患者转诊SOP中英文对照

StandardOperationProcedureforTransferTreatmentⅠ.ObjectiveFortheestablishmentofaunified,standardturnreferralsystem,andcomprehensivelyimprovethetreatmentandtransportcapacity,ensurethatpatientsinthediseaseneedtoturntootherlevelsofmedicalinstitutionstofurthertreatmenttogetfast,safetransport,receivetimelyeffectivetreatmentmeasuresandtreatment,thedevelopmentofthisprocess.Ⅱ.ScopeNeedtotransfertoothermedicalinstitutionsforfurthertreatmentofpatients.Ⅲ.Content1.Prehospitalduetolimitedconditionsoftechnologyandequipment,cannotmakeadiagnosisandgivetreatmenttothesick,throughthesectionsdiscussedorteamexpertconsultationdeterminewhetherapatientreferral;approvedbythecaptain,aheadofandtransferredtothehospital,askpermissionbeforereferral.Referraltothepatient'sillnesstoconductacomprehensiveassessment2.Emergencyreferral,emergencyhospitaltreatmentisneededforthepatients,accompaniedbymedicalpersonnel,forthefirsttimebyarescuevehicleturntothesuperiorhospital,temporarilyunabletocontactthefamiliesofpatients,tosavethelivesofpatientsprinciple,undertheleadershipoftheInstitutereportagrees,bytheDepartmentresponsibleforpeoplesignedtherelevantprotocols.Familymemberstoaccompanythepatientatthetimeofreferral,departmenttoinformthefamiliesofpatients,severityandpossibleconsequences,ifnecessary,sendmedicalattendants.3.Nonemergencyreferral,beforereferralbyhospitalexpertconsultation,thetreatingphysicianandfamilycontacttoinformtheconsultation,andthepatient'scondition,recommendedreferralfortreatment,andsignedtheinformedconsent.4.Infectiousdiseasepatientreferral(1).Whenfirstdiagnosedasinfectiousdiseases,suchasourhospitaldoesnothavetheabilitytotreat,shouldpromptlyreportthecaptain,whilecontactwithinfectiousdiseasehospitalreferral,referralatthesametimethepatientandmedicalrecordsweretransferredtotheinfectiousdiseasehospital.(2).Foundthatinfectiousdiseases,accordingtothecategoryamanagementofclassBinfectiousdiseaseorothermajorvirulentinfectiousdiseasepatientsshouldimmediatelyfirstisolatedandthenreferral.(3).Criticallyillpatientswithinfectiousdiseasessuchastheuseofourrescuevehicleescort,medicalpersonnel,ambulancedriverstodotheirownprotection,transportvehiclesintheendofthetransfershoulddoagoodjobindisinfection.(4)(4).Pathogencontaminationsites,itemsaccordingtothedispositionofhospitaldisinfectionandisolationsystem,patientgeneratedgarbageoninfectionofmedicalwastedisposal,medicalwastevisualpollutionsituationofharmlessdisposalintothedoubleyellowmedicalgarbagebagsintheclassifiedcollection,centralizedtreatment5.Prereferraltreatment,departmentsincarryingoutthereferralproceduresandmustoperateaccordingtomedicalpractice,giveactivetreatment,tobeinstableconditionafterreferraltreatment6.Patientreferralasestimatedwaymayaggravatetheconditionordeath,persistenceofmobilehospitaltreatment,tobeinstablecondition,ordangerousperiodafterretransferred.Ifthepatientfamilyhospitalrequirements,physiciansshouldbeclearlyinformedofthefamilymembersofpatientsmayhappenonthewayandtheneedtoundertakealltheconsequencesfamilyagreedtosignforreferral.7.Patientreferral,medicalrecordwiththepatienttoturnto.Patienttransferredtothehospitaldischargeshouldbetowritesummaryoftreatment,medicalrecordroom,returnedtotherolloutofthehospital.Intohomesandinstitutionsofpatientwithonlysummaryofthecasehistory.8.Referralitemizedinthereferral,themedicalinstitutionssigned,willturnintothesinglehandedovertothemedicalinstitutions,archivebarback.Ⅳ.Appendix：REFERRAL（STUB）No.：NameGender________Age___Diagnosis______________IDTEL_________________________Address_______________________________________________________TransferredToMedicalInstitutions__________________________________ReasonsForReferral____________________________________________PatientSignature______ReferralPhysician_______________Doctors’Signature_________________Date:___________________________Referral（Receive）No.：NameGender________Age___Diagnosis______________IDTEL_________________________Address_______________________________________________________TransferredToMedicalInstitutions__________________________________TransferredForMedicalInstitutions_________________________________ReferralPurpose:DiseaseSummary：ReferralMedicalInstitutions(OfficoalSeal)：ReferralPhysician：PatientSignatureDate:THEILLNESSConsciousnessTRANSFEROFGOODSCasePImageDataRBP（mmHg）FalseTeethSPO2（%）ValuablesPupilLightReflectionINDWELLINGPIPEPeripheralLVeinSpecialInfectionCentralVeinProposalArteryCatheterOralAdministrationTubeInjectionDrugDrainageTubeSkinConditionCatheterOtherNOTES：1Accordingtotheconditionsofpatientsintheformofthecorrespondingcolumnof"√"orfillintheblankcolumnoffigures,words,specialcircumstancestobenoted.2Consciousness：asoberbanesthesiacomacsleepinessdcomaeirritabilityfother3Drainagetube：aTpilebNegativepressureballcPeritonealdrainagetubedPercutaneousdrainageeThoracicdrainagefother______THEILLNESSConsciousnessTRANSFEROFGOODSCasePImageDataRBP（mmHg）FalseTeethSPO2（%）ValuablesPupilLightReflectionINDWELLINGPIPEPeripheralLVeinSpecialInfectionCentralVeinProposalArteryCatheterOralAdministrationTubeInjectionDrugDrainageTubeSkinConditionCatheterOtherNOTES：1Accordingtotheconditionsofpatientsintheformofthecorrespondingcolumnof"√"orfillintheblankcolumnoffigures,words,specialcircumstancestobenoted.2Consciousness：asoberbanesthesiacomacsleepinessdcomaeirritabilityfother3Drainagetube：aTpilebNegativepressureballcPeritonealdrainagetubedPercutaneousdrainageeThoracicdrainagefother______StandardOperationProcedureforTransferⅠ.ObjectiveThisprocessisstandardedtoestablishaunified,toefficientandstandardizedtransfersystem,andcomprehensivelytoimprovethetreatmentcapacity,toensurethatpatientsreceivetimelyinspection,toeffectivetreatmentmeasuresandactivetreatment,Ⅱ.ScopePatientswhoneedfurtherexaminationortreatmentduetotheirdiseasedevelopmentandpotentialrisks.Ⅲ.Content1.Getthenotificationofapatient'sneedtobetransported.，Thenexplainwiththepatientsandtheirfamiliesaboutthepurposeofthetransfer.2.Informingtherelevantdepartmentorexaminationroomaboutthepatients’condition,andtheitemsneedtobeprepared.3.Assessingthepatients’conditions.Preparinginvigilator，defibrillator，first-aidkit，oxygenandotherequipmentwhennecessary.4.Fixingthedrainagetubeproperly.5.Choosethewayoftransferringandaccompanymodeaccordingtotheillness.(1).Useawheelchairformobilityandescortedbynurses.(2).Useatransferpatienttrolleyforsurgeryandescortedbynurses,doctors,anesthetiststogetherpostoperative.(3).Usemovingbedforcritical,orpatientscan’tbemovedandescortedbynursesorbynursesanddoctorswhennecessary.6.Intransit,closelyobservationthechangesinpatients’conditionsandtakingnoteswhennecessary.7.Afterarrival,explainingclearlyaboutthesituationoftherescueintransit,thetreatment,themedication,thevitalsigns,theskinandpipelinewiththereceivingdepartment’sdoctorsandnurses.Andfillinthehandoverrecordaboutthepatients’items.Ⅳ.Appendix：PatientsTransferringProcessOperationOperationPatientCriticalPatientExaminationCriticalPatientTransferingPortablequipmentwhennecessaryChoosethewayoftransferringaccordingtotheillnessUseawheelchairformobilityUseatransferpatienttrolleyforsurgeryUsemovingbedforcritical,orpatientscan’tbemovedpostoperativeEscortedbynursesEscortedbynurses,doctors,anesthetiststogetherEscortedbynursesorbynursesanddoctorswhenneccessaryIntransit,closelyobservationthechangesinpatients’conditionsandtakingnoteswhennecessary.Afterarrival,explainingclearlyaboutthesituationoftherescueintransit,thetreatment,themedication,thevitalsigns,theskinandpipelinewiththereceivingdepartment’sdoctorsandnurses.Andfillinthehandoverrecordaboutthepatients’items.CriticalPatientsTransferringProcessInformingtherelevantdepartmentorexaminationroomaboutthepatientsInformingtherelevantdepartmentorexaminationroomaboutthepatients’condition,andtheitemsneedtobeprepared.Whenreceivingthedoctors’order,confiemingtheorderswiththedoctors.Thenexplainwiththepatientsandtheirfamiliesaboutthepurposeofthetransfer.Assessingthepatients’conditions.Preparingthecorrespondinggoodsandmedicines(portableventilatororoxygenpillow,firstaidtransferbox,micropumpandportablemonitorwhenneccessary)accordingtothepatients’conditions.Fillinginthetransferringlistandthesummary,fixingthedrainagetubeproperly.Toassessthepatientsagaintomakesureifthepatientsneedtobecalm,toestablishartificialairway,unobstructedvenouschannelisneeded.Informtheliftfeedertocarrythepatients.Contactingwiththerelebantdepartmentsagain,transferthepatientswithatransferpatienttrolleyormovingbedbytheICUprofessionalnursesanddoctors转诊SOP目的建立转诊标准操作规程，对需要的患者及时转运到适合的医疗机构，提高医疗安全和规范性。适用范围全体接诊患者转诊制度转诊前必须对患者的病情进行全面评估因患者病情需要紧急转诊治疗的，电话通知家属后，家属不能及时来院情况下，由医护人员陪同，第一时间转运到适合的医疗机构救治，并携带病例摘要非急诊患者建议转院治疗，经患者或家属同意并签署知情同意书危重患者须先征得转诊医院同意，如估计途中可能加重病情或死亡者，须留院处置，待病情稳定或度过危险期后再行转诊四、转诊条件各种急性中毒（毒物、毒气、毒品等）症状严重或较重者急、慢性疾病，病情较危、重者，或难以实施有效救治的病例诊断不明确或常规治疗无效的病例，不能确诊的疑难复杂病例有手术指针，现有手术条件无法满足的病