Time flies and hard work has come to an end. Looking back on the work during this period, we have made achievements, but there are also problems. Let's learn to write a self-inspection report together. Do you know the format of the self-inspection report? The following is my self-examination report carefully compiled in the health center, hoping to help everyone.

Self-inspection report of health centers 1 Our hospital conducts self-inspection according to the requirements of Grading Standard of Township Health Centers in Gansu Province (Trial), carefully organizes staff to study the spirit of the plan, and conducts self-inspection and special rectification activities on all aspects of hospital work as required. Since the implementation of the rectification activities, the problems existing in the self-inspection of our hospital and the rectification measures are reported as follows:

First, the existing problems:

(1). Medical quality problem

1. Problems in outpatient service

According to the requirements of emergency management, there is no separate emergency department in our hospital, and there is no fixed emergency staff with strong business skills. The rate of certified doctors in outpatient and emergency departments is not high, and there are cases of unlicensed and illegal medical practice.

Some medical staff have low professional skills, so they can't master and apply some commonly used first-aid equipment and some basic first-aid techniques skillfully. The cooperation between departments is not close enough, and the cooperation between department personnel is not enough.

Medical document writing is not standardized. Outpatient prescription writing is not standardized, the elements are incomplete, the dosage and usage are unknown, the application of antibiotics is not standardized, and there are unreasonable drugs. The content of medical records under observation in outpatient department is too simple to strictly regulate the writing of medical records under observation according to the hygienic evaluation standard of outpatient cases. The quality management of hospitalized cases is not in place, and some medical staff's medical records are not standardized and timely. Case writing does not conform to the actual situation of patients, and there are hidden dangers of medical safety. All kinds of records are not standardized, and the writing requirements are far from meeting the requirements of medical document writing quality standards. All kinds of outpatient logs are incomplete, discontinuous and incomplete.

Some medical systems and core systems are incomplete and imperfect. According to the requirements of the grade evaluation standard of township hospitals in Gansu Province, the relevant systems of various departments have been established, improved and implemented, especially the core system of continuous improvement of township hospitals, and some systems have not adapted to the needs of hospital management at this stage.

2. Problems existing in nursing department

The establishment of various nursing systems is incomplete and imperfect. The original system is not enough to meet the requirements of current management, and now it is necessary to establish relevant standard systems in combination with the actual situation of management in our hospital.

The organizational system of nursing management is incomplete. The relevant nursing management was not implemented according to the regulations of Nurses, and the target management responsibility system was not implemented. The nursing management department can not establish a perfect nursing management system according to the functions and tasks of township hospitals, and the responsibilities of each post are not clear, and there is mutual shirking in the work. The management of nursing human resources is not complete, and the nurse management system has not been established according to the actual situation of the unit. There are no clear requirements for the qualifications, technical abilities and technical standards of nurses at all levels, and the nurse grade and performance evaluation mechanism have not been established and improved. According to the hospital nursing staffing standards, ward nurses and beds can not meet the prescribed standards.

The assessment standard of nursing work is not comprehensive and perfect. The regular assessment of nursing work is not timely and becomes a mere formality. Nursing documents were not written in strict accordance with the Basic Norms of Case Writing, and the writing quality of nursing documents was not standardized. All kinds of incomplete registration, such as disinfection records, observation records, emergency records of critically ill patients, handover records, etc. The concept of aseptic technology is not strong, and the operation still needs to be further improved. The operation standard of nursing skills has not been effectively established, some nursing staff's skill operation is not standardized, and the destruction of disposable goods is not thorough and standardized. The health of outpatient and inpatient departments is poor, and there are hidden dangers of cross-infection. The quilt cover and sheets are old, the glass is not clean, and the cleaning is not timely.

3. Problems existing in pharmaceutical work

The pharmacy drug management system is incomplete. The management system of toxic, hemp and drama 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 moth-eaten drugs still exist. The registration of drug purchase and sale records is not timely, and the registration of disposable medical supplies purchase and sale records is not standardized.

The professional skills of medical staff can not meet the requirements of hospital development. The personnel actually engaged in drug dispensing in the hospital are non-pharmaceutical professional technicians, and other professional technicians are engaged in drug dispensing after being trained and qualified by the Food and Drug Administration. The knowledge of drug dispensing is not enough, prescription dispensing is not strictly controlled, and unqualified prescription dispensing occurs from time to time. Some dispensing personnel have a weak sense of responsibility and sometimes dispense the wrong drugs.

(2). Problems in service attitude

1. outpatient staff

Poor service attitude, patient reactions occur from time to time, poor service attitude, service awareness and service quality, and problems such as cold, collision, hardness and top in medical service need to be further improved.

2. Nursing staff

The service quality is not high, which fails to reflect humanized service. The basic nursing and grading nursing measures provided are not in place, and the nursing of inpatients stays in the primitive stage. The medical service quality of some medical staff is not high, the service attitude is poor, and the patients have a strong reaction. Some nurses have insufficient sense of responsibility, and the implementation of the "three checks and seven pairs" system is not in place, which has medical hidden dangers. The implementation of nursing error reporting and management system is not in place, the observation of patients is not in place, and nurses can not actively report some nursing adverse events.

3. Pharmacy staff

Service attitude needs to be further improved. The staff have poor service consciousness and attitude, and failed to establish a "patient-centered" pharmaceutical affairs management service model. The patient's service language is cold, his attitude is poor, and his reaction is strong. Service attitude needs to be further improved.

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

Some medical workers are enterprising, responsible and active. They need to further enhance their sense of responsibility, urgency and crisis, enhance their sense of service, improve their service methods, and improve the relationship between doctors and patients, so that the people's satisfaction with the style of medical institutions can be significantly improved.

Some medical staff have a poor mental outlook. They don't wear work clothes, do not apply for work permits, leave their posts without permission, don't chat, are depressed, and can't devote themselves to medical work in high spirits.

(4). Environmental health problems

For a long time, the health units of the medical system have been unsanitary. Through the inspection in our hospital, the floor and glass of all departments are generally dirty, messy and poor, and the desktop items are piled up and placed in confusion, which affects the image of medical and health units.

2. Rectification measures and time limit:

1. In order to ensure the smooth progress of health rectification work and meet the requirements of the rectification plan, a leading group for health rectification work was established to take charge of the hospital rectification work and provide a strong leadership guarantee mechanism. Hou Hongxing, the team leader, is fully responsible for the health rectification work of health centers and village health centers. Team members Feng Zhiyuan, Tian are responsible for the health rectification work of relevant departments.

Time limit for rectification: immediate (rectification has been implemented).

2. Strengthen medical quality management, establish rules and regulations, pay close attention to implementation, and put an end to medical accidents.

(1) Establish a long-term mechanism for the rectification system of medical and health work. The leading group of medical and health rectification activities is responsible for the management of medical quality and medical safety, and establishes a regular supervision system for medical and health management. Every week, the hospital organizes relevant department personnel to conduct special inspections on the medical work of each department, register the problems existing in the inspection on the medical and health supervision form, immediately put forward rectification measures, put the responsibility on people, rectify within a time limit, and organize relevant personnel to carry out rectification inspections.

Rectification period: organize regular inspection immediately. In view of the existing problems, according to the actual situation, immediately or in the short term (rectified and implemented).

(2) Establish and improve the relevant medical work management system. According to the requirements of grading standards of township hospitals in Gansu Province, establish and improve the relevant systems of various departments, especially the core system of continuous improvement in township hospitals, establish a mechanism for preventing and handling medical disputes, and properly handle medical disputes in a timely manner. Formulate medical accident prevention plans and procedures for handling major medical safety incidents, report major medical negligence and medical accidents as required, and effectively prevent accidents caused by non-medical factors.

Time limit for rectification: organize regular inspection, in the near future (rectification has been implemented).

(3) Establish and improve the system of supervision, assessment, rewards and punishments. Establish a medical quality supervision and assessment system, establish and improve a medical accident, medical error and medical quality analysis and evaluation meeting system, decompose medical quality and medical safety indicators into departments and individuals, and form medical safety responsibilities and indicators. Establish a regular meeting system of medical treatment and medical quality in our hospital, and discuss and analyze the problems existing in medical and health management in depth. Linking the problems existing in medical work with personal assessment, the hospital will include 20% of employees' file salary in performance assessment, forming a performance reward and punishment promotion mechanism.

Time limit for rectification: organize regular inspection, in the near future (rectification has been implemented).

(4) Strengthen the training of employees' business skills and improve the quality of medical services.

The improvement of hospital medical work is inseparable from the efforts of all medical workers, so strengthening the cultivation and improvement of comprehensive quality of medical workers in all aspects is the premise. Therefore, our hospital will strengthen the improvement of employees' comprehensive professional quality as a breakthrough.

According to the self-inspection report of hospitals in 2 xx, the health work in our hospital was carried out in turn around the requirements of signing the health work responsibility target book with the Health Bureau at the beginning of the year. Combined with the health work in our hospital in the first half of the year, we conducted self-examination and self-correction on the health work in the first half of the year, and now we report the self-examination of the health work objectives in our hospital in xx years as follows:

I. Essential drugs and medical reform

1. Usage of essential drugs: As of June 30th, xx, Gaochi Township Health Center has all been equipped with essential drugs according to regulations, and the proportion of supplementary drugs is all in line with regulations. 10 village clinics and health stations within the jurisdiction strictly implement the corresponding national basic drug system, and our hospital conducts supervision and inspection on schedule. And learned the "Guide to Clinical Use of Essential Drugs" and "Prescription Set of Essential Drugs".

2. Online procurement of essential drugs: Since the implementation of the system of essential drugs, online procurement of essential drugs has been carried out in accordance with regulations, and the sales rate is zero. The procurement process is reasonable, and there is no fraud or unauthorized procurement of non-winning drugs instead of winning drugs. Village clinics shall, according to the integrated management mode of villages and towns, report to the hospital before the 20th of each month the plan of implementing online procurement of essential drugs and implementing zero-difference sales, which shall be uniformly settled by township hospitals.

3. Supply and distribution of essential drugs

The supply and distribution of the winning drugs can basically arrive in time. However, there are still some problems: some suppliers cannot distribute some commonly used drugs, and some commonly used drugs have been out of stock since online bidding.

4. Payment and settlement of essential drugs

Our hospital remit drugs to the payment center of the Health Bureau on time every month, and the basic drugs are settled and paid in time, without misappropriation and illegal drug use.

Second, the work of Chinese medicine

1. Establish and strive to create the characteristics of traditional Chinese medicine: After the establishment of the national advanced county of traditional Chinese medicine, our hospital made great efforts to create the cultural characteristics of traditional Chinese medicine, and formed a relatively independent comprehensive service area of traditional Chinese medicine, including Chinese medicine clinic, Chinese medicine treatment room, traction room and acupuncture physiotherapy room. Set up a Chinese pharmacy, equipped with Chinese herbal medicine cabinet (medicine barrel), medicine cabinet, dispensing table, medicine basket, standard sieve and decocting machine. Our hospital now has 306 kinds of Chinese herbal medicines and 65 kinds of Chinese patent medicines. Can provide decocting service for patients. In order to better popularize the appropriate technology of traditional Chinese medicine and develop the cause of traditional Chinese medicine more widely, our hospital is equipped with a number of basic facilities and diagnosis and treatment equipment suitable for the development of traditional Chinese medicine, including acupuncture treatment bed, massage treatment bed, TDP magic lamp, electroacupuncture therapeutic instrument, wax therapy instrument, cervical and lumbar traction bed, and purchased acupuncture instruments, cupping, scraping oil, scraping board, pure moxa stick, intermediate frequency therapeutic instrument, moxibustion box and so on.

2. Actively promote appropriate technologies and extensively carry out TCM business: TCM doctors in our hospital use 1 1 TCM appropriate technologies including acupuncture, massage, cupping, application, scraping, fumigation, acupoint injection, wax therapy, bloodletting therapy and traction according to the principle of "simplicity, convenience and cheapness". Among them, the outpatient and emergency department of TCM accounts for 34% of the total outpatient and emergency department; The income of traditional Chinese medicine accounts for 35% of the total drug income, the income of traditional Chinese medicine accounts for 33% of the total business income, and the qualified rate of traditional Chinese medicine prescription writing is over 95%; Chinese medicine outpatient medical records have not been implemented.

3. Carry out health education and popularize the knowledge of Chinese medicine: Health education is one of the basic public health service items determined by the state, which plays an important role in improving people's health literacy, advocating a healthy lifestyle, and preventing and controlling infectious diseases and chronic diseases. In order to better carry out health education, our hospital actively produces health education materials of traditional Chinese medicine, including written materials with traditional Chinese medicine as the main content, and sets up publicity columns to popularize education. Formulate the popularization plan of Chinese medicine knowledge, carry out public health consultation of Chinese medicine, and guide rural residents to understand the knowledge and methods of Chinese medicine health care.

4. Strengthen business training and further study: In order to meet the needs of the development of traditional Chinese medicine in my hometown, our hospital sent 1 Chinese medicine professionals to Dingxi Traditional Chinese Medicine Hospital to study acupuncture and physiotherapy. According to the requirements of the relevant documents from the higher authorities and the business needs of the hospital, our hospital organized senior doctors to conduct centralized business training and study for the newly recruited personnel in village clinics and Chinese medicine practitioners, and achieved certain results.

Three. managed care

1. Establishing residents' health files and electronic files: By the beginning of June of xx, there were 6,823 people in our jurisdiction, and 6,823 people had established residents' health files, accounting for 100% of the total population, and 352 1 person had electronic files, accounting for 5 1% of the total population. The number of files in each village reaches the task index, and the format of health files is unified according to the assessment requirements, and the file management system is formulated. Follow-up and file update management were carried out for key populations such as hypertension, diabetes, pregnant women, children aged 0-6, elderly people over 65, and severe mental illness.

2. Health education: The health center has set up an organization, formulated an implementation plan, organized and implemented it according to the project requirements, carried out lecture consultation activities according to the requirements of the specifications, regularly changed publicity columns, and archived photos, activity summaries and sign-in activities; The clinic also earnestly carried out health education projects and carried out health education effect evaluation in accordance with the requirements of the specification; Within the jurisdiction, the health education bulletin board should be replaced at least once every two months 1 time; the hospital should hold at least 1 time health knowledge lectures every month; the village clinic should hold at least 1 time every two months; and the health consultation should be held at least once a month; In the first half of the year, 6 health knowledge lectures, 7 consultation and publicity activities were held, and 3,500 health education publicity materials were distributed.

3. Immunization planning: the qualified vaccination rate and timely vaccination rate of the "Five Vaccines" basic immunization vaccine in our hospital are above 95%; The card building rate reaches 100%. The national immunization program has expanded the coverage rate by over 97% and intensified the coverage rate by over 98%. Vaccination clinics are all standardized vaccination clinics, and all employees have vaccination qualification certificates. There is no charge for vaccination of Class I vaccine. Vaccination clinic shall carry out vaccination once every 10-14, observe the recipients for 30 minutes after inoculation, and regularly check for missing seeds and raise seedlings.

4. Reporting and handling of infectious diseases: The epidemic situation management system of health centers is complete, and an information notification mechanism has been established. The hospital regularly or irregularly reports the results of self-examination and the discovery of infectious diseases, and all departments have registration. From the spot check, the report rate of outpatient log is 100%, the timely rate is 100%, and the timely rate of online report is 100%. Standardize the referral of tuberculosis patients and follow up on time, and carry out publicity days such as 3.24 and 4.25 in daily health education. No infectious diseases were found in the outpatient registration of each village.

5. Maternal health care: Our hospital standardized maternal health care, registered the maternal roster completely, and reported the maternal health care information in time. The number of pregnant women in this area is 12. Health care coverage rate 100%, early pregnancy card establishment rate 80%, system management rate 85%, postpartum visit rate 100%. Postpartum visits are undertaken by hospitals and clinics.

6. Medical care for the elderly: there are 674 elderly people in the township, and 574 people are managed by the medical care system, with a system management rate of 90%; For the elderly over 65 years old, regular physical examination is conducted, risk factors are investigated, and health guidance such as health care service, injury prevention and self-help is provided.

7. Chronic disease management: hypertension management area 138 people. Standardized management 138 people, standardized management rate 100%. There were 23 people in diabetes management and 23 people in standardized management, and the standardized management rate was 100%. Villages regularly follow up the objects of chronic disease management, provide health guidance such as preventing risk factors, and hospitals conduct health checkups according to the requirements of the regulations.

8. Management of severe mental illness: 8 patients with severe mental illness were managed by * * * in our jurisdiction, with a management rate of 1.000%. The management object is followed up regularly, and the health center conducts physical examination according to the standard requirements.

The construction and integration of the three industries, as well as the construction of professional ethics and efficiency, were completed as scheduled according to the requirements of superiors.

Self-inspection report of health center 3 In order to further standardize the professional behavior and medical services of staff in our hospital and ensure the medical and drug safety of the broad masses of people, our hospital carried out self-inspection activities to standardize services in accordance with the spirit requirements of relevant documents of the county bureau. In order to implement this activity, strengthen hospital management, improve medical quality, ensure medical safety and improve medical services, our hospital decided to carry out standardized service self-inspection activities in the whole hospital. The report reads as follows:

1. Through the standardized construction of clinical departments and vaccination clinics in traditional Chinese medicine hospitals for public health and environmental construction, the infrastructure construction of department configuration, medical equipment configuration and use, and post appointment of professional and technical personnel in township hospitals has been further improved.

2. Through the unified management of people, talents and materials in township hospitals, the hospital has straightened out the management system of township hospitals in terms of technical personnel deployment, qualification access, fund investment, asset management, business guidance and work coordination, public health and medical market supervision.

3. The reform of personnel distribution system in township hospitals has been completed. On the basis of implementing the target responsibility system of the president's term of office and perfecting various management systems, the department setting of township hospitals is divided into public health and medical treatment, and it is clear that all township hospitals should focus on public health services. On this premise, the central hospital should further improve the level of medical technology and guide the business work of the surrounding general hospitals. A strict performance appraisal system has been established, and the salary distribution of personnel is linked to the services provided and labor contributions, which improves the internal vitality of township hospitals and stimulates the enthusiasm of cadres and workers.

4. The hospital's administration and business have been institutionalized. Formulate the class objectives and tasks of hospital leaders and department heads. The post responsibility system combining responsibility, right and benefit shall be implemented, and various medical and nursing work systems such as handover of clinical departments, standardized writing of medical documents, registration of errors and accidents, disinfection and isolation shall be established and improved to prevent medical disputes and put an end to medical liability accidents.

5. The establishment and management of health records. The establishment of health records in our hospital is mainly carried out in the form of outpatient publicity, data collection, coordination and arrangement of residents in the jurisdiction, physical examination and file management in hospitals. However, in the process of establishment, due to the older staff of Lancun clinic, the coordination and publicity work is not in place, the filing progress is slow, and some residents do not cooperate, resulting in a low filing rate.

Self-inspection report of health center 4 According to the requirement of XXX Health Bureau to carry out "three good and one satisfaction" activities, our hospital conducted a comprehensive inspection of key departments. Now the self-inspection results and rectification measures are reported as follows:

First, the existing problems:

(1) Some medical management systems are still not in place.

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

(2) The application of antibacterial drugs is still unreasonable.

The use of antibiotics by individual medical staff is unreasonable, such as the use of antibiotics for the common cold; Perioperative preventive medication is unreasonable and antibiotics are used for too long.

(3) Problems in the writing of hospital medical records.

1, the handwriting is scrawled and altered, and the name does not match the hospital number.

2. The course record lacks the analysis of the revised doctor's advice and positive test results, and the analysis of the contents of the ward round record is too formal.

3. Self-funded items such as drugs and disposable high-low value consumables with informed consent and irregular signature and without informed consent.

Second, the rectification measures:

(a) to further strengthen the quality and safety education, improve the safety and quality awareness of medical staff.

Medical staff generally attach importance to professional knowledge and ignore the study of quality management knowledge, lack quality management knowledge and have a weak sense of quality, so that they can not consciously and actively apply quality requirements to daily medical work, and it is difficult to ensure the realization of quality objectives. Quality management is a discipline. To improve medical quality, we should not only learn medical theory and technology, but also learn the basic knowledge of quality management and constantly update the concept of quality management to meet the needs of society. Only by making medical staff establish correct quality management consciousness and master quality management methods can passive quality control be changed into active self-quality control. Therefore, it is the basic work to improve medical quality by training all medical staff on quality management knowledge and enhancing quality awareness.

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

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

1. Further strengthen the work of quality ward round and medical record examination, pay attention to actual results, and cannot become a mere formality. In addition to explaining the problems found in person, repeated offenders must be punished financially.

2, strengthen the three basic training and assessment, to constantly improve the assessment methods, serious assessment discipline, pay attention to the effectiveness of assessment, not a mere formality.

3. Strengthen the quality management of medical records.

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

4. Further strengthen the monitoring of hospital infection.

Strictly implement various hospital infection management systems. Further strengthen the training and publicity of hospital infection knowledge, so that every medical staff should realize the importance of hospital infection control, consciously abide by aseptic operation technology, do a good job of personal control, give play to the role of hospital infection management Committee, actively carry out work, and put an end to the omission of hospital infection events.

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

According to the spirit of the document "Guiding Opinions on the Management of Clinical Application of Antibacterials in Guangdong Province", our hospital established the "Clinical Application Management Group of Antibacterials" to strictly implement the management of clinical application of antibiotics and attach importance to the monitoring of preventive medication during perioperative period. Further implement the classification management system of antibacterial drugs, set prescription authority, ensure the implementation of the system, improve the rate of bacterial culture and drug sensitivity test, and ensure the rational use of antibacterial drugs.

(three) to further strengthen professional ethics education, and effectively improve the service level of medical personnel. Medical ethics education should be carried out for medical staff according to the requirements of Medical Ethics Standards and Implementation Measures of the Ministry of Health. Cultivate a modest and prudent work style, aspire to be a respected medical worker with noble medical ethics, truly establish the concept of "people-oriented, patient-centered", and truly treat patients as relatives without seeking personal gain.

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