【正文】 傳染性廢物雙層垃圾袋，并注明“傳染性”字樣。餐具按要求充分清洗，煮沸消毒。一次性滅菌物品存放在清潔干燥區(qū)域，無(wú)過(guò)期，無(wú)破損。配備有液體洗手皂液和快速手消毒液，手依從性強(qiáng)，護(hù)士在操作過(guò)程中能遵循手衛(wèi)生指征。1拖把、抹布區(qū)分使用，標(biāo)記清楚，定點(diǎn)放置，用后消毒處理晾干備用，容器清潔。氧氣濕化瓶、吸氧管一人一用，長(zhǎng)期使用每周更換一次，濕化液用蒸餾水，每日更換，鼻導(dǎo)管（面罩）清潔。進(jìn)入治療室必須穿工作服，戴工作帽，在治療臺(tái)前、處理無(wú)菌物品、加藥、注射等操作時(shí)戴口罩，手衛(wèi)生符合要求。各垃圾桶加蓋、清潔，每天消毒。按要求進(jìn)行床單終末消毒處理。各消毒液濃度符合要求，督促院感科做好監(jiān)測(cè)，監(jiān)測(cè)回執(zhí)保存完好。無(wú)菌紗布、棉球、棉簽等一經(jīng)打開24小時(shí)內(nèi)使用，注明開啟時(shí)間。三、對(duì)疑有醫(yī)院感染者督促有關(guān)醫(yī)護(hù)人員留取標(biāo)本送檢驗(yàn)科做病原學(xué)檢查。三、按照醫(yī)院感染診斷標(biāo)準(zhǔn)，經(jīng)常了解 病人的病情變化。目錄醫(yī)院感染管理體系和框架圖本科管理小組成員名單及分工院感管理小組工作職責(zé)院感監(jiān)控醫(yī)師職責(zé)院感監(jiān)控護(hù)士職責(zé)醫(yī)院感染及傳染病質(zhì)控管理考核標(biāo)準(zhǔn)醫(yī)院感染管理年度工作計(jì)劃第三季度1) 醫(yī)院感染培訓(xùn)記錄2) 醫(yī)院感染監(jiān)控自查記錄（3）3) 第一季度抗菌藥物使用情況調(diào)查登記（3）4) 第一季度抗菌藥物使用情況匯總及分析5) 第一季度醫(yī)院感染病例登記6) 第一季度醫(yī)院感染因素分析及控制對(duì)策7) 第一季度監(jiān)測(cè)結(jié)果匯總登記表8) 第一季醫(yī)院感染存在的問題及整改情況記錄第四季度（同上）科內(nèi)院感年度工作總結(jié)院內(nèi)感染質(zhì)量管理辦公室 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jiān)控醫(yī)生負(fù)責(zé)填寫或由科主任指派有關(guān)人員負(fù)責(zé)填寫，作為各科室醫(yī)院感染管理工作考核依據(jù)，必須按時(shí)如實(shí)認(rèn)真記錄和填寫。消毒效果監(jiān)測(cè)結(jié)果按月登記在手冊(cè)內(nèi)，按季度匯總分析。七、有針對(duì)性進(jìn)行目標(biāo)監(jiān)測(cè)，采取有效措施，降低本科醫(yī)院感染發(fā)病率；八、按時(shí)參加醫(yī)院組織召開的醫(yī)院感染管理會(huì)議、培訓(xùn)等?？剖裔t(yī)院感染監(jiān)控護(hù)士職責(zé)一、在科主任、護(hù)士長(zhǎng)領(lǐng)導(dǎo)下和醫(yī)院感染管理科專職人員業(yè)務(wù)指導(dǎo)下進(jìn)行工作；二、監(jiān)督檢查本科室預(yù)防醫(yī)院感染管理制度的落實(shí)情況。有擦手紙或干手設(shè)施（設(shè)備），能滿足正常需要。一次性物品不得重復(fù)使用。霧化器、螺紋管一人一用一消毒，用前加藥，霧化器用后水槽及霧化罐干燥放置。醫(yī)療廢物分類放置，標(biāo)識(shí)清楚，垃圾袋、利器盒使用規(guī)范，專物專用。無(wú)菌紗布