Nâng cao chất lượng chăm sóc người bệnh

UBND T1NH HA TINH
SO Y TE
/SYT-NVY
V/v nang cao chat hicmg cong tac
Người ký: Sở YKSNK
tế
va dieu duang CSNB krang
Email:
ted su hai long cua ngueri benh
SO:


vn
Cơ quan: Tỉnh Hà
Tĩnh
Thời gian ký:
08.02.2017
08:44:53 +07:00

Kinh

CONG HOA
Hoc

xx HO! CHU NGHiA VIVI' NAM
- Tty do - H#nh phtic

Ha Tinh, ngay

thang 02 nam 2017

Cac benh vien trong tinh.

Trong thad gian qua cong tac kiem soar nhiern khuan (KSNK) va dieu
clueing cham soc nguoi benh tai the benh vien tren dia ban tinh da c6 nhieu cai
tien, gop phan nang cao chat luting benh vien, huang tai six hai long cila nguoi
benh. Tuy nhien qua ket qua danh gia chat luting benh vien nam 2016, Si Y to
nhan thy tieu chi C4. Phong ngira va kiem soat,nhiem khuan, C6. Hoat dOng dieu
duang va cham soc nguoi benh dang mirc rat thdp; nhan, vien y to chua thgc
hien tot cac hugng dan phOng ngira va kiem sok nhi;em khuan; hoat dOng tu van,
giao chic sirc,khoe cho nguoi benh chua dat you cau; viec ghi chop phial theo doi
cham soc mat nhieu, thiyi gian, thong tin chua day
va trUng lap nhung chua
dugc quan tam cai tien,...

Nham nang cao chat luting cong tac KSNK va dieu duang hugng six hai
long dm nguoi benh, Giam dOc So. Y to de nghi Giam doc cac benh vien chi ciao
thirc hien tot nhang not dung sau:
1.Tiep tuc thirc hien chi ciao dm Sae Y to tai Cong van so 1014/SYT-NVY
ngay 16/6/2014 Ve viec tang cuong chit luting cong tac dieu clang cham soc
ngtrOi benh va Cong van so 12/SYT-NVY ngay 06/01/2016 ve viec tang man
ding tac KSNK;
2. TO chirc te -1g ket, danh gia viec thirc hien Thong tu 07/2011/TT-BYT va
Thong to so 18/2009/TT-BYT d6' rut kinh nghirn, khdc phiic ton tai va xay Ong
ke hoach thirc hien trong giai doan tai. Tiep tuc phO bien, huong dan, thirc hien
nghiem tuc Thong tu 07/2011/TT-BYT ngay 26/01/2011 dm BO Y to Huong dan
cong tac dieu duang ve cham soc nguoi benh trong benh vien, Thong tu so
18/2009/TT-BYT hating dan to chdc thirc hien cong tac kiem soat nhi6m khuan
tai cac co so kham, chita berth va Ke hoach hanh dOng quOc gia KSNK giai doan
2016-2020.
3. CUng c6, tang ctrarng he theing to chirc gnarl ly KSNK va dieu duang; bo

sung nhan ltrc dieu du&ng, hO sinh va cac trang thiet bi, phucmg tien cham soc de
bao dam thirc hien tot cac nhiem vu chuyen mon cham soc nguoi benh theo quy
dinh. Xay dung ke hoach cu the cai tien chat luting cac tieu chi C4. Phong ngira
va kiem sok nhiern khuan, C6. Hoat dOng dieu duang va cham soc nguoi benh.


4. Xay dung, ban hanh huang clan thuc ‘hien phan cap cham soc nguaci
benh, tang cueng S1,1 phoi hop Oita bac si va dieu duemg/hO sinh trong phan cap
cham soc.
5. Trien khai thirc hien ghi chep phieu theo dai - cham soc cai tien theo Ket
Juan cua Giam doc Si Y to tai Hoi nghi trien khai cong tac dieu du"ang nam 2017
(Thong bao s6 155/TB-SYT ngdy 20/01/2017 cna So. Y te); to chtrc tap huan
huOng clan viec ghi chep phi'eu theo doi - cham soc dam bap chat luong; dank gia,
rut kinh nghiem viec thuc hien (cac mau phie'u theo cloi - chain soc kern theo).
6. Tang cueing kiem tra, danh gia viec thuc hien quy dinh, quy trinh chuyen
mon k'S"T thuat linh v‘rc KSNK va dieu duOng cham soc nguiyi benh, dOng vien,
khen thuong kip theyi cac tap the, ca nhan thuc hien tot 6ng theyi kiem diem trach
nhiem, xir ly nghiern cac tap the, ca nhan vi pham./.
Nol nhan:
- Nhtr tren;
- Cuc Quan ly KCB-BYT; (de bac) cao)
- Giarn d6c Sa; (de bac) cao)
- Ltru: VT, NVY.

T. GIAM DOC
IAM DOC

Nguyen Tun

Phieu so

Mau so 1: Danh cho he n.oi, HSCC
IBCNH VICNI :

PHIEU THEO DOI - CHAM SOC

Ma BN•

KHOA :

Ho ten benh nhan:
Chan down:
Tien sir di an : Co
Ngay/thang

ThuOc thtremg quy
Thu4zic b6 sung
Xet nghim
Tha 02
Che 0' an

Tu. van - GDSKHan h clOng clam soc

Thirc hieu y 1. "1-1h

Dich truyen (so
lu.ong : m l, tOc (10: g/p )

Dau h ie.0

khac

Gio
Phan cap cham soc
Mach (l/p)
NI)* do
Fluyet dp (mmHg)
Nhip thO/Sp02 (%)
Da, niem mac
Tri giac, diem Glasgow
Can Ong (kg)/BMI
Van Ong
Loet/ Vi tri
Phan
Tieu: BT/Sonde(MS, SL)

DiLlu

du•o'ng thirc lien

Tuoi•
Khon

Loa i

Nam/ Nil
SO buOng/GuOng


Phi6u so

Mau so 2: Depth cho Khoa Nhi

Ma BN-

PHIEU THEO DOI - CHAM SOC

BCNH VICN :
KIIOA :
Ho ten benh nhan:

Nam/ Nit

Tuoi

So bu'Ong/Gtrong

ChAn doan:
Tien sir di irn : Co
Ngay/thang
Gi6
Phan cap cham soc

Khan

Loai •

Mach (Up)
Nhiet dO (OC)
Huyet dp (mmHg)

Nhip ther/Sp02 (%)
Tri gide, diem Glasgow
Da, niem mac
Chieu cao/can Ong
Dich da day
Phan
Sonde(MS, SL)
binh thuong

Dich truy sn (s6
hicmg : ml, toc dO: glp )

DAu h ieu
khac

,
Tie u

ThuOc b6 sung
Xet nghiem
Ther 02
Che dO an

HanhdOng cham sOc

Thkrc h i0 y 10h

ThuOc thutmg quy

-

a4

;,5
H
Di&I ( trang thtic NO

-1--

—

--- -

_


Phi6u so

Milu se; 3: Danh cho Khoa Ngoigi - Chdn thurrng
PHIEU THEO DOI - CHAM SOC
13CINH VIN :
KHOA :
Ho ten berth nhan:

Thu6c thtrorng quy
Thu6c b6 sung
Xet nghi6m
Thos 02
Chec d6 an

Hanh Ong cham soc

Thgc hieu y

Dich truyL(so
luvng: ml, t6c cr6: g/p)

D'Au hieu
khac

Chan down:
Ti&I sir di frn : Co
Ngay/thing
Gib
Phan cap chaff' s6c
Mach (l/p)
Nhi6t d6 (OC)
Huy6t ap (mmHg)
Nhip tha/Sp02 (%)
Da, niem mac
Tri giac, di6M Glasgow
Can nOng (kg)/BMI
Ve't m6NT/DAn luu
Dich din km
Phan
Ti&i: BT/Sonde(MS, SL)

.':
2

E-

Dieu &din thkrc hi4n

MA BN•
Tu6i:

Khon

Loai •

Nam/ Nix
St) butmg/GLrong


Mau so 4: Danh cho Khoa San
BCNIH VIEN :

PhiL so

PHIEU THEO DOI - CHAM SOC

Ma BN•

KFIOA :

Ho ,ten Nnh nhan:
Chan doan:
Ti&) sir di im : Co

Nam/ Nu
Se) buemg/Guarig

Tue)i•
Khon

Loai •

Ngay/thang
Gib
Phan cap cham soc
Tri giac, diem Glasgow
Mach (l/p)
Nhiet do (OC)
Huy& dp (mmHg)
Nhip ther/Sp02 (%)
Da, niem mac
Can Wang (kg)/BMI
Co hal tit. cung
San dich
Vet me/Dan Itru
Dich clan Itru
Phan

Dic h truy&I (s6
ml, t6c cl6:

DAu h izu
kh ac

Tieu: BT/Sonde(MS, SL)

Thuac ba sung
Xet nghiem
Thor 02
Che do an

Tu van - G DS K H anh Ong cham soc

T hvc hizn y l '@th

Thueic thtrang quy

Dieu throng thtyc hi0

-

-


IVILAU

al/ ✓ .

LJUMIL.111/

cuc 1...rtutycri nrrvu, uur16 .y

1301H VICIN :

PHIEU THEO DOI - CHAM SOC

Ma BN•

KHOA :

Ho ten BN:
Chan doan:
Ti'n sir di an : CO
Ngay/thang
Gi6
Phan cap chain soc
Tri giac, diem Glasgow
Mach (lip)
Nhiet dO (OC)
Huyet dp (mmHg)
Nhip ther/Sp02 (%)
Da, niem mac
Cao/nang/BMI

Dich truy 'n (so
lugng : m l, fjk 110: g/p )

Ddu hieu
khdc

Phan
Ntrorc tieu

ThuOc thu•ang quy

Xet nghiem
Tha 02
Che 0 an

Tu. van - GDSK

Hanh Ong chain soc

Thuc hieu y

ThuOc bO sung

Dieu ( u•o'ng thu•c hien

TuOi:
1 KW& [

Loai •

Nam/ Nit.
SO buOng/Gu•Ong


Phu lyc: Throng thin ghi cite')
PHIEU THEO DOI - CHAM SOC

BENH VleN :
KHOA :
Ho ten BN:

Chan doan:
Tien sit di irn : Co

] Khan

Mach (1/p)

D'Au hi0
khac

Glucose5% x 500, XL

Thuc hin y l 'nh

Dau

Dich truy 'en (s6
ml, te)c 0: g/p )

Nhiet de (OC)
Huy& ap (mmHg)
Nhip tho/Sp02 (%)
Da, niem mac
Can Ong (kg)/BMI
Van deng
Loet/ Vi tri
Phan
Tieu: BT/Sonde(MS, SL)

Ma BN•
Nam/ Nit
So bu6ng/Gtrang

Tu6i:

Ngay/thing
Gi6
Phan cap chain soc
Tri gide, diem Glasgow

Tu van - GDSKHanh Ong cham sac

Phieu so

Loai

]
20/10
8h
I
Tinh
80
38
120/80
22/85
xanh tim
55/21
+

11h
I
Tinh
80
37.5
115/80
22/96
H6ng

thuerng
BT, 1500/24h

Non
Phit

Thu6c thuemg quy

Bat dau

het, an town

x

x

x

x

x

x

x

Thuec be sung
Xet nghiem

x

Thos 02

C, 31/p

Che de an

DD 13

Ttr thj
Hitt rtia phe qucin
Dat sonde da day
Thong tle.0
Duy tri thu de
' qua BTD
Chtrenn mat
Dinh &rang
NOi quy
Phong bin cluing
Chet (45 an

d'au 20 de
x
x
x
x
x

x

x

x

x
x

x

x

Rut
RCA
x

x
cam, DD13

x
x

Di&I duOng time hi0
Chi chi]: Van Ong tir

(+); Van dOng h6 try hoan toan: (-); van &Ong he try 1 phan: (+/-)
Khong (-) Co (+) Co nhiki (++/+++) / Loet: DO I:v6t do da; dell: ten thuang bieu Kum da; de 111: hoai tir; de IV: loet
Tri gide (tinh, la ma, vat va, Won me, thang diOrn Glasgow); Tha oxy (l/p-Canulla:C, Mask:M)
D'Au hiOu khac: Dau, non, kilo ther, ho, phu, d6m, v6t thuang, dan luu, be bet._