胃镜室工作制度及职责指南.docx
胃镜室工作制度及职责指南
目录
一、总则...................................................5
1.1指导思想与目标.........................................6
1.2适用范围...............................................6
1.3工作原则...............................................6
二、组织架构与岗位职责....................................10
2.1组织设置..............................................10
2.1.1负责人及构成........................................11
2.1.2内部小组划分........................................12
2.2主要岗位职责..........................................13
2.2.1室主任/主管职责.....................................13
2.2.2医生职责............................................15
2.2.3护士职责............................................16
2.2.4技术员职责..........................................18
2.2.5清洗消毒员职责......................................20
三、诊疗流程规范..........................................20
3.1预约与登记管理........................................22
3.2患者告知与知情同意....................................23
3.3检查前准备要求........................................23
3.3.1禁食禁水规定........................................24
3.3.2药物使用指导........................................25
3.3.3身体状况评估........................................26
3.4检查过程操作规范......................................27
3.4.1设备器械使用流程....................................29
3.4.2检查中监护与应急处理................................29
3.5检查后观察与处理......................................31
3.5.1短期监护要求........................................32
3.5.2患者注意事项交代....................................33
3.5.3病历记录与报告书写..................................35
四、设备设施与环境管理....................................36
4.1胃镜等关键设备维护保养................................36
4.1.1日常检查与校准......................................37
4.1.2定期保养计划........................................39
4.2器械物品管理..........................................40
4.2.1储存与发放..........................................40
4.2.2备用物品保障........................................42
4.3腔镜室环境清洁与消毒..................................43
4.3.1每日清洁消毒流程.....................