Health Center Self-examination Report (Selected 4 articles)

Time flies and the hard work has come to an end. Looking back on the work during this period, I have achieved results. There are also problems. Let us learn to write a self-examination report together. Does anyone know the format of the self-examination report? The following is a health center self-examination report that I carefully compiled. I hope it will be helpful to everyone.

Health Center Self-examination Report 1

Our hospital conducted a self-examination according to the requirements of the Gansu Province Township Health Center Grade Evaluation Standard (Trial), and carefully organized the majority of employees to learn the spirit of the plan, and according to the requirements Self-examination and special rectification activities were conducted on all aspects of the hospital's work. Since the rectification activities were carried out, the problems and rectification measures that existed during the self-inspection of our hospital are now reported as follows:

1. Existing problems:

(1) Existing problems in medical quality Problems

1. Problems in outpatient departments

According to the management requirements of outpatient and emergency departments, the outpatient and emergency departments of our hospital are not set up separately, and there is no fixed department with strong professional skills. , emergency staff. The employment rate of outpatient and emergency doctors with certificates is not high, and there are cases of practicing medicine without certificates and illegally.

Some medical staff do not have high professional skills, cannot master and apply some common first aid equipment proficiently, and are not proficient enough in some basic first aid techniques. The cooperation between various departments is not close enough, and the collaboration between department personnel is not enough.

Medical documents are not written in a standardized manner. Outpatient prescriptions are not written in a standardized way, with incomplete elements, unknown dosage and usage, irregular application of antibiotics, and irrational drug use. The content of outpatient observation medical records is too simple and cannot be written strictly in accordance with the "Health Assessment Standards for Outpatient Cases". The quality management of inpatient cases is not in place, and the case writing by some medical staff is not standardized and timely. The writing of the case does not conform to the actual condition of the patient and poses medical safety risks. Various records are not standardized, and the writing requirements are far from meeting the quality standards for writing medical documents. Various outpatient diary records are incomplete, discontinuous and incomplete.

Some medical systems and core systems are incompletely established and imperfect. According to the requirements of the "Grade Evaluation Standards for Township Health Centers in Gansu Province", relevant systems for each department have been established, improved, and implemented. In particular, the core systems for continuous improvement of township hospitals have not been implemented in place. Some systems no longer meet the needs of hospital management at the current stage. .

2. Problems in the Nursing Department

Various nursing systems are incompletely established and imperfect. The original system is no longer sufficient to meet the requirements of current management. It is now necessary to establish relevant standard systems based on the actual management situation of our hospital.

The nursing management organizational system is not complete. Failure to implement relevant nursing management work in accordance with the provisions of the "Nursing Regulations" and failure to implement the target management responsibility system. The nursing management department is unable to establish a complete nursing management system in accordance with the functions and tasks of township health centers. The responsibilities of each position are not clear, and there is mutual blame-shifting in the work. Nursing human resources management is not complete, and a nurse management system has not been established based on the actual situation of the unit. There are no clear requirements for the qualifications, technical capabilities, and technical standards of nurses at all levels and types, and a sound nurse level and performance appraisal mechanism has not been established. According to the hospital's nursing staffing standards, ward nurses and beds do not meet the required standards.

The assessment standards for nursing work are incompletely established and imperfect. The regular assessment of nursing work is not timely and is just a formality. Nursing documents are not written strictly in accordance with the "Basic Standards for Case Writing", the writing of nursing documents is not standardized, and the writing quality is not high. Various registrations are incomplete, such as disinfection records, observation records, emergency and critical patient rescue records, shift handover records, etc. The concept of aseptic technique is not strong and the operation still needs to be further improved. Failure to effectively establish standards for the operation of various nursing skills, some nursing staff's skills are not standardized, and the destruction of disposable items is not thorough and standardized. The hygiene of outpatient and inpatient departments is poor, and there are potential risks of cross-infection. Quilt covers and sheets are old, the glass is dirty, and cleaning is not timely.

3. Problems in pharmacy work

The pharmacy drug management system is not complete. The management system for poisons, anesthetics and drugs is not implemented in place, accounting records are not standardized, and there are hidden dangers in management. Drug management is not in place, and expired and insect-eaten drugs still exist. The registration of drug purchase and sale records is not timely, and the registration of purchase and sale records of disposable medical supplies is not standardized.

The professional skills and quality of medical staff cannot meet the requirements of hospital development. The personnel actually engaged in drug dispensing in the hospital are non-pharmaceutical professional and technical personnel. Other professional and technical personnel will be employed in pharmaceutical dispensing after being trained by the Food and Drug Inspection Bureau. The knowledge about related drug dispensing is insufficient, and the control of prescription dispensing is not strict, and unqualified prescription dispensing sometimes occurs. Some dispensing personnel do not have a strong sense of responsibility, and sometimes the wrong medicines are dispensed.

(2) Problems in service attitude

1. Outpatient staff

The service attitude is not good, patients often react, service attitude, service Awareness and service quality are poor, and there are problems such as coldness, bumping, hardness, and overbearing in medical services. The service attitude needs to be further improved.

2. Nursing staff

The service quality is not high and fails to reflect humanized service.

The basic care and advanced care measures provided are not in place, and the care for inpatients remains at the primitive stage. The quality of medical services provided by some medical staff is not high and their service attitude is poor, which has caused strong complaints from patients. Some nurses have insufficient sense of responsibility in their positions, and the "three checks and seven pairs" system is not implemented in place, resulting in medical risks. The nursing error reporting and management system is not implemented in place, the observation of patients is not in place, and nurses cannot proactively report some adverse nursing events.

3. Pharmacy staff

The service attitude needs to be further improved. The staff had poor service awareness and attitude, and failed to establish a "patient-centered" pharmaceutical management service model. The service to patients is cold, the attitude is poor, and the patients react strongly. The service attitude needs to be further improved.

(3) Problems in the work style and mental outlook of cadres and staff

Some medical workers are muddle-headed and lack enterprising spirit, sense of responsibility and initiative, and need to further enhance their sense of work responsibility. , sense of urgency and crisis, enhance service awareness, improve service methods, improve doctor-patient relationship, and significantly improve the public's satisfaction with the style of medical institutions.

Some medical staff have a poor mental outlook. They do not wear work clothes or work IDs during work, are off duty, chatting, and are listless and unable to devote themselves to medical work in a high-spirited working state.

(4) Problems in environmental sanitation

For a long time, health units in the medical system have been unhygienic. Through inspections of our hospital, the floors and glass of various departments are generally dirty. The situation is messy and poor, and items on the table are piled and placed randomly, which affects the image of the medical and health unit.

2. Rectification measures and deadlines:

1. In order to ensure the smooth progress of the health rectification work and meet the requirements of the rectification plan, a health work rectification leading group has been established to be responsible for the hospital rectification work. , to provide a strong leadership guarantee mechanism. Team leader Hou Hongxing is fully responsible for the health rectification of the health center and village health centers. Team members Feng Zhiyuan, Chen Mei, and Tian Liangji are responsible for the rectification of health work in various relevant departments.

Time limit for rectification: Immediate (rectification has been implemented now).

2. Strengthen medical quality management, establish regulations and systems, and pay close attention to implementation to prevent medical accidents.

(1) Establish a long-term mechanism for the rectification system of medical and health work. The leading group for medical and health rectification activities is responsible for medical quality and medical safety management, and has established a system for regularly organizing personnel to manage and supervise medical and health work. The hospital organizes personnel from relevant departments to conduct special inspections of the medical work of each department every week, and will report existing problems during the inspection. Register in the medical and health inspection form, immediately propose rectification measures, assign responsibility to the person, carry out rectification within a time limit, and organize relevant personnel to inspect the rectification situation.

Rectification deadline: regular inspections, immediately. For existing problems, we will deal with them immediately or in the short term according to the actual situation (now rectified and implemented).

(2) Establish and improve relevant medical work management systems. In accordance with the requirements of the "Grade Evaluation Standards for Township Health Centers in Gansu Province", establish and improve relevant systems for each department, especially the core system for continuous improvement of township hospitals, establish a medical dispute prevention and disposal mechanism, and promptly and properly handle medical disputes. Formulate medical accident prevention plans and handling procedures for major medical safety incidents, report major medical negligence and medical accidents in accordance with regulations, and effectively prevent accidental injuries caused by non-medical factors.

Rectification period: regular inspections, in the near future (rectifications have been implemented).

(3) Establish and improve the supervision, assessment, reward and punishment system. Establish a medical quality supervision and assessment system, establish and improve the medical accident, medical error and medical quality analysis and review meeting system, and decompose medical quality and medical safety indicators to departments and individuals, so that everyone has responsibilities and indicators for medical safety. Establish a regular special conference system on medical care and medical quality in our hospital to conduct in-depth discussions and analysis of existing problems in medical and health management. Linking existing problems in medical work with personal assessment, the hospital incorporates 20% of employee file wages into performance assessment to form a performance reward and punishment promotion mechanism.

Rectification period: regular inspections, in the near future (rectifications have been implemented).

(4) Strengthen employee professional skills training and improve the quality of medical services.

The improvement of hospital medical work is inseparable from the efforts of all medical workers. Therefore, strengthening the training and improvement of the comprehensive quality of medical workers in all aspects is a prerequisite. To this end, our hospital will strengthen The breakthrough point is to improve the comprehensive professional quality of employees. Health Center Self-examination Report 2

In XX, the health work of our hospital closely focused on the requirements of the health work responsibility target letter signed with the Health Bureau at the beginning of the year. Various tasks are carried out in conjunction with the health work of our hospital in the first half of the year. In response to the situation, we conducted self-examination on the health work in the first half of the year. We now report the self-examination of the health work targets of our hospital in the first half of xx as follows:

1. Basic medicines and medical reform work

1. The distribution and use of basic drugs: As of June 30, 2009, Gaochi Township Health Center has all equipped and used basic drugs in accordance with regulations, and the proportion of supplementary drugs is all in compliance with regulations. The 10 health stations in each village clinic within the jurisdiction strictly implement the national essential medicine corresponding system, and our hospital supervises and inspects them on a regular basis.

And studied the "Guidelines for the Clinical Use of Essential Drugs" and the "Essential Drug Formulary".

2. Online procurement of essential drugs: Since the implementation of the essential drugs system, all essential drugs have been purchased online in accordance with regulations and sold with zero margin. The procurement process is reasonable, and there is no fraud or unauthorized procurement of non-bidden drug substitutions. The phenomenon of winning drug bids. In accordance with the integrated management method of townships and towns, village clinics report plans before the 20th of each month to implement online procurement of essential drugs with zero margin sales in conjunction with health centers, and the township health centers will make unified settlements.

3. Supply and distribution of essential drugs

The supply and distribution of the winning bidders can basically arrive in time. But there are still some problems: some suppliers are unable to deliver some commonly used drugs, and some commonly used drugs have been out of stock since the online bidding and procurement.

4. Settlement of basic medicines

Our hospital remits medicines to the payment center of the Health Bureau on time every month. The settlement and payment of basic medicines are standardized and timely, and there is no misappropriation or illegal use. The phenomenon of drug payments.

2. Traditional Chinese Medicine work

1. Carry out the creation and strive to create the characteristics of traditional Chinese medicine: After launching the creation of the national advanced counties for traditional Chinese medicine work, our hospital strives to create the cultural characteristics of traditional Chinese medicine and form a relatively independent The comprehensive service area for traditional Chinese medicine includes a traditional Chinese medicine diagnosis and treatment room, a traditional Chinese medicine treatment room, a traction room, and an acupuncture physiotherapy room. A Chinese medicine dispensary is set up, equipped with Chinese medicine pieces cabinets (medicine hoppers), medicine cabinets, dispensing tables, medicine racks, standard sieves and medicine decoction machines. Our hospital is now equipped with 306 kinds of Chinese medicine pieces and 65 kinds of Chinese patent medicines; and can provide patients with Decoction service. In order to better promote the appropriate technology of traditional Chinese medicine and develop traditional Chinese medicine business more extensively, our hospital has equipped a number of basic facilities and diagnostic and treatment equipment suitable for carrying out traditional Chinese medicine business, including acupuncture treatment beds, massage treatment beds, TDP magic lamps, Electro-acupuncture treatment equipment, wax treatment equipment, cervical and lumbar traction beds, and purchased acupuncture equipment, cupping pots, scraping oil, scraping boards, pure moxa sticks, medium frequency treatment equipment, moxibustion boxes and other equipment.

2. Actively promote appropriate technologies and extensively carry out traditional Chinese medicine services: Our hospital’s traditional Chinese medicine doctors use acupuncture, moxibustion, massage, cupping, and compresses according to the principles of “simplicity, convenience, testing, and cost-effectiveness.” 11 appropriate TCM techniques such as scraping, fumigation, acupoint injection, wax therapy, bloodletting, and traction are used to diagnose and treat a variety of common diseases. Among them, the number of outpatient and emergency visits of traditional Chinese medicine accounts for 34% of the total outpatient and emergency visits; the income of traditional Chinese medicine accounts for 35% of the total pharmaceutical income, the income of traditional Chinese medicine accounts for 33% of the total business income, and the pass rate of writing prescriptions of traditional Chinese medicine is above 95%; the outpatient medical records of traditional Chinese medicine are not implemented .

3. Carry out health education and popularize knowledge of traditional Chinese medicine: Health education is one of the basic public health service projects determined by the state. Health education plays an important role in improving the health literacy of the general public and advocating a healthy lifestyle. It plays an important role in preventing and controlling infectious diseases and chronic diseases. In order to better implement health education work, our hospital actively produces traditional Chinese medicine health education materials, including text materials focusing on traditional Chinese medicine content, and sets up publicity boards to popularize education. Formulate an education plan to popularize TCM knowledge, conduct public health TCM consultation, and guide rural residents to understand TCM health care knowledge and methods.

4. Strengthen business training and further study: In order to meet the development needs of traditional Chinese medicine work in our hometown, our hospital sent a traditional Chinese medicine professional to study acupuncture and physiotherapy in Dingxi Traditional Chinese Medicine Hospital. According to the requirements of relevant documents from superiors and the business needs of the hospital, our hospital organized senior doctors to conduct centralized professional training and learning for new recruits and traditional Chinese medicine practitioners in village clinics, and achieved certain results.

3. Health Management Work

1. Establishing residents’ health records and electronic files: By the beginning of June 2019, the total population of our district was 6,823, and 6,823 residents’ health records had been established. , accounting for 100% of the total population in the jurisdiction, and 3521 electronic files, accounting for 51% of the total population. The number of files established in each village has met the task target, the health file format has been unified according to the assessment requirements, and a file management system has been formulated. Follow-up and file update management were conducted for key groups such as hypertension, diabetes, pregnant women, children aged 0-6 years, elderly people over 65 years old, and severe mental illness.

2. Health education: The health center has established an organization, formulated an implementation plan, organized and implemented it according to project requirements, carried out lectures and consultation activities according to specification requirements, and regularly changed publicity boards, photos, activity summaries and sign-ins. All activities such as this are archived; the health office also carefully carries out health education projects in accordance with regulatory requirements and conducts health education effect evaluations; health education bulletin boards within the jurisdiction are replaced at least once every two months, and health knowledge lectures are given at least once a month in the health center. It is held once, and the village clinic holds it at least once every two months, and health consultation is held at least once a month; in the first half of the year, 6 health knowledge lectures were held, 7 consultation and publicity activities were held, and 3,500 health education and publicity materials were distributed.

3. Immunization plan: The qualified vaccination rate and timely rate of the "five vaccines" basic immunization vaccine in our hospital are over 95%; the card creation rate is 100%.

The vaccination rate of the expanded national immunization program is more than 97%, and the booster vaccination rate has reached more than 98%. The vaccination clinics are all standardized vaccination clinics. All employees have vaccination qualification certificates. There is no charge for vaccination of Class I vaccines. The vaccination clinics are at Vaccinations will be carried out every 10th to 14th day, and the requirement of keeping the vaccinated for 30 minutes after vaccination will be fulfilled. Missed vaccinations will be checked regularly and vaccination certificates will be checked at day care and school.

4. Reporting and handling of infectious diseases: The health center has a complete epidemic management system and has established an information reporting mechanism. Regular or irregular in-hospital reporting systems are provided for self-examination results and the discovery of infectious diseases. Each department has Register. From the inspection, the outpatient log reporting rate is 100%, the timely rate is 100%, and the network reporting timely rate is 100%. Patients in the tuberculosis project are referred in a standardized manner and follow-up visits are conducted on time. Education and publicity on publicity days such as 3.24 and 4.25 are carried out in daily health education. Checking the outpatient registration of each village found no infectious diseases.

5. Maternal health care: Our hospital carries out maternal health care work in a standardized manner. The maternal roster is complete and maternal health care information is reported in a timely manner. There are 12 pregnant women in the jurisdiction. The health care coverage rate is 100%, the early pregnancy card creation rate is 80%, the system management rate is 85%, and the postpartum visit rate is 100%. Postpartum visits are undertaken by health centers and clinics.

6. Health care for the elderly: There are 674 elderly people in the township, 574 are managed by the health care system, and the system management rate is 90%; general physical examinations are conducted regularly for people over 65 years old, risk factor surveys are carried out, and provided Health services, injury prevention, self-help and other health guidance.

7. Chronic disease management: 138 people with high blood pressure are managed in the jurisdiction. Standardized management of 138 people, with a standardized management rate of 100%. 23 people were managed with diabetes and 23 were under standardized management, with a standardized management rate of 100%. Each village conducts regular follow-up visits to chronic disease management subjects and provides health guidance such as risk factor prevention. The health center conducts health examinations in accordance with the requirements of the "Standards".

8. Management of severe mental illness: *** in our jurisdiction manages 8 patients with severe mental illness, with a management rate of 100%. The managed subjects are followed up regularly, and the health center conducts physical examinations in accordance with the requirements of the "Standards".

Relevant work such as modernization construction, integration and industry efficiency construction were completed on schedule in accordance with the requirements of superiors. Health Center Self-Inspection Report 3

In order to further standardize the professional behavior and medical services of our hospital staff and ensure the safety of medical treatment and medication safety of the general public, in accordance with the requirements of the spirit of relevant documents of the county bureau, our hospital A standardized service action was launched. In order to implement this activity, strengthen hospital management, improve the quality of medical care, ensure medical safety, and improve medical services, our hospital decided to launch a self-examination activity for standardized service actions throughout the hospital. The report is now as follows:

1. Through the standardized construction and environmental construction of various clinical departments of the health center and public health vaccination clinics, we have further improved the configuration of departments, the equipment and use of medical equipment, and the positions of professional and technical personnel. Infrastructure construction of township health centers including recruitment, etc.

2. Through the unified management of people, talents, and materials in township health centers, the health centers are responsible for the deployment of technical talents, qualification access, funding, asset management, and business of the unit and village clinics within its jurisdiction. Guidance and work coordination, public health, medical market supervision, etc. have streamlined the management system of township health centers.

3. Completed the reform of the personnel allocation system of township health centers. On the basis of implementing the target responsibility system for the director’s tenure and improving various management systems, the department settings of township health centers were divided into public health departments. and medical care. It is clarified that each township health center mainly provides public health services. On this premise, the central health center must further improve the level of medical technology and guide the business work of surrounding general health centers. A strict performance appraisal system has been established, and the distribution of personnel wages is linked to the services provided and labor contributions, which has improved the intrinsic vitality of township health centers and stimulated the enthusiasm of the majority of cadres and employees.

4. Institutionalized management has been implemented in both the administrative and business aspects of the health center. Class-oriented goals and tasks for hospital leaders and department heads were set. Implement a job responsibility system that combines responsibilities, rights, and interests, and establish and improve various medical care work systems including handover of clinical departments, standardized writing of medical documents, error and accident registration, disinfection and isolation, etc., to prevent medical disputes and eliminate medical liability accidents occurrence.

5. Establishment and management of health records. The establishment of health records in our hospital is mainly carried out by the health office publicizing, collecting information, coordinating and arranging residents in the jurisdiction, and the health center completing physical examinations and archiving and entry management. However, during the establishment process, because the staff of the Lan Village Clinic were older, coordination and publicity work was not in place, the file establishment progress was slow, and some residents did not cooperate, resulting in a low file establishment rate. Health Center Self-Inspection Report 4

In accordance with the requirements of the XXX Health Bureau to carry out the "Three Goods and One Satisfaction" campaign to rectify medical quality and safety, our hospital conducted a comprehensive inspection of key departments and departments.

The self-examination results and corrective measures are now reported as follows:

1. Existing problems:

(1) Some medical management systems are not implemented properly

The awareness of medical quality and safety among individual medical staff is not high enough, and core systems such as the first-diagnosis physician responsibility system, check-up system, case discussion system, consultation system, and transfer system cannot be well implemented.

(2) The application of antibacterial drugs is still unreasonable

Some medical staff use antibacterial drugs unreasonably, such as antibiotics for common colds; perioperative prophylaxis is unreasonable , antibiotics are used for too long.

(3) Problems that still exist in the writing of hospitalization medical records.

1. The handwriting is illegible, there are alterations, and the name and hospitalization number do not match.

2. There is a lack of analysis of modified medical orders and positive test results in the disease course records, and there is little analysis of the content of the ward round records and they are too formal.

3. There are informed consent forms, irregular signatures, and no informed consent forms for self-financed items such as medicines and disposable high- and low-value consumables.

2. Rectification measures:

(1) Further strengthen quality and safety education and improve the safety and quality awareness of medical staff.

Medical staff generally attach great importance to professional knowledge and despise the learning of quality management knowledge. They lack quality management knowledge and have weak quality awareness. As a result, they cannot consciously and proactively apply quality requirements in daily medical work. It is difficult to ensure the achievement of quality objectives. Quality management is a discipline. If you want to improve medical quality, you must not only learn medical theory and medical technology, but also learn basic knowledge of quality management, constantly update quality management concepts, and adapt to the needs of society. Only by enabling medical staff to establish a correct awareness of quality management and master quality management methods can passive quality control be transformed into active self-quality control. Therefore, training all medical staff in quality management knowledge and enhancing quality awareness are the basic tasks for improving medical quality.

First of all, we must strengthen medical-related laws, regulations, and rules. Medical staff must master relevant laws and regulations and the core system of medical quality, and improve their quality awareness, safety awareness and prevention awareness.

(2) Strengthen supervision and inspection to ensure the implementation of core systems.

1. Further strengthen quality ward rounds and operational medical record inspections, pay attention to actual results, and not be a formality. In addition to explaining the problems found in person, repeated offenders must be punished through financial penalties. .

2. It is necessary to strengthen the training and assessment of the three basics, constantly improve the assessment methods, strictly assess the disciplines, pay attention to the actual results of the assessment, and not become a mere formality.

3. Strengthen the management of medical record quality.

Carry out standardized training on medical record writing throughout the hospital, further improve relevant systems and medical record inspection standards, and ensure the timely filing and safe circulation of inpatient medical records.

4. Further strengthen the monitoring of hospital infections.

Strictly implement various hospital infection management systems. Further increase the training and publicity of hospital infection knowledge, so that every medical staff must realize the importance of hospital infection control, consciously abide by aseptic operating techniques, do a good job in personal control, fulfill the responsibilities of the hospital infection management committee, and actively carry out work to prevent underreporting of hospital infections.

5. Further strengthen the management of the use of antibacterial drugs.

According to the spirit of the document "Forwarding the Guidance on Issuing the Clinical Application Management of Antimicrobial Drugs in Guangdong Province", our hospital's "Antimicrobial Drug Clinical Use Management Group" organization was established to strictly carry out the clinical use management of antimicrobial drugs and pay attention to monitoring. Perioperative prophylaxis medication status. Further implement the hierarchical management system of antimicrobial drugs, set up prescription authority, ensure the implementation of the system, increase the rate of bacterial culture and drug susceptibility testing, and ensure the rational use of antimicrobial drugs.

(3) Further strengthen professional ethics education and effectively improve the service level of medical personnel. In accordance with the requirements of the Ministry of Health's "Medical Ethics Standards and Implementation Measures for Medical Staff", medical ethics education is provided to medical staff. Cultivate a work style that is modest, prudent, and neither arrogant nor arrogant. Determine to be a medical worker with noble medical ethics and respected by the people. Truly establish the concept of "people-oriented, patient-centered" and truly treat patients as their own relatives. , not seeking personal gain.

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