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: soyte@hatinh.gov 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 - H#nh phtic Ha Tinh, thang 02 nam 2017 Cac benh vien 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 16/6/2014 Ve viec tang cuong chit luting cong tac dieu clang cham soc ngtrOi benh va Cong van so 12/SYT-NVY 06/01/2016 ve viec tang man ding tac KSNK; 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 giai doan tai Tiep tuc phO bien, huong dan, thirc hien nghiem tuc Thong tu 07/2011/TT-BYT 26/01/2011 dm BO Y to Huong dan cong tac dieu duang ve cham soc nguoi benh 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 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 phan cap cham soc 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) 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 "1-1h 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)* 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) ': 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 (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 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 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 an Tu van - GDSK Hanh Ong chain soc Thuc hieu y ThuOc bO sung Dieu ( u•o'ng thu•c hien TuOi: 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 phan: (+/-) Khong (-) Co (+) Co nhiki (++/+++) / Loet: DO I:v6t 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._ ... 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... (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... 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