实施细则等相关规定要求，为维护医保参保患者的合法权益，确保住院前三天的急诊留观费用纳入住院费用总额进行报销，同时更好的做好门急诊留观病人管理、提高门诊病历书写及管理质量，特制定以下条例，请参照执行：一、急诊科留观室病人管理规范1、凡暂不具备住院条件，但根据病情必须输液或观察的病人，可留急诊科观察、治疗，观察时间不超过72小时。2、遇有专科性较强的病人治疗时，医师应根据情况收住专科。如专科无床，留观中需请专科会诊，以指导处置，并与专科联系，一旦有床，应及时专科治疗。3、急诊科医生、护士应对留观室所有病人进行床头交接，详细了解观察病人病情变化及治疗情况，并做好详细记录。4、责任护士对所管病人做好治疗、护理、相关检查及记录等。危重、特殊病人的转科由责任护士护送并与病房护士交接。5、严格执行各项查对制度，每日核对医嘱，发现疑问立即向有关人员反馈。原则上不执行口头医嘱，紧急情况执行抢救口头医嘱时，护士必须复述并保留药物空瓶，以便抢救完毕后核对。6、加强对年老、体弱、昏迷及意识不清病人的管理，24小时内必须有人陪护；床头挂有防意外伤害的警示标识牌，使用床档；躁动不安者四肢约束带约束，以防坠床等意外事件的发生；患儿床旁不放置热水瓶，以防碰倒发生烫伤。7、对有精神症状的患者应放在单人房间，房间内不得有锐器等危险物品，以防自杀或伤及他人。8、有自杀倾向的患者应通知家属、值班医生、护士长并做好记录，加强心理护理、严格床头交接及巡视制度，实施24小时监护。9、严格执行护理分级管理的相关制度，按时巡视病房。10、严格遵守毒麻药物管理制度，杜绝不安全隐患。11、加强消防安全管理及消防知识的宣传，责任落实到人，随时查除不安全隐患，所有工作有员必须掌握应急事件的处理。12、加强急救物品、药品、器械、设备的管理，时时处于应急状态，以确保急救措施的顺利实施。二、急诊留观流程：1、医保持卡实时结算人员，门急诊病情达到留观程度需急诊留观者，由急诊医生开具急诊留观证（即我院住院证，住院科别写急诊，同时加盖急诊留观章）到住院处办理急诊留观手续，预交起付金及押金，留观结束后结算。留观号以住院号（四位号码）前加“LG”前缀标示，以便与正常住院患者区分。2、急诊留观患者留观期间需参照住院患者管理流程录入及处理住院医嘱，无需交费，直接到中心药房或门诊药房取药。3、患者留观时间一般不得超过3天。4、如病情严重无法控制，需转入本院住院的患者，急诊医生必须在2h内开具住院证至住院处办理留观结账及住院手续（不需另交起付金，计算机系统内按“转科”处理，病案室按新入院病人统计）；急诊前期费用不得超过600元。超出部分计入转入科室。5、如患者需转至其他医院住院诊治者，急诊医生开具急诊留观证明、转诊证明书写出观小结交给患者，其到住院处办理留观结账，到医务科和医保办公室办理转院手续；6、离院后24小时内再回本院留观、住院者，只需支付一次起付金，超过24小时者需再次支付起付金。7、急诊留观患者停止留观后，由急诊当班医生完善急诊留观病历，急诊护士核对留观遗嘱进行核账，留观病历由急诊科存档保管。三、急诊留观病历管理规范：1、急诊留观病历内容及规范 急诊留观记录：一般项目、病史、查体、初步诊断、重要检查结果、急诊处置、医生签名(格式参照入院记录，内容简单明确。)2、留观首次病程：简要病历特点、本次诊断和主要鉴别诊断、一般处置、上级医师指导意见，格式参照住院病历首次病程记录。3、病程记录：每次记录有精确到分钟的时间，观察病情记录每次24小时不得不少于两次，急、危、重症随时记录，留观期间能反映出上级医师查房制度的执行；交接班、会诊、专科、收入院、转院均应有病程记录。4、病情分析：病案中体现主要诊断和处置原则变化的记录与分析。5、出观记录：留观时情况，诊疗经过，离开时病情及有关复诊遗嘱的说明，简单明确；出观诊断；患者离开留观室时，应记录去向（格式参照出院记录）。6、其他：体温单、医嘱单、化验粘贴单、特殊检查（治疗）同意书、麻醉同意书、手术同意书、麻醉记录单、手术及手术护理记录单、病理资料、护理记录、疑难病例讨论记录、会诊记录、死亡病例讨论记录等（书写格式及排列顺序参照住院病历）。7、急诊留观病历运行及保存：急诊留观结束时由当班医师将“留观小结”