1、編寫說明三中、四中、為貫徹落實精神，根據國務院關于推進分級診療制度建設的指導意見（國辦發201570 號）要求，衛生計生委組織制定了三級綜合醫院醫療服務能力指南（2016 年版）（以下簡稱指南）。各三級綜合醫院要按照指南要求，嚴格落實“十三五”衛生與健康、區域衛生和醫療機構設置，醫院規模，重視醫院內涵建設；明確三級綜合醫院功能，開展與自身功能相適應的診療服務，不斷提升醫療服務能力與水平；充分發揮技術輻射和帶動作用，通過對口幫扶、醫聯體等多種方式，促進醫療縱向整合，引導優質醫療下沉，提升基層醫療機構服務能力，推動構建分級診療模式。本指南提及的醫療服務能力是指為符合三級醫院功能的醫療服務能力，包含

2、醫院配置、技術、工作效率與效果、醫療診治能力與醫療技術水平等。本指南由六章組成，涵蓋了三級綜合醫院基本設置、運行績效、疾病/手術覆蓋、臨床專科服務能力、醫技科室服務能力、臨床路徑單病種平均住院日等，用客觀數據來衡量三級綜合醫院各方面的真實水平。客觀數據主要來源于三級醫院醫療服務能力基線。本指南適用于三級綜合醫院，側重于醫療服務能力要求，不涉及對特需醫療服務的要求。目錄1 基本設置 ··················

3、··············1.1 床位規模 ································1.2 診療科目 ·

4、·······························1.3 醫療設備 ·················

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18、83;····· 11················131.4 人力··························

19、3;·····4· 5· 551.5 信息化建設 ································2 運行績效 ·······

20、;·························2.1 工作負荷 ·······················&#

21、183;········2.2 工作效率 ································2.3 服務質量 ······&#

22、183;·························3 臨床專科醫療服務能力 ······················&

23、#183;·····················66····························

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30、;······63.1 內科 ··········································

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38、83;··················7791013151719213.1.1 心內科 ···························&#

39、183;····3.1.2 呼吸內科 ································3.1.3 消化內科 ·········

40、3;······················3.1.4 神經內科 ··························

41、;······3.1.5 內科 ································3.1.6 腎病學科 ········

42、83;·······················3.1.7 血液內科 ························

43、3;·······3.1.8 免疫學科 ································3.2 外科 ·······

44、3;························3.2.1 普通外科 ························

45、;········3.2.2 骨科································3.2.3 神經外科 ······

46、3;·························3.2.4 泌尿外科 ·······················

47、;·········3.2.5 胸外科·······································&#

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57、183;·········232325323435· 37·····································

58、;············3.2.6 心臟大外科 ································3.3 婦產科 ··

59、83;·····························3.3.1 婦科···················&

60、#183;············3.3.2 產科····································

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65、;···························3.4 兒科 ·····················

66、3;··········3.4.1 新生兒科 ································3.4.2 兒科其他 ····

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72、3.5 眼科 ································3.6 耳鼻咽喉科 ···············&

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76、#183;···505313.7 口腔科 ································3.8 皮膚科 ··········

77、3;·····················3.9 精神科 ···························&#

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93、83;·················643.11 腫瘤科 ······························

94、3;·673.12醫學科································683.13 康復醫學科·············&

95、#183;··················3.14 麻醉科······························

96、;··3.15 重癥醫學科································3.16 疼痛科·············

97、;···················3.17 中醫科·····························

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102、3;···························784.1 藥學 ·····················&

103、#183;··········4.2 檢驗 ································4.3 病理 ·····

104、;···························4.4 醫學影像 ·····················&#

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109、183;·····················976 疾病病種/手術及操作覆蓋 ·························

110、83;···············································1032三級綜合醫院醫療服務能

111、力指南（2016 年版）三級綜合醫院是跨區域提供醫療衛生服務，具有醫療、教學、科研、公共衛生服務等功能的醫療機構。其主要任務是提供專科（包括特殊專科）醫療服務，解決危急重癥和疑難復雜疾病，接受醫院轉診，對下級醫院進行業務技術指導和培訓；承擔培養各種高級醫療專業的教學任務和承擔省級以上科研項目；參與和指導一、預防工作。1 基本設置應具有與三級醫院相適應的基本設置，包括床位規模、診療科目、醫療設備以及結構合理的衛生技術，以滿足三級醫院服務功能、技術水平及管理要求。1.1 床位規模1.1.1 外科床位數占醫院實際開放床位數比例30%。1.1.2 重癥醫學科（含所有專業 ICU）的床位數占醫院實際開放

112、床位數比例 2%-8%。1.2 診療科目可以設置但不僅限于以下診療科目：1.2.1 一級診療科目應當設置以下一級診療科目并提供相對應的醫療服務：預防科、內科、外科、婦產科、兒科、眼科、耳鼻咽喉科、口腔科、皮膚科、精神科、科、腫瘤科、1醫學科、康復醫學科、麻醉科、重癥醫學科、醫學檢驗科、病理科、醫學影像科、中醫科。可設置以下一級診療科目并提供相對應的醫療服務：小兒外科。1.2.2診療科目1.2.2.1 內科應當提供與以下診療科目相對應的專科醫療服務：呼吸內科、消化內科、神經內科、心內科、血液內科、腎病學科、內科、免疫學科。可提供與以下診療科目相對應的專科醫療服務：老年病科。1.2.2.2 外科應

113、當提供與以下診療科目相對應的專科醫療服務：普通外科、骨科、神經外科、泌尿外科、胸外科。可提供與以下診療科目相對應的專科醫療服務：心臟大外科、整形外科、燒傷科。1.2.2.3 婦產科應當提供與以下診療科目相對應的專科醫療服務：婦科、產科。可提供與以下診療科目相對應的專科醫療服務：計劃科、生殖健康與不孕癥科、優生學科、婦科內專科。21.2.2.4 兒科應當提供與以下診療科目相對應的專科醫療服務：新生兒科。可提供與以下診療科目相對應的專科醫療服務：小兒傳染病科、小兒消化科、小兒呼吸科、小兒心臟病科、小兒腎病科、小兒血液科、小兒神經病科、小兒內科、小兒遺傳科、小兒免疫科。1.2.2.5 精神科應當提供

114、與以下診療科目相對應的專科醫療服務：心身醫學科、心理治療科。可提供與以下診療科目相對應的專科醫療服務：老年精神科、精神康復科、兒童少年精神科、睡眠醫學科。1.2.2.6 醫學檢驗科應當提供與以下診療科目相對應的專業醫療服務：臨床體液檢驗、血液檢驗，臨床微生物學檢驗，臨床生化檢驗，臨床免疫、血清學檢驗，臨床細胞遺傳學檢驗。1.2.2.7 醫學影像科應當提供與以下診療科目相對應的專業醫療服務：X 線診斷、計算機斷層掃描（CT）診斷、磁共振成像（MRI）診斷、核醫學診療、超聲診斷、心電診斷、腦電及腦血流圖診斷、神經肌肉電圖診斷、介入放射診療、放射治療。1.3 醫療設備3必備醫療設備：與三級醫院服務功

115、能相匹配，能夠滿足臨床診治疑難重癥及開展醫療技術等服務需求。包括全自動生化分析儀、全自動化學發光免疫分析儀、彩超（二維彩超、三維彩超）、計算機斷層掃描（CT）（64 排及以上）、數字 X線（DR、CR）、磁共振成像（MRI）（1.5T 及以上）、數字減影造影（DSA）、數字胃腸機、乳腺 X 光機、胃腸 X 光機、移動式臂數字減影造影機等。1.4 人力（1）衛生技術與實際開放床位之比1.2:1（2）醫師與實際開放床位之比0.3:1（3）護理崗位與實際開放床位之比0.4:1（4）護理崗位與醫師之比1.6 : 1（5）臨床藥師5 名1.5 信息化建設1.5.1 信息系統建設電子系統符合電子基（試行）

116、、電子系統功能規范（試行）和中醫電子基有關要求。電子數據標準符合衛生計生委頒布發的相關標準要求。落實并執行保護建設，符合信息安全保護相關標準和要求，建立安全防護、系統互聯共享和個人隱私保護等制度。1.5.2醫療41.5.2.1 要設立專門部門對醫療業務和進行管理。加強醫療建設與管理，逐步實現可追溯、可、可統計的全過程管理。按照衛生計生部門有關要求，開放衛生信息統計數據接口，定期上報統計數據信息。1.5.2.2醫療平臺應當符合衛生計生委醫療相關標準和服務項目管理規范。醫學影像學相關業務應當配置醫用顯示器系統，能夠無損還原數字影像、病理掃描圖片等影像資料。1.5.2.3 音交互系統應當能支持多點同

117、時交互，不少于 30 點同時交互業務，清晰度不小于 1080P。有合理穩定的通訊保障措施。1.5.2.4醫療平臺應當建立信息互通共享機制，能夠支持雙向轉診和醫保支付的信息共享，支持醫療和培訓等相關業務運行，支持醫務開展會診診斷、監護等業務，支持跨學科、跨機構之間協同業務，滿足對疑難重癥病例的診療需求，并對各項業務進行全過程管理和。1.5.2.5 建立醫療數據庫，對醫療產生的數據進行和歸檔，并參照醫療機構管理規定實行病歷數據管理。采用必要，建立數據使用或開放共享的審批和管理機制、知識產權保護措施，制定切實有效的數據安全和患者隱私保護管理措施。52 運行績效運行績效反映醫療機構的工作運行能力與管理

118、水平，主要衡量指標包括工作負荷、工作效率、服務質量等方面。2.1 工作負荷年外科手術人次占外科出院人次比例65%。2.2 工作效率年床位使用率 93%-97%。2.3 服務質量（1）年醫院發生率10.0% ，漏報率10.0%。（2）年重癥醫學科（含所有專業 ICU）病死率。（3）年入院診斷與出院診斷符合率。（4）年手術前診斷與術后病理診斷符合率。(1)為范圍參考指標，(2)(3)(4)可通過電子系統導出指標進算。入院診斷與出院診斷符合率以入院診斷和出院診斷 ICD-10 編碼前 4 位比較計算。3 臨床專科醫療服務能力臨床專科醫療服務能力是三級綜合醫院競爭力，反映醫院的整體能力水平和學術地位。

119、本指南將臨床專科醫療服務能力標準分為基本標準和推薦標準。基本標準為臨床專科應當達到的基礎能力要求；推薦標準是鼓勵臨床專科提升能力后達到的要求，是臨床專科建設發展的方向指引。說明：疑難重癥和中涉及到的檢驗、影像、病6理及藥學服務等內容，應當由醫院統一設置的醫技科室統一提供。可以提供的疑難重癥和服務能力，是指包含但不限于列表中的疑難重癥及能力，提供的數量越多，表明服務能力越高。關鍵醫療技術如涉及限制臨床應用的醫療技術(2015版)在列醫療技術的，應當按照相關醫療技術臨床應用管理規范，經自我對照評估符合所規定條件的，由核發其醫療機構執業證的衛生計生行政部門在該機構醫療機構執業證副本備注欄注明，并向省

120、級衛生計生行政部門備案，方可開展。3.1 內科3.1.1 心內科3.1.1.1 疑難重癥診治（1）基本標準。應當具備診治以下疑難重癥的醫療服務能力：疾病名稱診斷主要治療方法查體、CT、彩色多普勒超聲心動圖心源性休克、主動脈內球囊反搏術置入術查體、化驗、彩色多普勒超聲心動圖難治性心力衰竭、心臟再同步化治療、埋藏式體內自動復律除顫器置入術、經皮導管射頻消融術室速室顫心電圖、彩色多普勒超聲心動圖心電圖、彩色多普勒超聲心動圖、動態心電圖心房纖顫、經皮導管射頻消融術傳導阻滯查體、心電圖、起搏器植入陣發性室性、室上性心動過速查體、心電圖、射頻消融術急性心肌梗死心電圖、化驗、冠脈造影靜脈溶栓、經皮冠狀動脈介

121、入治療7心臟瓣膜病查色多普勒超聲心動圖、介入、外科手術性心內膜炎查色多普勒超聲心動圖、外科手術擴張型心肌病查色多普勒超聲心動圖、心臟再同步化治療限制性心肌病查色多普勒超聲心動圖、埋藏式體內自動復律除顫器置入術、化學消融肥厚型心肌病查色多普勒超聲心動圖（2）推薦標準。在應當診治疑難重癥疾病的基礎上，可以具有診治以下疾病的服務能力，如：疾病名稱診斷主要治療方法先天性心臟病查色多普勒超聲心動圖介入封堵、外科手術急性高血壓查體、化驗、動態血壓監測頑固性高血壓和繼發性高血壓查體、影像、化驗3.1.1.2 關鍵醫療技術（1）基本標準。應當具備開展以下的服務能力：主要應用范圍緊急臨時起搏器安裝臨時起搏或選擇

122、性臨時起搏心臟再同步化治療難治性心力衰竭心源性休克主動脈內球囊反搏術泵衰竭經皮導管射頻消融術室上性室性心動過速冠脈血流儲備測定冠心病經皮冠狀動脈介入治療技術冠心病超聲引導下心包穿刺術心包積液（2）推薦標準。在應當開展的基礎上，可以具有開展以下的服務能力，如：主要應用范圍埋藏式體內自動復律除顫器置入術室性心動過速室顫空間射頻消融術心房纖顫起搏器置入術竇房結綜合征8傳導阻滯頑固性高血壓經皮腎動脈交感神經消融術性高血壓冠狀動脈光學相干斷層成像冠心病先心病介入封堵術先心病3.1.2 呼吸內科3.1.2.1 疑難重癥診治（1）基本標準。應當具備診治以下疑難重癥的醫療服務能力：疾病名稱診斷主要治療方法肺

123、CT、痰液支肺泡液機械通氣、抗功能支持治療、多系統重癥性支抽吸隱源性機化性肺 CT、肺活檢病理激素肺 CT、臨床癥狀肺間質化激素、抗化、氧療炎性肺部病變肺 CT、組織病理激素、其他免疫抑制劑機械通氣、大劑量激素、丙球等治療、血漿置換彌漫性肺泡肺 CT、支肺泡呼吸衰竭血氣分析機械通氣（2）推薦標準。在應當診治疑難重癥疾病的基礎上，可以具有診治以下疾病的服務能力，如：疾病名稱診斷主要治療方法肺曲霉菌病肺功能、肺 CT激素、抗曲霉菌治療支良性狹窄鏡、胸部CT 支三維重建球囊擴張、冷凍運動心肺功能運動氣體交換、右心導管內皮素受體拮抗劑等療治肺動脈高壓溶栓的高危肺栓塞肺動脈造影導管下碎栓3.1.2.2

124、關鍵醫療技術（1）基本標準。應當具備開展以下的服務能力：主要應用范圍9主要應用范圍診斷支腫瘤結核支鏡檢查技術間質性肺疾病結節病呼吸衰竭無創機械通氣術急性呼吸窘迫綜合征早期睡眠呼吸暫停低通氣綜合征呼吸病因鑒別肺功能檢測術前心肺功能評估呼吸衰竭有創機械通氣術急性呼吸窘迫綜合征經皮穿刺肺活檢技術肺內病變睡眠監測睡眠性疾病氣道異物良性肉芽腫支鏡介入治療技術（2）推薦標準。在應當開展的基礎上，可以具有開展以下的服務能力，如：主要應用范圍肺功能檢測康復運動處方結核支腫瘤支鏡介入治療技術瘢痕狹窄淀粉樣變肺動脈高壓右心導管檢查術肺栓塞3.1.3 消化內科3.1.3.1 疑難重癥診治（1）基本標準。應當具備診治

125、以下疑難重癥的醫療服務能力：10疾病名稱診斷主要治療方法空腔臟器急性穿孔腹部立位平片內科保守、外科治療胃泌素瘤胰腺影像、血清胃泌素測定抑酸、手術治療腸結核消化內鏡、病理、TB-SPOT抗結核、營養支持影像學、病理、TB-SPOT、腹腔鏡結核性腹膜炎抗結核、營養支持或探查、體液檢查小腸疾病膠囊內鏡、小腸鏡病因治療潰瘍性結腸炎結腸鏡、病理糖皮質激素、免疫抑制劑缺血性腸病消化內鏡、影像、介入抗凝、溶栓、介入、手術焦慮抑郁評分表、胃排空試驗、胃動力檢測功能性胃腸病中藥肝病自身抗體、肝穿、肝病自身抗體、影像糖皮質激素、免疫抑制劑、人工肝、肝移植自身免疫肝炎抗核抗體、CT、MRI 胰膽管造影、肝穿性膽汁性

126、肝硬化激素、熊去氧膽酸病因治療、內鏡治療、介入治療、外科治療非硬化性門脈高壓癥影像、檢查、骨穿病因、保肝、并發癥治療、人工肝、肝移植肝衰竭檢查、影像學檢查腹部 CT、脂肪酶）檢查（血淀粉酶、補液、抗炎、胰酶抑制劑、血液凈化、營養支持急性胰腺炎慢性胰腺炎病史、胰腺 CT、內鏡超聲檢查內鏡治療、胰酶替代不明消化道膠囊內鏡、小腸鏡、介入、影像病因治療腹水待查腹穿及腹水相關檢查、腹部 CT病治療（2）推薦標準。在應當診治疑難重癥疾病的基礎上，可以具有診治以下疾病的服務能力，如：疾病名稱診斷主要治療方法內鏡流病的胃食管反食管 24 小時 PH 檢測、食管測壓抑酸、促動力、精神用藥胃黏膜相關淋巴組織淋巴瘤

127、胃鏡、病理根除幽門螺桿菌、手術切除嗜酸細胞性胃腸炎胃鏡、腸鏡、活檢激素肝活檢普魯士藍染色、血清鐵、血清轉鐵蛋白血色病放血療法胃腸道淋巴瘤影像學、消化內鏡、病理、TB-SPOT化療、營養支持治療胃腸道淀粉樣變影像學、消化內鏡、病理、TB-SPOT治療、病因治療克羅恩病胃鏡、結腸鏡、病理免疫抑制劑、腸內外營養肝臟增強CT肝小靜脈閉塞病抗凝、支持對癥治療11疾病名稱診斷主要治療方法MRI肝性脊髓病降血氨、對癥治療自身免疫性胰腺炎胰腺增強CT激素胰早期診斷影像學、消化內鏡、病理保守、外科治療3.1.3.2 關鍵醫療技術（1）基本標準。應當具備開展以下的服務能力：主要應用范圍碳 13 呼氣試驗胃相關疾病

128、鋇膠條標記法測胃腸動力胃腸動力性疾病經內鏡黏膜下腫瘤剝離術消化道早期腫瘤診斷和治療消化道腫瘤分期內鏡超聲檢查消化道粘膜下腫瘤膽胰疾病內鏡超聲引導下細針穿刺術消化道及周圍的活檢炎癥性腸病腸內營養急性胰腺炎食管靜脈曲張內鏡治療肝硬化肝動脈栓塞術肝臟腫瘤內鏡下消化道異物取出術消化道異物治療內鏡下消化道診療術消化道的診療（2）推薦標準。在應當開展的基礎上，可以具有開展以下的服務能力，如：主要應用范圍消化道支架置入術和消化道狹窄擴張術消化道狹窄治療胃食管返流病24 小時食管 PH 測定胃腸動力性疾病鋇膠條標記法測胃腸動力胃腸動力性疾病人工肝肝衰竭膽胰疾病經內鏡逆行性胰膽管造影術膽道疾病12主要應用范圍膽胰梗阻及炎癥膽道狹窄膽總管及占位急性高脂血癥血液凈化治療重癥急性胰腺炎內鏡超聲引導下細針穿刺術消化道及周圍組織的活檢和治療3.1.4 神經內科3.1.4.1 疑難重癥診治（1）基本標準。應當