醫(yī)院感染管理制度目錄（93項）

1、山東省立醫(yī)院感染管理辦公室醫(yī)院感染管理規(guī)章制度與流程（2012年9月修訂）醫(yī)院感染管理辦公室地址行政辦公樓122室電話645570891目錄醫(yī)院感染管理制度..................................................................................................................................1醫(yī)院感染管理培訓考核制

2、度..................................................................................................................1手衛(wèi)生管理制度.................................................................................................

3、.....................................2醫(yī)務人員手消毒效果監(jiān)測流程..............................................................................................................3醫(yī)院感染職業(yè)防護制度................................................

4、..........................................................................3血液、體液職業(yè)暴露預防及報告登記制度..........................................................................................4醫(yī)務人員血液、體液職業(yè)暴露防護流程...................

5、...........................................................................6醫(yī)院感染病例監(jiān)測報告及反饋制度......................................................................................................7醫(yī)院感染監(jiān)測流程..................

6、................................................................................................................8醫(yī)院感染暴發(fā)報告與處置制度..............................................................................................

7、................9醫(yī)院感染突發(fā)事件監(jiān)測流程................................................................................................................10醫(yī)院消毒滅菌管理制度...................................................................

8、.....................................................10消毒滅菌效果及環(huán)境衛(wèi)生學監(jiān)測制度................................................................................................12環(huán)境衛(wèi)生學監(jiān)測采樣規(guī)程........................................

9、............................................................................12環(huán)境衛(wèi)生學監(jiān)測項目和監(jiān)測頻次........................................................................................................14物體表面消毒效果監(jiān)測流程..........

10、......................................................................................................16多重耐藥菌感染管理制度.........................................................................................................

11、...........16多重耐藥菌感染監(jiān)控流程....................................................................................................................19多重耐藥菌感染定植患者報告流程...............................................................

12、....................................20醫(yī)院消毒隔離制度................................................................................................................................20無菌操作制度......................................

13、..................................................................................................21消毒（劑）藥械使用管理制度...........................................................................................................

14、.21一次性無菌醫(yī)療用品使用管理制度....................................................................................................22治療室、換藥室、檢查室醫(yī)院感染管理制度.................................................................................

15、...23醫(yī)療廢物管理制度................................................................................................................................23醫(yī)療廢物收集運送流程...................................................................

16、.....................................................25普通病房醫(yī)院感染管理制度................................................................................................................26普通病房消毒隔離制度.............................

17、...........................................................................................26山東省立醫(yī)院感染管理辦公室醫(yī)院感染管理規(guī)章制度與流程（2012年9月修訂）醫(yī)院感染管理辦公室地址行政辦公樓122室電話645570893消毒供應中心設備管理制度...............................................

18、.................................................................49消毒供應中心環(huán)境衛(wèi)生學監(jiān)測制度....................................................................................................50消毒供應中心滅菌效果監(jiān)測制度......................

19、..................................................................................50消毒供應中心清洗質量監(jiān)測制度........................................................................................................51消毒供應中心去污區(qū)消毒隔離制度.

20、...................................................................................................51消毒供應中心檢查、包裝及滅菌區(qū)消毒隔離制度............................................................................52消毒供應中心無菌物品存放區(qū)消毒隔離制度.

21、...................................................................................53內鏡室醫(yī)院感染管理制度....................................................................................................................53內鏡室消毒隔

22、離制度............................................................................................................................55內鏡室儲鏡柜清潔消毒制度...............................................................................

23、.................................56內鏡清洗消毒標準操作流程................................................................................................................56內鏡消毒效果監(jiān)測流程.................................................

24、.......................................................................59血液透析室醫(yī)院感染管理制度............................................................................................................59血液透析室消毒隔離制度.............

25、.......................................................................................................60血液透析室醫(yī)院感染監(jiān)控制度......................................................................................................

26、......61血液透析室透析液和透析用水質量監(jiān)測制度....................................................................................62血液透析室透析液和透析用水采樣流程..........................................................................................

27、..63口腔門診醫(yī)院感染管理制度................................................................................................................64口腔診療環(huán)境消毒隔離制度..............................................................................

28、..................................66口腔拍片過程中醫(yī)院感染控制制度....................................................................................................66口腔科門診牙科綜合治療椅醫(yī)院感染控制制度...............................................

29、.................................67口腔器械清洗滅菌制度........................................................................................................................67口腔科器械消毒滅菌效果監(jiān)測制度......................................

30、..............................................................68口腔科診療工作人員手衛(wèi)生制度........................................................................................................68口腔科門診個人防護工作制度.......................

31、.....................................................................................69產房醫(yī)院感染管理制度........................................................................................................................70產

32、房消毒隔離制度................................................................................................................................71門診、急診醫(yī)院感染管理制度......................................................................

33、......................................72門診、急診消毒隔離制度....................................................................................................................73介入診療科醫(yī)院感染管理及消毒隔離措施制度...............................