What is the three-level doctor rounds system?

1. Resident rounds: The course records of critically ill patients should be written at any time according to the changes of their condition, at least/kloc-0 times a day, and the recording time should be specific to minutes. For critically ill patients, the course of disease should be recorded at least once every 2 days. For patients with stable condition, the course of disease should be recorded at least once every 3 days.

2, the attending physician rounds the attending physician's first visit record should be completed within 48 hours of the patient's admission. The contents include name, professional and technical position, supplementary medical history and signs, diagnosis basis, differential diagnosis and treatment plan, etc. The time interval of the attending physician's daily rounds is determined according to the condition and diagnosis and treatment, including the name of the attending physician, professional and technical positions, condition analysis and diagnosis and treatment opinions. ?

3, director (deputy director) of the physician or chief physician rounds or with deputy chief physician or above professional and technical post qualifications of the physician rounds records, including the name of the physician rounds, professional and technical positions, disease analysis and diagnosis and treatment advice.

Objective: In order to ensure that clinicians at all levels perform their duties, ensure that patients get consistent medical services, continuously improve the quality of medical care and improve the medical level of doctors at all levels, a three-level physician rounds system is formulated.

Extended data:

First diagnosis responsibility system

1.？ The first-visit doctor or department is the first-visit doctor and the first-visit department, and the first-visit doctor is responsible for the examination, diagnosis, treatment, rescue, transfer and major change of patients.

2.？ The first-time physician must inquire about the medical history in detail, carry out physical examination, necessary auxiliary examination and treatment, and carefully record the medical records. Patients diagnosed should be actively treated or put forward treatment suggestions; Patients with unclear diagnosis should be treated symptomatically, and should be consulted by doctors at higher levels or doctors in relevant departments in time.

3.？ Before coming off work, the first-time physician should hand over the patient to the successor physician, explain the patient's condition and matters needing attention, and make handover records.

4.？ For acute, dangerous and serious patients, the first-time doctor should take active measures to be responsible for the implementation of rescue. In the case of non-professional diseases or cross-professional diseases, relevant departments should be organized for consultation or reported to the competent department of the hospital for consultation. If critically ill patients need to be examined, hospitalized or transferred, the first-time doctor should accompany them or arrange medical staff to accompany them; If it is necessary to be transferred due to limited hospital conditions, the first-time doctor should contact the transferred hospital and make arrangements for further transfer.

5.？ When dealing with patients, especially acute, dangerous and severe patients, the first-time physician has the right to organize relevant personnel to consult and decide on the medical behavior of the patient's admission department, and no department or individual may shirk or refuse for any reason.

References:

Hospital Core System-Baidu Encyclopedia