The consultation system of traditional Chinese medicine should organize multi-professional consultation when it is difficult to diagnose and treat critically ill patients or involves multi-professional problems. Our hospital encourages western medicine departments to invite Chinese medicine doctors to make rounds, and promotes the dual diagnosis and treatment mode of Chinese and western medicine to promote the mutual integration of the two kinds of medicine. In order to standardize the consultation system of traditional Chinese medicine in our hospital and ensure the quality and safety of medical treatment, combined with the actual situation of our hospital, some systems of consultation of traditional Chinese medicine in our hospital are stipulated as follows.
(a) outpatient consultation according to the condition, if you need Chinese medicine consultation, you need to check and sign by a doctor with high experience in this outpatient clinic, and indicate it in the outpatient medical record, and the patient holds the door.
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Check the medical records and directly invite the department for consultation. The consultant should record the consultation opinions on the outpatient medical record and sign the full name at the same time; Undergraduate diseases are handled by consultants, and non-undergraduate patients can be returned to the invited department or other relevant departments for consultation.
(2) Ward consultation application consultation department must provide a brief medical history, physical examination, necessary auxiliary examination findings, as well as the purpose and requirements of preliminary diagnosis and consultation, and the resident should fill in the above information in the consultation form carefully, and send it to the Chinese medicine department for consultation after being reviewed and signed by the attending physician. According to the requirements of the application department, the invited Chinese medicine department will send an attending physician or a designated physician to complete the consultation within 24 hours according to the condition. Consultation should be accompanied by the attending physician. The consultant should consult carefully and put forward detailed opinions on the examination results, diagnosis and treatment.
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Put it in the medical record. In case of difficult problems or complicated illness, please immediately ask a superior doctor to assist in consultation, make a diagnosis and treatment plan as soon as possible, and put forward specific opinions for the reference of the inviting department. Apply for consultation one hour before work at night (except emergency).
1. Consultant qualification: In-hospital consultation must be undertaken by a doctor with the qualification of practicing Chinese medicine or integrated traditional Chinese and western medicine and the title of resident or attending physician in other countries and hospitals; If the consultant of the invited department cannot be present in time for some reason, other doctors at the same level or superior doctors in the department should be invited to consult on their behalf; For special or difficult critically ill patients who need consultation with the director of the department, it must be agreed and signed by the director (or chief physician) who applies for consultation.
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2. After consultation, it is confirmed that the patient needs to change his major, and the consultant will sign a professional opinion. After signing, the patient's diagnosis and treatment responsibility will be transferred to the department; When it is temporarily impossible to transfer out for various reasons, the transfer department must ensure that the patient does not have any delay in diagnosis and treatment; Emergency patients should be transferred to hospital in time, and if there are difficulties, they should be reported to the hospital Committee for coordination.
Second, urgent consultation.
(1) When the acute, dangerous and severe patients who are difficult to handle in the undergraduate course are in urgent need of assistance from the relevant departments of traditional Chinese medicine, the attending physician shall apply for emergency consultation, and the word "urgent" shall be marked on the emergency medical record or consultation list. Under special circumstances, you can invite by phone. Before the consultation, the emergency department should write the emergency medical records completely and make necessary preparations.
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Auxiliary examination, indicating the purpose of consultation in emergency medical records. The inviting department of the ward should write the hospital medical records completely, make necessary auxiliary examinations, standardize the writing of consultation sheets, have a clear purpose of consultation, and write down the time of inviting consultation.
(2) Without special circumstances, the doctor who invited the consultation will arrive within 10 minutes.
(3) During the consultation, the applicant must be present to cooperate with the consultation rescue personnel.
(4) After the consultation, the invited doctors should write the inspection results and diagnosis and treatment opinions on the emergency medical records and consultation sheets, and make clear the diagnosis and treatment suggestions for critically ill patients to the original attending doctors.
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(5) If the diagnosis is still uncertain after consultation, the patient's department (room) shall temporarily assume the main responsibility for diagnosis and treatment, and shall not shirk, and timely ask the relevant superior doctors to check and determine the diagnosis and treatment plan.
(6) If the illness requires consultation from multiple departments, the patient's department (room) shall report to the hospital committee, and the hospital committee shall convene relevant departments for consultation, and make it clear that a certain department shall bear the main responsibility according to the illness.
(seven) the rescue of critically ill patients should be carried out in a timely manner, and the diagnosis and treatment should not be delayed due to consultation.
Part II: Consultation system.
consultation system
I. Consultation requirements
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1. In case of undiagnosed cases within three days after admission, or in case of difficulty in diagnosis and treatment in the department due to illness change during diagnosis and treatment, technical support inside and outside the hospital is needed to assist in diagnosis and treatment, you should apply for consultation in time. Consultation should be completed in accordance with the provisions of the consultation application form (in case of emergency, you can consult first and then fill in the form).
2. In addition to the oral request for emergency consultation, it is necessary to clearly record the time of oral notification. Other consultations need nurses to pass to the consultation department and the consultant, and the emergency consultation should be filled in in time so that the consultant can sign the consultation opinion as the basis for the determination of medical responsibility. For patients who are allowed to move freely due to illness and need special instruments and examination sites, especially ophthalmology, otolaryngology and other departments, the department that proposes consultation can consult with the inviting department in advance.
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Empirical diagnosis: the attending doctor reports the medical records, and makes preparations and records before consultation. When consulting, it is necessary to conduct a detailed inspection, carry forward the academic democratic style, and clearly put forward advice. The host made a summary and carefully organized and implemented it.
4. No department or individual may refuse all kinds of consultation requests invited through normal channels for any reason or excuse.
5. Consultation records should be timely sorted into medical records.
6 to participate in the consultation of doctors, should have more than attending specialist qualifications (including attending doctors, the same below. ), generally designated by the consulting department or the specialist second-line doctor on duty, the designated doctor or second-line doctor on duty cannot attend due to surgery or internal rescue.
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Increase the consultation, the director of the report department can arrange participants to complete the consultation in time. Emergency consultation can be the responsibility of the chief resident physician.
7. In the process of consultation, due to the patient's special circumstances or diagnosis and treatment technology, the consultant's office will negotiate and assign someone to accompany the patient to the invited department for consultation.
Failing to put forward a clear diagnosis and treatment opinion, it should report to the superior doctor or director in time, and the superior doctor or director should guide the consultant, and invite the superior doctor or director to participate in the consultation directly when necessary.
8. After the consultation, the consultant shall, under the principle of observing the protective medical system, diagnose and deal with the patient's condition, medical risks and treatment together with the doctors in the inviting department.
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Inform the patient's opinion and answer the patient's consultation. After the consultation, the consultant should track and follow up the patient's condition.
9. Put forward the consultation department outside the hospital to assist the medical department and the hospital to receive the invited doctors.
Second, the form of consultation.
1. Cross-departmental consultation: proposed by the attending physician, agreed by the department director, and filled in the consultation form. The invited doctor should finish it within 24 hours and write the consultation record. If you are a mild patient in a specialist consultation, you can go to a specialist for examination.
2. Emergency consultation: The invited doctor must be on call and arrive within 15 minutes, and the green channel emergency consultation should arrive within 10 minutes.
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3. Consultation in the center: proposed by the department director and agreed by the center director, the consultation time is determined, and the center secretary will organize relevant personnel to participate. Presided over by the director of the application department, if necessary, members of the central expert group will participate.
4. In-hospital consultation: proposed by the director of the department and agreed by the director of the center (referring to those who have established the center, the same below). ) and report to the medical department, determine the consultation time, notify the relevant personnel to attend. Presided over by the director of the application department or the director of the center, and sent by the medical department when necessary.
5. Out-of-hospital consultation: Our hospital has difficulties in one-time diagnosis and treatment of difficult and critical cases, or needs out-of-hospital doctors to guide the operation of diagnosis and treatment technology because of new technology projects. Proposed by the director of the department, with the consent of the director of the center, the attending and above doctors fill in the consultation form and report it according to the regulations.
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The medical department shall contact the inviting unit after the examination and approval, and notify the relevant departments after the consultation time is determined by both parties through consultation. The consultation shall be presided over by the department director.
6. Our doctor went out for consultation;
(1) After receiving the consultation form or telephone invitation from the other hospital, the medical department should obtain the opinions of the consultant appointed by the consultation department or the consultation unit, inform the other party after determining the consultation time, and ask the way to pick up the doctor.
(2) When there is an emergency consultation or the other party designates a doctor outside office hours, the invited doctor must first obtain the consent of the department director, report it to the medical department or hospital for the record, and hand over to treat and arrange work before going out for consultation. After the consultation, you must go through the consultation formalities in the medical department.
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(3) All out-of-hospital consultations must be registered with the Medical Department with an invitation letter from the inviting unit. Otherwise, all consequences shall be borne by the parties concerned.
(4) Implement the relevant provisions of the Ministry of Health, the Provincial Health Department and the Municipal Health Bureau.
Chapter III: Consultation System
consultation system
1, in case of difficult cases, you should apply for consultation in time.
2. Please fill in the consultation record carefully during the consultation, and clearly write out the patient's brief medical history, preliminary diagnosis opinions and consultation purpose. Each department should set up a consultation form for signing, and submit it to the invited doctor or department for signing when sending the consultation form, and indicate the signing time. Use logistics
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The system must call the inviting department when sending the consultation form, and the invited department will call the inviting department for confirmation and registration after receiving the notice.
3. The consultation is accompanied by the invited department doctor and introduces the condition. After the consultation, the invited doctor must carefully write the consultation record and put forward clear diagnosis and treatment opinions or suggestions. If the consultant is not sure whether the diagnosis and treatment are correct, please consult a superior doctor. When consulting for critically ill patients, the consultant should be a doctor with the title of subtropical high or above. In case of emergency, the doctor on duty should arrive at the invited department for consultation and rescue within the specified time, and at the same time inform the doctor with senior title to arrive quickly to participate in the rescue.
4. In-hospital consultation: patients who are not diagnosed within 3 days after admission are proposed by the attending physician or the attending physician and called by the department director.
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Convene relevant medical personnel for general consultation and discussion. If the general discussion is still undiagnosed, the director of the department should make suggestions to the medical department in time, organize the whole hospital consultation, and the discussion results should be recorded on the medical record page.
5. Cross-departmental consultation: proposed by the attending physician, with the consent of the superior physician, fill in the consultation form. Specially invited doctors should generally complete the consultation within 2 4 hours and write the consultation record. If you need a specialist consultation, you can go to the specialist examination consultation with a consultation form and medical records, and be accompanied by the staff of the inviting department.
6. Emergency consultation: We must master the emergency standards realistically. For general emergency consultation, the attending physician shall fill in the consultation form, which shall be signed by the superior doctor and marked with the word "urgent" to invite the department to send a doctor in time.
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Division wants. Under special circumstances, you can invite by phone, then fill in the consultation form, or mark the word "urgent" on the consultation form. The invited department must send a doctor immediately (10 minutes) without delay. During the consultation, the applicant doctor must be present to cooperate with the consultation and rescue work.
7. In-hospital consultation: If a difficult case needs multi-disciplinary consultation, it shall be proposed by the director of the department, and the consultation time shall be determined with the consent of the medical department, and the relevant departments and personnel shall be notified to attend. Consultation is generally presided over by the director of the application department, and the medical department sends people to attend, and the dean attends when necessary.
8. Consultation in other hospitals: For difficult cases or operations that can't be solved in our hospital, the director of the department should put forward, fill in a written invitation letter, and contact the relevant hospital with the consent of the medical department.
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Determine the consultation time. The consultation shall be presided over by the director of the application department, and the medical department or the competent dean shall be invited to participate if necessary.
9. Go out for consultation. When a foreign hospital invites a doctor from our hospital for consultation, an invitation letter will be issued, and the invited hospital will contact the medical department of our hospital. According to the requirements of the consulting hospital, the medical department will send relevant personnel to participate in the consultation without affecting their own work. Try to arrange the invited doctors during the roll call consultation. All round-trip travel expenses are paid by the inviting unit. Visits can only be made with the consent of the chief attendant on holidays or at night, and no one can go out for consultation without permission.
10, questions to pay attention to in consultation:
10. 1, the consultation department should strictly grasp the consultation indications.
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10.2, general consultation should be conducted by doctors with the title of attending physician or above, and consultation should be conducted for critically ill patients.
Doctors with the title of associate high school or above.
10.3, effectively improve the quality of consultation, fully prepared before consultation, and attended by special personnel. The attending doctor should introduce the case in detail, and the participants should check it carefully. Seriously discuss and give full play to technical democracy. All participants in the consultation, regardless of their professional titles, are equal when discussing issues, and should speak freely and put forward clear consultation opinions. The host should make a summary, and if there are differences, the doctor at the next higher level or the director of the department should put forward the diagnosis and treatment plan.
10.4, no department or individual may refuse all kinds of consultation invited through normal channels for any reason or excuse.
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Requirements.
Chapter IV: Consultation System
consultation system
First, the patient's disease involves many specialties, and it is temporarily impossible to clearly diagnose or treat difficult cases with poor results. The attending physician should apply for consultation in time. Consultation includes consultation between different specialties in the department, consultation between departments (emergency), consultation in the hospital and consultation outside the hospital.
Second, the consultation between different professions in the department.
Patients should be treated according to the principle of professional treatment. If patients suffer from other professional diseases, they should be consulted by relevant professional doctors. The inviting party shall issue an advisory opinion.
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According to the doctor's advice, the invitee personally examines the patient and writes the consultation record according to the regulations.
Third, cross-departmental consultation.
(a) each department must arrange for doctors with resident and above titles to conduct cross-departmental consultation. Doctors in charge of consultations in various subjects should leave their contact information at the nurse station for easy contact.
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