AutoevaluaciónOtorgamientoIPShospitalariaParte1

7/24/2019 AutoevaluacinOtorgamientoIPShospitalariaParte1

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INFORME DE AUTOEVALUACINESTNDARES IPS HOSPITALARIAS

PARTE 1. PERFIL DE LA INSTITUCINVISITA DE OTORGAMIENTO

CIUDAD: __________________________

FECHA: ___________________________

DIRECTOR O GERENTE (O DESIGNADO): ___________________________________________________________________

INSTITUCIN: __________________________________________________________________________________________

DILIGENCIADA POR: ____________________________________________________________________________________

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INDICE

INTRODUCCIN ....................... .......................... ......................... .......................... ......................... .......................... ......................... ......................... ........... .. 6

PERFIL DE LA INSTITUCION .......................... ......................... .......................... ......................... .......................... ......................... ......................... ........... .. 6

REQUISITOS PARA DILIGENCIAMIENTO Y PRESENTACIN DEL PERFIL ......................... .......................... ......................... .......................... .....7

SECCION A. INFORMACIN GENERAL DE LA INSTITUCIN ........................ .......................... ......................... ......................... ....................... ....... 8

SECCION B. DESCRIPCIN DE LOS SERVICIOS ........................ .......................... ......................... ......................... .......................... ....................... .....26

1. HOSPITALIZACIN GENERAL ...................... .......................... ......................... ......................... .......................... ......................... .................... ........ .26

2. MATERNO INFANTIL ........................ .......................... ......................... .......................... ......................... ......................... .......................... ............... ....31

3. URGENCIAS ....................... .......................... ......................... .......................... ......................... ......................... .......................... ......................... ............37

. CIRUGIA ....................... ......................... ......................... .......................... ......................... .......................... ......................... ......................... .............. .....2

!. CUIDADOS INTENSIVOS Y CUIDADO INTERMEDIO ......................... ......................... ......................... .......................... ................. ........ ........ ... 8

6. CONSULTA E"TERNA ......................... .......................... ......................... ......................... .......................... ......................... .......................... .............. ...!6

7. LABORATORIO CL#NICO$ BANCO DE SANGRE Y PATOLOG#A ....................... ......................... .......................... ......................... ............. .......62

8. IM%GENOLOG#A$ PROCEDIMIENTOS DIAGNSTICOS Y TERAP&UTICOS ................................................................................................66ES-P-AS-01-F-005 Pgina ! "# A$%&'a&: 01-0-0*

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'. REHABILITACIN ...................... .......................... ......................... ......................... .......................... ......................... .......................... ................. ........ .6'

1(. SEDES INTEGRADAS ........................ .......................... ......................... ......................... .......................... ......................... ....................... ........ ........ .... 71

SECCIN C. INFRAESTRUCTURA Y GESTION DE TECNOLOG#A BIOM&DICA ......................... .......................... ......................... ........ ........ .... 7!

SECCIN D. DISTRIBUCIN Y TIPO DE CONTRATACIN DE TALENTO HUMANO ........................ .......................... ..................... ........ ........ .. 81

SECCION E. GESTION DE LA INFORMACIN ...................... ......................... .......................... ......................... .......................... ..................... ........ .....8

SECCIN F. INDICADORES DE GESTIN ......................... .......................... ......................... ......................... .......................... ......................... ...............8!

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RELACION DE TABLAS

Ta'/a N& 1 Di,%i'23i4n ! /a P&'/a3i4n A!niaTa'/a N& C&n!ni&, ! D&3!n3ia S!%i3i&Ta'/a N& . E,2i&, ! In!,iga3i4n !n Sa/2Ta'/a N& # A32!%&, Sini3a/!,

Ta'/a N& 5 E,a6,i3a, S!%i3i& H&,$ia/i7a3i4n T&a/Ta'/a N& E,a6,i3a, S!%i3i& H&,$ia/i7a3i4n A2/&,Ta'/a N& P%i8!%a, 10 Ca2,a, ! 9&%'i/ia H&,$ia/a%iaTa'/a N& * P%i8!%a, 10 Ca2,a, ! Eg%!,&, H&,$ia/a%i&,Ta'/a N& " P%i8!%a, 10 Ca2,a, ! 9&%a/ia H&,$ia/a%ia

Ta'/a N& 10 E,a6,i3a, S!%i3i& H&,$ia/i7a3i4n ! P!ia%6aTa'/a N& 11 E,a6,i3a, S!%i3i& H&,$ia/i7a3i4n 9a!%n& P!%inaa/Ta'/a N& 1 P%i8!%a, 10 Ca2,a, ! C&n,2/a S!%i3i& O',!%i3iaTa'/a N& 1. P%i8!%a, 10 Ca2,a, ! Eg%!,&, S!%i3i& O',!%i3iaTa'/a N& 1# P%i8!%a, 10 Ca2,a, ! 9&%a/ia S!%i3i& O',!%i3ia

Ta'/a N& 15 E,a6,i3a, S!%i3i& U%g!n3ia,Ta'/a N& 1 P%i8!%a, 10 Ca2,a, ! C&n,2/a S!%i3i& U%g!n3ia,Ta'/a N& 1 P%i8!%a, 10 Ca2,a, ! 9&%a/ia S!%i3i& U%g!n3ia,

Ta'/a N& 1* E,a6,i3a, S!%i3i& Ci%2g6a

Ta'/a N& 1" P%i8!%&, 10 Diagn4,i3&, ! Ci%2g6aTa'/a N& 0 P%i8!%&, 10 Diagn4,i3&, ! Ci%2g6a A8'2/a&%iaTa'/a N& 1 P%i8!%a, 10 Ca2,a, ! 9&%a/ia !n Ci%2g6a

Ta'/a N& E,a6,i3a, S!%i3i& ! C2ia&, In!n,i&, C2ia& In!%8!i&Ta'/a N& . P%i8!%a, 10 Ca2,a, ! 9&%'i/ia C2ia&, In!n,i&,Ta'/a N& # P%i8!%a, 10 Ca2,a, ! 9&%'i/ia C2ia&, In!%8!i&,Ta'/a N& 5 P%i8!%a, 10 Ca2,a, ! 9&%a/ia !n C2ia&, C%6i3&,

Ta'/a N& E,a6,i3a, S!%i3i& ! C&n,2/a E;!%naTa'/a N& P%i8!%a, 10 Ca2,a, ! 9&%'i/ia C&n,2/a E;!%naES-P-AS-01-F-005 Pgina # ! "# A$%&'a&: 01-0-0*

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Ta'/a N& * 9&%'i/ia Sa/2 O%a/

Ta'/a N& " E,a6,i3a, S!%i3i& La'&%a&%i& C/6ni3&


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INTRODUCCIN

La !3i,i4n ! a3%!ia%,! $&% $a%! ! 2na in,i23i4n ! ,a/2 in&/23%a 2n an/i,i, in!%n& ! ,2, @&%a/!7a, = &$&%2nia!, !8!&%a8i!n& !/ 3&8$%&8i,& 3&n !/ 8!&%a8i!n& 3&nin2& ! /a 3a/ia ! /a a!n3i4n !n ,a/2 !/ 3&n&3i8i!n& !/ $%&3!,& !a3%!ia3i4n = /a $%&=!33i4n B2! >,a %!$%!,!na !n !/ 8a%3& na3i&na/ ! in!%na3i&na/

Un& ! /&, %!B2i,i&, ! !n%aa $a%a a33!!% a /a a3%!ia3i4n !, /a $%!,!na3i4n !/ C!%i@i3a& ! C28$/i8i!n& ig!n! ! /&,!,na%!, = 3%i!%i&, ! Ha'i/ia3i4n !;$!i& $&% /a Di%!33i4n T!%%i&%ia/ ! Sa/2 3&%%!,$&ni!n! !/ 32a/ i8$/i3a /a 3!%i@i3a3i4n !/328$/i8i!n& ! /&, %!B2i,i&, >3ni3& 3i!n6@i3&, a8ini,%ai&, = @inan3i!%&, = !/ 8an!ni8i!n& ! ,2 328$/i8i!n& 2%an! !/ $!%6&&! ig!n3ia !,a'/!3i& $&% /a a2&%ia 3&8$!!n! Pa%a !/ $%&3!,& ! a3%!ia3i4n !, @2na8!na/ B2! /a &%gani7a3i4n !,a'/!73a8!3ani,8&, 3&nin2&, = ,i,!8i3&, B2! !a/!n !/ 328$/i8i!n& ! !,&, %!B2i,i&, ! !n%aa

A!8, ! %!B2i,i&, ! !n%aa /a a3%!ia3i4n !n ,a/2 i!n! 3&8& !!, @2na8!na/!, /a ,!g2%ia !/ $a3i!n! /a ?28ani7a3i4n ! /aa!n3i4n /a g!,i4n ! /a !3n&/&g6a = !/ !n@&B2! ! %i!,g& /&, 32a/!, ,! !,a%%&//an 3&n 2n !n@&B2! ! A!n3i4n 3!n%aa !n !/ U,2a%i& =,2 Fa8i/ia = !/ 9!&%a8i!n& 3&nin2& 3&n !/ @in ! g!n!%a% %an,@&%8a3i4n 32/2%a/ = !/ !!%3i3i& ! /a R!,$&n,a'i/ia S&3ia/ $&% /& an&!/ 328$/i8i!n& ! /&, !,na%!, !n !/ 8a%3& !/ 8&!/& !a/2ai& ! /a a3%!ia3i4n @a3i/ia% ,2 !,a%%&//&

E,! @&%8a& In@&%8! ! A2&!a/2a3i4n Pa%! 1 P!%@i/ ! /a In,i23i4n $%!!n! &'!n!% in@&%8a3i4n g!n!%a/ ! /a in,i23i4n ,&'%!a/g2n&, ! /&, %!B2i,i&, ! $2!%a ! !n%aa !/ !,a%%&//& ! /&, !!, ! a3%!ia3i4n = !/ !n@&B2! %!,$!3& a /a A3%!ia3i4n !n Sa/2 !n/a &%gani7a3i4n

PERFIL DE LA INSTITUCION

E/ $%!,!n! in,%28!n& 3&%%!,$&n! a /a $%i8!%a $a%! ! /a a2&!a/2a3i4n $%!!n! &%i!na% a /a, in,i23i&n!, !n ,2 $%&3!,& in!%n& !a2&!a/2a3i4n &@%!3!% 2na g26a $%3i3a %!23i% /a ?!!%&g!n!ia !n /a $%!,!na3i4n ! /a in@&%8a3i4n = @a3i/ia% a /&, !a/2a&%!, /aa%!a ! an/i,i, = 3&8$a%a3i4n ! /a in@&%8a3i4n an!, ! /a !a/2a3i4n !;!%na P&% ,2 3a%3!% ! g26a !'! !;i,i% 3/a%ia !n B2!ICONTEC $2!! %!B2!%i% in@&%8a3i4n 3&8$/!8!na%ia a /a !;$%!,a8!n! 3&n!8$/aa !n >,!

E/ $!%@i/ !n ,2 3&n!ni& a'&%a !8a, g!n!%a/!, ! /a in,i23i4n !,! ,2 &%gani7a3i4n @2n3i&na/ &%i!na3i4n !,%a>gi3a $&'/a3i4n a /a32a/ $%!,a ,2, ,!%i3i&, !,a%%&//& ! /&, !!, ! a3%!ia3i4n ?a,a /a 3&n@&%8a3i4n ! /&, ,!%i3i&, a,i,!n3ia/!, !ni!n& !n 32!na ,2in@%a!,%232%a ,2 !3n&/&g6a ! in@&%8a3i4n ,2, 3&8$&n!n!, 3/6ni3&-a8ini,%ai&, in3/2i&, /&, %!,2/a&, ! ,2, ini3a&%!, !g!,i4n ,2 a/!n& ?28an& = g!,i4n !3n&/4gi3a B2! ,&$&%a /&, $%&3!,&, &%gani7a3i&na/!,

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REQUISITOS PARA DILIGENCIAMIENTO Y PRESENTACIN DEL PERFIL

D!'! !,3%i'i%,! !n /!%a ! 1 $2n&, a8a& 3a%a a 2n !,$a3i& !n 2na 3&n@ig2%a3i4n !/ "0 $&% !/ an!%,& = %!!%,& ! /a$gina

En /a in@&%8a3i4n ,&/i3iaa &n! ,! !,$!36@i3a A& a32a/ (3&%! 8!, an!%i&%) ,! %!@i!%! a /a in@&%8a3i4n 3&n,&/iaa a/ /i8&6a !/ /i8& 8!, an!%i&% a /a $%!,!na3i4n ! !,! in@&%8!

En !/ 32!%$& !/ In@&%8! ! a2&!a/2a3i4n Pa%! 1 !n3&n%a% !'a& ! 3aa ,!33i4n !n /a B2! ,! ,&/i3ia in@&%8a3i4n 2na R//,!g2ia ! N8!%& ! $gina, !,& ini3a R R!,$2!,a $a%a B2! %!a3! a $a%i% ! /a 8i,8a /a %!,$2!,a ! a32!%& 3&n !/

/68i! ! $gina, !;$/63i& N& ,! !'! !,3%i'i% !n%& ! /&, %!32a%&, !n /&, B2! ,! !n32!n%an /&, !n2n3ia&, Pa%a !/ i/ig!n3ia8i!n& ! in@&%8a3i4n !n /a, a'/a, %!B2!%ia, 2i/i3! /a 3&n!n3i4n ND: N& Di,$&ni'/! !n 3a,& ! n& 3&na% 3&n

/a in@&%8a3i4n ,&/i3iaa = NA ,i n& a$/i3a /a ,&/i3i2 En /a, a'/a, 3&%%!,$&ni!n!, a/ n28!%a/ ! E,a6,i3a, !n /a, 3&/28na, %!,$!3ia, !'! %!gi,%a% !/ n28!%a&% !/

!n&8ina&% = !/ %!,2/a& En /a, Ta'/a, ! !,a6,i3a, in,!%! /a, @i/a, n!3!,a%ia, B2! %!B2i!%a $a%a %!gi,%a% in@&%8a3i4n ! /&, ini3a&%!, ,!gn ni!/ !

!,ag%!ga3i4n ! /a S!33i4n F 2 &%a in@&%8a3i4n ,!gn a$/iB2! En /a, a'/a, ! 8&%'i/ia = 8&%a/ia /a in@&%8a3i4n ,&/i3iaa ,! %!@i!%! a /a ,28a&%ia ! /&, # a&, 3&8$/!&, (!n!%& a

i3i!8'%!) an!, ! /a $%!,!na3i4n n& in3/2=! /a ig!n3ia !n /a 32a/ ,! ?a3! /a $%!,!na3i4n !/ in@&%8! E,! @&%8a& !'! $%!,!na%,! $&% 2$/i3a& !n 8!i& @6,i3& = !n 8!i& 8agn>i3& (9i3%&,&@ O@@i3! &% !;3/2,ia8!n!)

ICONTEC ga%ani7a% !/ $%in3i$i& ! 3&n@i!n3ia/ia 3&8& /& !,a'/!3! /a n&%8a ,&'%! !/ Si,!8a O'/iga&%i& ! Ga%an6a !

Ca/ia $a%a !/ 3&8$&n!n! ! A3%!ia3i4n !n Sa/2

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SECCION A. INFORMACIN GENERAL DE LA INSTITUCIN

1. Plataf!"a #$t!at%&'(aC&8$/!! /a ,ig2i!n! in@&%8a3i4n

11 9i,i4n

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-. M#l # at#,(',C&8$/!! /a ,ig2i!n! in@&%8a3i4n

1 En@&B2!

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In!g%a/ia ! /a $%!,a3i4n !/ ,!%i3i&

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0. E$t!(t!a !&a,'2a(',al

An!;! !/ !,B2!8a ! /a !,%232%a ! /a !nia !n 2na $gina

3. !&a,$ # '!#((',

#1 D!,3%i'a /a @!3?a ! 3&n@&%8a3i4n = /&g%&, ! /a J2na Di%!3ia & J2na ! A33i&ni,a, & J2na ! S&3i&, 4 !/ (/&,) 8;i8&(,)4%gan&(,) ! i%!33i4n ! /a in,i23i4n ,!gn a$/iB2!

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4. C,f!"a(', # la alta '!#((',

C&8$/!! /a ,ig2i!n! in@&%8a3i4n:51 In!g%an!, ! J2na i%!3ia

Ca%g& N&8'%! P%&@!,i4n F!3?a ! n&8'%a8i!n& & !!/!33i4n !n !,! 3a%g&

5 In!g%an!, !/ Ni!/ Di%!3i&Ca%g& N&8'%! P%&@!,i4n F!3?a ! n&8'%a8i!n& & !

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5. P6la(', at#,'aC&8$/!! /a ,ig2i!n! in@&%8a3i4n:

Ta'/a N& 1 Di,%i'23i4n ! /a P&'/a3i4n A!niaA@i/ia3i4n A& # an!%i&% a /a

$%!,!na3i4n !/in@&%8! _____

A& . an!%i&% a /a$%!,!na3i4n !/in@&%8! ____

A& an!%i&% a /a$%!,!na3i4n !/in@&%8! ____

A& 1 an!%i&% a /a$%!,!na3i4n !/in@&%8! ____

A& A32a/ P%!,!na3i4n!/ in@&%8! ______C&%! 8!, an!%i&%:

N8!%& N8!%& N8!%& N8!%& N8!%& R>gi8!n

C&n%i'2i&R>gi8!n

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P%&@!,i&na/!,+in32/a&,

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1 Fa3&%!, !;!%n&, B2! ?an i8$a3a& /a &%gani7a3i4n

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9. D#$a!!ll # l$ #:#$ # a(!#'ta(',R!a/i3! 2na !,3%i$3i4n 3&n3%!a a3!%3a !/ !,a%%&//& ! /a in,i23i4n !n: H28ani7a3i4n ! /a A!n3i4n S!g2%ia ! Pa3i!n! G!,i4n! T!3n&/&g6a = En@&B2! = G!,i4n !/ Ri!,g& a,6 3&8& /&, 3a8'i&, B2! ?a g!n!%a& !/ %a'a& !n A3%!ia3i4n !n Sa/2 !n /aT%an,@&%8a3i4n C2/2%a/ = !n /a R!,$&n,a'i/ia S&3ia/9.1. H"a,'2a(', # la at#,(',

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9.-. S#&!'a #l *a('#,t#*1 P&/6i3a ! ,!g2%ia !/ $a3i!n!

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* In233i4n = %! in233i4n !/ $!%,&na/ !n ,!g2%ia !/ $a3i!n!

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*. A33i&n!, ! $a%i3i$a3i4n !/ $a3i!n! !n 8a!%ia ! ,!g2%ia

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*5 9!a, in!%na3i&na/!, ! ,!g2%ia

*51 I!ni@i3a3i4n 3&%%!3a ! $a3i!n!,

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* P%!!n3i4n = 3&n%&/ ! in@!33i&n!,

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16/94



* R!,2/a&, ! a2i&%6a ! ?i,&%ia, 3/6ni3a, ,&'%! 3&8$/!i2 $!%in!n3ia %!gi,%& = an/i,i, ! %!,2/a&, ! !;8!n!,iagn4,i3&, = ,28ini,%& ! in@&%8a3i4n a/ $a3i!n! = ,2 @a8i/iaR//) *+&',a

** G!,i4n ! 8!i3a8!n&, = @a%8a3&igi/an3ia

**1 P!%@i/ @a%8a3&!%a$>2i3&

R//; *+&',a

** Si,!8a ! 2ni&,i,

R//; *+&',a

**. R!3&n3i/ia3i4n 8!i3a8!n&,a

R//; *+&',a

**# A/!%a, ,&'%! a/!%gia, a 8!i3a8!n&, = 8!i3a8!n&, 3&n !8$aB2! = n&8'%!, $a%!3i&,R//; *+&',a

**5 I!ni@i3a3i4n in!%!n3i4n = ,!g2i8i!n& a @a3&%!, ! %i!,g& a,&3ia&, a/ 3i3/& ! g!,i4n !/ 8!i3a8!n&

R//; *+&',a

** Di,!& = a$/i3a3i4n ! /i,a, ! 3?!B2!&ES-P-AS-01-F-005 Pgina 1 ! "# A$%&'a&: 01-0-0*

+!%,i&n 0


17/94



R//

; *+&',a

*" H!8&igi/an3ia ,i a$/i3a

R//1 *+&',a

*10 G26a, ! $%3i3a 3/6ni3a 8>i3a

*101 E/a'&%a3i4n = 3&n,!n,&

R//) *+&',a

*10 A32a/i7a3i4n

R//) *+&',a

*10. Ea/2a3i4n ! a?!%!n3ia

R//) *+&',a

*11 E!n&, a!%,&, 3!nin!/a,

*111 Ti$&, ! !!n&, a!%,&, 3!nin!/a, 3%6i3&, $%!,!na&, !n !/ /i8& a& = @%!32!n3ia

R//1 *+&',a

*1 P%3i3a, ,!g2%a, !,a%%&//aa, 2%an! !/ $%&3!,& ! $%!$a%a3i4n $a%a /a a3%!ia3i4n (,&/& !nn3i!/a,)

R//

ES-P-AS-01-F-005 Pgina 1 ! "# A$%&'a&: 01-0-0*

+!%,i&n 0


18/94



1 *+&',a

9.0. G#$t', # t#(,l&


19/94



R//

) *+&',a*5 I8$/!8!na3i4n

R//) *+&',a

*5. Ca8'i&, g!n!%a&, $&% !/ $%&3!,& ! A3%!ia3i4n !n Sa/2

R//) *+&',a

*5# R!,2/a&,

R//) *+&',a

9.5.R#$*,$a6'l'a $('al*1 En@&B2!

R//) *+&',a

* I8$/!8!na3i4n

R//) *+&',a

*. Ca8'i&, g!n!%a&, $&% !/ $%&3!,& ! A3%!ia3i4n !n Sa/2

R//

ES-P-AS-01-F-005 Pgina 1" ! "# A$%&'a&: 01-0-0*

+!%,i&n 0


20/94



) *+&',a

*# R!,2/a&,

R//) *+&',a

?. G#$t', # ("'t%$

D!,3%i'a /a @!3?a ! 3&n@&%8a3i4n $!%i&i3ia ! %!2ni&n!, = /&g%&, &'!ni&,:

"1 C&8i> ! Di%!33i4n & C&8i> ! G!%!n3ia & C&8i> ! G!,i4n !3 S! !ni!n! $&% !,&, 3&8i>, aB2!//&, B2! %!n!n a /&,/i!%!, & %!,$&n,a'/!, ! /&, $%&3!,&, ,!%i3i&, & %!a, ! /a in,i23i4n $a%a in!g%a% = $%&8&!% /a a!n3i4n 3&n !n@&B2!

3!n%a& !n !/ 2,2a%i& = 3&n,!32!n!8!n! /&g%a% /&, %!,2/a&, !,$!%a&,R//) *+&',a

" C&8i> ! >i3a ?&,$ia/a%ia

R//) *+&',a

". C&8i> ! >i3a ! /a in!,iga3i4n

R//) *+&',a

"# C&8i> ! ,!g2%ia !/ $a3i!n!

R//) *+&',a

"5 C&8i> ! in@!33i&n!, in%a?&,$ia/a%ia,

ES-P-AS-01-F-005 Pgina 0 ! "# A$%&'a&: 01-0-0*

+!%,i&n 0


21/94



R//) *+&',a

" C&8i> ! @a%8a3ia = !%a$>2i3a

R//) *+&',a

" C&8i> ! ?i,&%ia, 3/6ni3a,

R//) *+&',a

"* C&8i> ! @a%8a3&igi/an3ia

R//) *+&',a

"" C&8i> ! !3n&igi /an3ia

R//) *+&',a

"10 C&8i> ! %an,$/an!,

R//) *+&',a

"11 C&8i> ! igi/an3ia !$i!8i&/4gi3aR//) *+&',a

"1 C&8i> ! 8&%a/ia

R//) *+&',a

"1. C&8i> >3ni3& 3i!n6@i3&

ES-P-AS-01-F-005 Pgina 1 ! "# A$%&'a&: 01-0-0*

+!%,i&n 0


22/94



R//) *+&',a

"1# C&8i> $a%ia%i& = ! ,a/2 &32$a3i&na/

R//) *+&',a

"15 J2na, 8>i3a, $a%a an/i,i, ! 3a,&, & 3&8$/i3a3i&n!,

R//) *+&',a

1@. C,#,'$ (#,('a$#!'('

Ta'/a N& C&n!ni&, ! D&3!n3ia S!%i3i&101 R!gi,%! /a ,ig2i!n! in@&%8a3i4n ,i a$/i3a

N&8'%! ! /a in,i23i4n 3&n /a B2! ,! i!n! !/ 3&n!ni& P%&g%a8a a3a>8i3& F!3?a ! ini3i&

ES-P-AS-01-F-005 Pgina ! "# A$%&'a&: 01-0-0*

+!%,i&n 0


23/94



11. I,#$t'&a(', #, $al

111 R!/a3i&n! ,i a$/i3a /&, 3&n!ni&, a@i/ia3i&n!, 8!8'%!,6a, = %!/a3i&n!, 3&n &%a, in,i23i&n!, $a%a in!,iga3i&n!,ig!n!,

R//1 *+&',a

Ta'/a N& . E,2i&, ! In!,iga3i4n !n Sa/211 R!gi,%! ,i a$/i3a %!,$!3& a /&, !,2i&, ! in!,iga3i4n !n Sa/2 !n 32%,& = /&, !,a%%&//a&, !n /&, /i8&, # a&, /a

,ig2i!n! in@&%8a3i4n:T!8a ! in!,iga3i4n C&n!ni& 3&n: F!3?a ! ini3i& !

/a in!,iga3i4nF!3?a ! @ina/i7a3i4n

! /a in!,iga3i4nR!gi,%! /&, &, ()

$%in3i$a/!, %!,2/a&,A$/i3a3i4n

in,i23i&na/ !

/&, %!,2/a&,

ES-P-AS-01-F-005 Pgina . ! "# A$%&'a&: 01-0-0*

+!%,i&n 0


24/94



1-. P!#$ta(', # $#!'('$ #, "al'a # t#!(#!'2a(',

11 En28!%! /&, ,!%i3i&, !%3!%i7a&, !n 3a,& B2! a$/iB2!

R//) *+&',a

1 D!,3%i'a /a $a%i3i$a3i4n ! /&, ,!%i3i&, !%3!%i7a&, !n !/ $%&3!,& ! a3%!ia3i4n in,i23i&na/

R//) *+&',a

10. A(#!$ $','(al#$

Ta'/a N& # A32!%&, Sini3a/!,1.1 R!gi,%! /a ,ig2i!n! in@&%8a3i4n:

N&8'%! Sini3a& F!3?a, ! A32!%&, A32!%&, !,a'/!3i&, = 3&,&, ! /&, 8i,8&,

ES-P-AS-01-F-005 Pgina # ! "# A$%&'a&: 01-0-0*

+!%,i&n 0


25/94



13. E(a(', #, $al

1#1 D!,3%i'a /a, !,%a!gia, = a3iia!, &%i!naa, a/ $a3i!n! @a8i/ia 2,2a%i& = 3&82nia

R//) *+&',a

14. Sat'$fa((', > =#:a$

151 D!,3%i'a !/ (/&,) 8!3ani,8& $a%a /a %!3&/!33i4n an/i,i, g!,i4n = ,!g2i8i!n& a /a, B2!a,

R//1 *+&',a

15 E,$!3i@iB2! /a, 3in3& (5) $%in3i$a/!, 3a2,a, ! B2!a, $&% a& ! /&, /i8&, # a&,R//1 *+&',a

15. R!gi,%! !/ (/&,) 8!3ani,8& $a%a 8!i% /a ,ai,@a33i4n !/ 3/i!n! !;!%n& in3/2=!n& /a $!%i&i3ia ! /a 8!i3i4n = ,!gna$/iB2! !/ 8!3ani,8& !;i,!n! $a%a !@ini% !/ n8!%& ! 3/i!n!, !;!%n&, &'!& ! !a/2a3i4n ! ,ai,@a33i4n

R//1 *+&',a

15. R'#$&$ > f!tal#2a$ !&a,'2a(',al#$

11 R!gi,%! /&, 3in3& (5) $%in3i$a/!, %i!,g&, i!ni@i3a&, !n /a &%gani7a3i4nR//) *+&',a

1 R!gi,%! /a, 3in3& (5) $%in3i$a/!, @&%a/!7a, ! /a &%gani7a3i4n

R//) *+&',a

ES-P-AS-01-F-005 Pgina 5 ! "# A$%&'a&: 01-0-0*

+!%,i&n 0


26/94



17. R#t$ > "#:!a$ !&a,'2a(',al#$

11 R!&,: !,3%i'a ! @&%8a %!,28ia /&, 3in3& (5) $%in3i$a/!, %!&, B2! !n@%!na /a &%gani7a3i4n !n !/ 3&n!;& a32a/ /&, 3in3&(5) $%in3i$a/!, %!&, B2! !n@%!na% /a in,i23i4n !n !/ 8!ian& $/a7& = 3in3& (5) $%in3i$a/!, %!&, !n !/ /a%g& $/a7&

R//1 *+&',a

1 9!&%a,: !,3%i'a /a, i!7 (10) $%in3i$a/!, 8!&%a, &%gani7a3i&na/!, g!n!%aa, $&% !/ $%&3!,& ! a3%!ia3i4n !n ,a/2

R//) *+&',a

ES-P-AS-01-F-005 Pgina ! "# A$%&'a&: 01-0-0*

+!%,i&n 0


27/94



SECCION B. DESCRIPCIN DE LOS SERVICIOS

1. HOSPITALIACIN GENERAL

1.1.G#,#!al'a#$

D!,3%i'a /a in@&%8a3i4n B2! ,! ,&/i3ia a 3&nin2a3i4n:111 Di,%i'23i4n ! %!a, !/ ,!%i3i&

R//) *+&',a

11 P%&3!,& ! a8i,i4n = 6a, ! a33!,& !/ $a3i!n! a/ ,!%i3i& ! ?&,$ia/i7a3i4n

R//) *+&',a

11. 9!3ani,8&, $a%a a,igna% 3a8a,

R//) *+&',a

11# P%&3!,& ! %a,/a& !/ $a3i!n! !/ ,!%i3i& ! ?&,$ia/i7a3i4n a/ ,!%i3i& ! 3i%2g6a

R//) *+&',a

115 P%&3!,& ! %a,/a& !/ $a3i!n! !/ ,!%i3i& ! ?&,$ia/i7a3i4n a 32ia& in!n,i& = 32ia& in!%8!i&

R//) *+&',a

ES-P-AS-01-F-005 Pgina ! "# A$%&'a&: 01-0-0*

+!%,i&n 0


28/94


29/94



Ta'/a N& E,a6,i3a, S!%i3i& H&,$ia/i7a3i4n A2/&,SER+ICIO

HOSPITALIKACINADULTOS

A& # an!%i&% a /a$%!,!na3i4n !/in@&%8! _____

A& . an!%i&% a /a$%!,!na3i4n !/

in@&%8! ____

A& an!%i&% a /a$%!,!na3i4n !/

in@&%8! ____

A& 1 an!%i&% a /aP%!,!na3i4n !/

in@&%8! ____

A& A32a/ P%!,!na3i4n!/ in@&%8! ______C&%! 8!, an!%i&%:

N8!%& ! 3a8a, $a%a?&,$ia/i7a3i4n

N8!%& ! !g%!,&, a2/&,

P&%3!na! &32$a3i&na/(S!33i4n F N 1)P%&8!i& 6a !,an3ia

(S!33i4n F N )

Gi%& 3a8a(S!33i4n F N .)

1.0.M!6'l'a > M!tal'a

1.1 9&%'i/ia H&,$ia/a%ia: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a /a $%!,!na3i4n !/in@&%8! (a& # M a& . M a& M a& 1)

Ta'/a N& P%i8!%a, 10 Ca2,a, ! 9&%'i/ia H&,$ia/a%ia

P%i8!%a, 10 Ca2,a, ! 9&%'i/ia H&,$ia/a%ia 9a,32/in& F!8!nin& T&a/ 1

.

#

5

ES-P-AS-01-F-005 Pgina " ! "# A$%&'a&: 01-0-0*+!%,i&n 0


30/94



*

"

10

T&a/ O%a, Ca2,a,

T&a/ Ca2,a,

1. Eg%!,&, H&,$ia/a%i&,: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a /a $%!,!na3i4n !/in@&%8! (a& # M a& .M a& M a& 1)

Ta'/a N& * P%i8!%a, 10 Ca2,a, ! Eg%!,&, H&,$ia/a%ia

P%i8!%a, 10 Ca2,a, ! Eg%!,&, ?&,$ia/a%i&, 9a,32/in& F!8!nin& T&a/

1

.

#

5

*

"

10

T&a/ O%a, Ca2,a,

T&a/ Ca2,a,

ES-P-AS-01-F-005 Pgina .0 ! "# A$%&'a&: 01-0-0*+!%,i&n 0


31/94



1.. 9&%a/ia H&,$ia/a%ia: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a /a $%!,!na3i4n !/in@&%8! (a& # M a& .M a& M a& 1)

Ta'/a N& " P%i8!%a, 10 3a2,a, ! 9&%a/ia H&,$ia/a%ia

P%i8!%a, 10 Ca2,a, ! 9&%a/ia H&,$ia/a%ia 9a,32/in& F!8!nin& T&a/ 1

.

#

5

*

"

10

T&a/ O%a, Ca2,a,

T&a/ Ca2,a,



32/94



-. MATERNO INFANTIL

-.1.G#,#!al'a#$

D!,3%i'a /a in@&%8a3i4n B2! ,! ,&/i3ia a 3&nin2a3i4n:11 Di,%i'23i4n ! %!a, !/ ,!%i3i& 8a!%n& in@ani/ ($!ia%6a = gin!3&&',!%i3ia)

R//) *+&',a

1 P%&3!,& ! a8i,i4n !/ $a3i!n! a/ ,!%i3i& 8a!%n& in@ani/ ($!ia%6a = gin!3&&',!%i3ia)

R//) *+&',a

1. 9!3ani,8&, $a%a a,igna% 3a8a,

R//) *+&',a

1# P%&3!,& ! %a,/a& !/ $a3i!n! ! ?&,$ia/i7a3i4n 8a!%n& in@ani/ a/ ,!%i3i& ! 3i%2g6a

R//) *+&',a

15 P%&3!,& ! %a,/a& !/ $a3i!n! ! ?&,$ia/i7a3i4n 8a!%n& in@ani/ a 32ia& in!n,i& = 32ia& in!%8!i&

R//

ES-P-AS-01-F-005 Pgina . ! "# A$%&'a&: 01-0-0*+!%,i&n 0


33/94



) *+&',a

-.-.E$ta%i3a

N8!%& ! 3a8a, $a%a%a'a& ! $a%&N8!%& ! ,a/a, ! $a%&

ES-P-AS-01-F-005 Pgina .. ! "# A$%&'a&: 01-0-0*+!%,i&n 0


34/94



N8!%& ! $a3i!n!,a!nia, !n &',!%i3ia

N8!%& ! $a%&,

N8!%& ! $a%&,agina/!,N8!%& ! $a%&, $&%3!,%!a

R!/a3i4n $a%&, agina/!,, $a%&, $&% 3!,%!a(S!33i4n F N 1.)

P%&8!i& ! 3&n%&/!,$%!naa/!,(S!33i4n F N 11)

C&'!%2%a ! 3&n%&/$%!naa/(S!33i4n F N 1)N8!%& ! !g%!,&,&',>%i3&,

A?!%!n3ia a g26a !$%3i3a 3/6ni3a 8>i3a !?!8&%%agia, III %i8!,%! !g!,a3i4n(S!33i4n F N 1#)

A?!%!n3ia a g26a !$%3i3a 3/6ni3a 8>i3a !

%a,&%n&, ?i$!%!n,i&, !/a g!,a3i4n(S!33i4n F N 15)P&%3!na! &32$a3i&na/(S!33i4n F N 1)P%&8!i& !,an3ia(S!33i4n F N )Gi%& 3a8a(S!33i4n F N .)

C&8$/i3a3i4n &',>%i3a

ES-P-AS-01-F-005 Pgina .# ! "# A$%&'a&: 01-0-0*+!%,i&n 0


35/94



(S!33i4n F N 1)

En&8!%ii, $&,$a%&(S!33i4n F N 1*)Ra74n ! 8&%a/ia8a!%na(S!33i4n F N 1)

N8!%& &a/ ! n!&na&,

N!&na&, i&, ! 500g%a8&,

N!&na&, i&, ! 500g%a8&,

Ta,a ! 8&%a/ia$!%inaa/(S!33i4n F N 1")

-.0.M!6'l'a > M!tal'a

.1 Ca2,a, ! C&n,2/a ,!%i3i& 9a!%n& In@ani/: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a/a $%!,!na3i4n !/ in@&%8! (a& # M a& .M a& M a& 1)

Ta'/a N& 1 P%i8!%a, 10 Ca2,a, ! C&n,2/a S!%i3i& O',!%i3ia

P%i8!%a, 10 Ca2,a, ! C&n,2/a S!%i3i& O',!%i3ia T&a/

1

.

#

5



36/94



*

"

10

T&a/ O%a, Ca2,a,

T&a/ Ca2,a,

. Ca2,a, ! Eg%!,&, ,!%i3i& 9a!%n& In@ani/: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a

/a $%!,!na3i4n !/ in@&%8! (a& # M a& .M a& M a& 1)

Ta'/a N& 1. P%i8!%a, 10 Ca2,a, ! Eg%!,&, S!%i3i& O',!%i3ia

P%i8!%a, 10 Ca2,a, ! Eg%!,&, S!%i3i& O',!%i3ia T&a/

1

.

#

5

*

"

10

T&a/ O%a, Ca2,a,

T&a/ Ca2,a,ES-P-AS-01-F-005 Pgina . ! "# A$%&'a&: 01-0-0*+!%,i&n 0


37/94



.. Ca2,a, ! 9&%a/ia ,!%i3i& 9a!%n& In@ani/: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!,a /a $%!,!na3i4n !/ in@&%8! (a& # M a& .M a& M a& 1)

Ta'/a N& 1# P%i8!%a, 10 Ca2,a, ! 9&%a/ia S!%i3i& O',!%i3ia

P%i8!%a, 10 Ca2,a, ! 9&%a/ia S!%i3i& O',!%i3ia T&a/

1

.#

5

*

"

10

T&a/ O%a, Ca2,a,T&a/ Ca2,a,



38/94



0. URGENCIAS

0.1.G#,#!al'a#$

C&8$/!! /a ,ig2i!n! in@&%8a3i4n $&% i$&, ! 2%g!n3ia, (a2/&, $!i%i3&, = &',>%i3&,):.11 N8!%& ! 3&n,2/&%i&, ! 2%g!n3ia, = n8!%& ! 3a8a, ! &',!%a3i4n

R//; *+&',a

.1 Di,%i'23i4n ! %!a,

R//) *+&',a

.1. P%&3!,& ! a8i,i4n a8ini,%aia !/ $a3i!n!

R//) *+&',a

.1# P%&3!,& ! a8i,i4n 3/6ni3a !/ $a3i!n! (%iag!)

R//) *+&',a

.15 P%&3!,& ! a!n3i4n !/ $a3i!n! !n !/ ,!%i3i& ! 2%g!n3ia,

R//) *+&',a

.1 P%&3!,& ! %a,/a& !/ $a3i!n! !/ ,!%i3i& ! 2%g!n3ia, a/ ,!%i3i& ! ?&,$ia/i7a3i4n

R//) *+&',a

.1 P%&3!,& ! %a,/a& !/ $a3i!n! !/ ,!%i3i& ! 2%g!n3ia, a/ ,!%i3i& ! 3i%2g6a

R//) *+&',aES-P-AS-01-F-005 Pgina .* ! "# A$%&'a&: 01-0-0*+!%,i&n 0


39/94



.1* P%&3!,& ! %a,/a& !/ $a3i!n! ! 2%g!n3ia, a 32ia& in!n,i& = 32ia& in!%8!i&

R//) *+&',a

0.1 E$ta%i3a,R!/a3i4n ! 3&n,2/a,2%g!n3ia, , 3&n,2/a,! %iag!

ES-P-AS-01-F-005 Pgina ." ! "# A$%&'a&: 01-0-0*+!%,i&n 0


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(An!;& F N 0)

R!ing%!,&, a/ ,!%i3i& !2%g!n3ia, $&% /a 8i,8a3a2,a an!, ! ?&%a,(An!;& F N 1)

N8!%& ! $a3i!n!,@a//!3i&, !n 2%g!n3ia,an!, ! /a, # ?&%a,N8!%& ! $a3i!n!,@a//!3i&, !n 2%g!n3ia,!,$2>, ! #* ?&%a,

A?!%!n3ia a g26a !$%3i3a 3/6ni3a 8>i3a

! ?!8&%%agia, III%i8!,%! ! g!,a3i4n(S!33i4n F N 1#)

A?!%!n3ia a g26a !$%3i3a 3/6ni3a 8>i3a! %a,&%n&,?i$!%!n,i&, ! /ag!,a3i4n(S!33i4n F N 15)Ta,a ! 3&8$/i3a3i4n&',>%i3a(S!33i4n F N 1)

0.- M!6'l'a > M!tal'a

..1 Ca2,a, ! C&n,2/a ,!%i3i& U%g!n3ia,: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a /a$%!,!na3i4n !/ in@&%8! (a& # M a& .M a& M a& 1)

Ta'/a N& 1 P%i8!%a, 10 Ca2,a, ! C&n,2/a S!%i3i& U%g!n3ia,

ES-P-AS-01-F-005 Pgina #0 ! "# A$%&'a&: 01-0-0*+!%,i&n 0


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P%i8!%a, 10 Ca2,a, ! C&n,2/a S!%i3i& U%g!n3ia, 9a,32/in& F!8!nin& T&a/

1

.

#

5

*

"10

T&a/ O%a, Ca2,a,

T&a/ Ca2,a,

.. 9&%a/ia ,!%i3i& ! U%g!n3ia,: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a /a$%!,!na3i4n !/ in@&%8! (a& # M a& .M a& M a& 1)

Ta'/a N& 1 P%i8!%a, 10 Ca2,a, ! 9&%a/ia S!%i3i& U%g!n3ia,

P%i8!%a, 10 3a2,a, ! 9&%a/ia S!%i3i& ! U%g!n3ia, 9a,32/in& F!8!nin& T&a/

1



42/94



.

#5

*

"

10

T&a/ O%a, Ca2,a,

T&a/ Ca2,a,

ES-P-AS-01-F-005 Pgina # ! "# A$%&'a&: 01-0-0*+!%,i&n 0


43/94



3. CIRUGIA

3.1.G#,#!al'a#$

D!,3%i'a /a in@&%8a3i4n B2! ,! ,&/i3ia a 3&nin2a3i4n:

#11 Di,%i'23i4n ! %!a, ! ,a/a, ! 3i%2g6a

R//) *+&',a$

#1 P%&3!,& ! a8i,i4n !/ $a3i!n! a ,a/a, ! 3i%2g6a !,$!3i@iB2! /a a8i,i4n a 3i%2g6a $%&g%a8aa = a 3i%2g6a n&$%&g%a8aa

R//) *+&',a$

#1. 9!3ani,8&, $a%a a,igna% ,a/a, ! 3i%2g6a

R//) *+&',a$

#1# P%&3!,& ! %a,/a& !/ $a3i!n! ! ,a/a, ! 3i%2g6a a 32ia& in!n,i& = 32ia& in!%8!i&R//) *+&',a$

#15 P%&3!,& ! %a,/a& !/ $a3i!n! ! ,a/a, ! 3i%2g6a a/ ,!%i3i& ! ?&,$ia/i7a3i4n

R//) *+&',a$

ES-P-AS-01-F-005 Pgina #. ! "# A$%&'a&: 01-0-0*+!%,i&n 0


44/94



3.-.E$ta,i3a

N8!%& ! $a3i!n!,B2i%%gi3&,

N8!%& ! 3i%2g6a,

&a/!,

N8!%& ! 3i%2g6a, !2%g!n3ia,

N8!%& ! 3i%2g6a,a8'2/a&%ia,

N8!%& ! 3i%2g6a,$%&g%a8aa, !

ES-P-AS-01-F-005 Pgina ## ! "# A$%&'a&: 01-0-0*+!%,i&n 0


45/94



$a3i!n!, ?&,$ia/i7a&,

N8!%& ! 3i%2g6a,$%&g%a8aa, %!a/i7aa,! $a3i!n!,?&,$ia/i7a&,Can3!/a3i4n ! 3i%2g6a$%&g%a8aa(S!33i4n F N )

Can3!/a3i4n ! 3i%2g6a$&% 3a2,a in,i23i&na/(S!33i4n F N .)

Can3!/a3i4n ! 3i%2g6a$&% 3a2,a n&

in,i23i&na/(S!33i4n F N #)

R!/a3i4n !$%&3!i8i!n&, !/!3i&,, $%&3!i8i!n&, n&!/!3i&,(S!33i4n F N 5)

In@!33i4n !/ ,ii&B2i%%gi3&(S!33i4n F N )

3.0.D'a&,$t'($ > M!tal'a



46/94



#.1 Diagn4,i3&, ! Ci%2g6a: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a /a $%!,!na3i4n !/in@&%8! (a& # M a& .M a& M a& 1)

Ta'/a N& 1" P%i8!%&, 10 Diagn4,i3&, ! Ci%2g6a

P%i8!%&, 10 Diagn4,i3&, ! Ci%2g6a 9a,32/in& F!8!nin& T&a/

1

.

#

5

*

"

10

T&a/ O%&, Diagn4,i3&,

T&a/ Diagn4,i3&,

#. Diagn4,i3&, ! Ci%2g6a A8'2/a&%ia: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a /a$%!,!na3i4n !/ in@&%8! (a& # M a& .M a& M a& 1)



47/94



Ta'/a N& 0 P%i8!%&, 10 Diagn4,i3&, ! Ci%2g6a A8'2/a&%ia

P%i8!%&, 10 Diagn4,i3&, ! Ci%2g6a A8'2/a&%ia 9a,32/in& F!8!nin& T&a/

1

.

#

5

*

"

10

T&a/ O%&, Diagn4,i3&,

T&a/ Diagn4,i3&,

#.. 9&%a/ia !n Ci%2g6a: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a /a $%!,!na3i4n !/in@&%8! (a& # M a& .M a& M a& 1)

Ta'/a N& 1 P%i8!%&, 10 Ca2,a, ! 9&%a/ia !n Ci%2g6a



48/94



P%i8!%a, 10 Ca2,a, ! 9&%a/ia !n Ci%2g6a 9a,32/in& F!8!nin& T&a/

1

.

#

5

*

"10

T&a/ O%a, Ca2,a,

T&a/ Ca2,a,

ES-P-AS-01-F-005 Pgina #* ! "# A$%&'a&: 01-0-0*+!%,i&n 0


49/94



4. CUIDADOS INTENSIVOS Y CUIDADO INTERMEDIO

4.1.G#,#!al'a#$


511 Di,%i'23i4n ! %!a, !/ ,!%i3i&

R//) *+&',a

51 P%&3!,& ! a8i,i4n !/ $a3i!n! a 32ia&, in!n,i&, & 32ia& in!%8!i&

R//) *+&',a

51. 9!3ani,8&, $a%a a,igna% 3a8a,

R//) *+&',a

ES-P-AS-01-F-005 Pgina #" ! "# A$%&'a&: 01-0-0*+!%,i&n 0


50/94



4.-.E$ta


51/94



(S!33i4n F N")

UCI INTER9EDIAADULTOS A& # an!%i&% a /a$%!,!na3i4n !/in@&%8! _____

A& . an!%i&% a /a$%!,!na3i4n !/in@&%8! ____

A& an!%i&% a /a$%!,!na3i4n !/in@&%8! ____

A& 1 an!%i&% a /aP%!,!na3i4n !/in@&%8! ____

A& A32a/ P%!,!na3i4n!/ in@&%8! ______C&%! 8!, an!%i&%:

N &a/ ! 3a8a,

N ! !g%!,&, &a/!,

P&%3!na! &32$a3i&na/(S!33i4n F N 1)P%&8!i& 6a !,an3ia(S!33i4n F N )

UCI PEDIQTRICA A& # an!%i&% a /a$%!,!na3i4n !/

in@&%8! _____

A& . an!%i&% a /a$%!,!na3i4n !/

in@&%8! ____

A& an!%i&% a /a$%!,!na3i4n !/

in@&%8! ____

A& 1 an!%i&% a /aP%!,!na3i4n !/

in@&%8! ____

A& A32a/ P%!,!na3i4n!/ in@&%8! ______

C&%! 8!, an!%i&%:N &a/ ! 3a8a,

N ! !g%!,&, &a/!,

P&%3!na! &32$a3i&na/(S!33i4n F N 1)P%&8!i& 6a !,an3ia(S!33i4n F N )In@!33i4nin%a?&,$ia/a%ia(S!33i4n F N #)Ta,a ! In@!33i4n

in%a?&,$ia/a%ia(S!33i4n F N 5)R!ing%!,&, $&% in@!33i4nin%a?&,$ia/a%ia(S!33i4n F N)

Ta,a ! in@!33i4n !6a, 2%ina%ia, a,&3iaa,a ,&na !,i3a/(S!33i4n F N)

Ta,a ! n!28&n6a

ES-P-AS-01-F-005 Pgina 51 ! "# A$%&'a&: 01-0-0*+!%,i&n 0


52/94



a,&3iaa a/ !ni/a&%(NA+)

(S!33i4n F N*)Ta,a ! in@!33i4n !/&%%!n! 3i%32/a&%i&(S!33i4n F N")

Pa3i!n!, $!i%i3&,3&n n!28&n6a, '%&n3&-a,$i%aia,(S!33i4n F N 10)

UCI INTER9EDIAPEDIQTRICA

A& # an!%i&% a /a$%!,!na3i4n !/in@&%8! _____

A& . an!%i&% a /a$%!,!na3i4n !/

in@&%8! ____

A& an!%i&% a /a$%!,!na3i4n !/

in@&%8! ____

A& 1 an!%i&% a /aP%!,!na3i4n !/

in@&%8! ____

A& A32a/ P%!,!na3i4n!/ in@&%8! ______C&%! 8!, an!%i&%:

N8!%& &a/ ! 3a8a,

N8!%& ! !g%!,&,&a/!,

P&%3!na! &32$a3i&na/(S!33i4n F N 1)

P%&8!i& 6a !,an3ia(S!33i4n F N )Pa3i!n!, $!i%i3&,3&n n!28&n6a, '%&n3&-a,$i%aia,(S!33i4n F N 10)

UCI NEONATAL A& # an!%i&% a /a

$%!,!na3i4n !/in@&%8! _____

A& . an!%i&% a /a

$%!,!na3i4n !/in@&%8! ____

A& an!%i&% a /a

$%!,!na3i4n !/in@&%8! ____

A& 1 an!%i&% a /a

P%!,!na3i4n !/in@&%8! ____

A& A32a/ P%!,!na3i4n

!/ in@&%8! ______C&%! 8!, an!%i&%:N8!%& &a/ ! 3a8a,

N8!%& ! !g%!,&,&a/!,

P&%3!na! &32$a3i&na/(S!33i4n F N 1)

P%&8!i& 6a !,an3ia(S!33i4n F N )



53/94



In@!33i4nin%a?&,$ia/a%ia

(S!33i4n F N #)Ta,a ! In@!33i4nin%a?&,$ia/a%ia(S!33i4n F N 5)R!ing%!,&, $&% in@!33i4nin%a?&,$ia/a%ia(S!33i4n F N )

Ta,a ! in@!33i4n !6a, 2%ina%ia, a,&3iaa,a ,&na !,i3a/(S!33i4n F N )

Ta,a ! n!28&n6a

a,&3iaa a/ !ni/a&%(NA+)(S!33i4n F N *)

Ta,a ! in@!33i4n !/&%%!n! 3i%32/a&%i&(S!33i4n F N ")

Pa3i!n!, $!i%i3&,3&n n!28&n6a, '%&n3&-a,$i%aia,(S!33i4n F N 10)

UCI INTER9EDIANEONATAL

A& # an!%i&% a /a$%!,!na3i4n !/

in@&%8! _____

A& . an!%i&% a /a$%!,!na3i4n !/

in@&%8! ____

A& an!%i&% a /a$%!,!na3i4n !/

in@&%8! ____

A& 1 an!%i&% a /aP%!,!na3i4n !/

in@&%8! ____

A& A32a/ P%!,!na3i4n!/ in@&%8! ______

C&%! 8!, an!%i&%:N8!%& &a/ ! 3a8a,

N8!%& ! !g%!,&,&a/!,

P&%3!na! &32$a3i&na/(S!33i4n F N 1)P%&8!i& 6a !,an3ia(S!33i4n F N )Pa3i!n!, $!i%i3&,

ES-P-AS-01-F-005 Pgina 5. ! "# A$%&'a&: 01-0-0*+!%,i&n 0


54/94



3&n n!28&n6a, '%&n3&-a,$i%aia,

(S!33i4n F N 10)

4.0.M!6'l'a > M!tal'a

5.1 9&%'i/ia ! C2ia&, In!n,i&,: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a /a$%!,!na3i4n !/ in@&%8! (a& # M a& .M a& M a& 1)

Ta'/a N& . P%i8!%a, 10 Ca2,a, ! 9&%'i/ia ! C2ia&, In!n,i&,

P%i8!%a, 10 Ca2,a, ! 9&%'i/ia ! C2ia&, In!n,i&, 9a,32/in& F!8!nin& T&a/

1

.

#

5

*

"

10

T&a/ O%a, Ca2,a,

T&a/ Ca2,a,

ES-P-AS-01-F-005 Pgina 5# ! "# A$%&'a&: 01-0-0*+!%,i&n 0


55/94



5. Diagn4,i3&, ! C2ia&, In!%8!i&,: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a /a$%!,!na3i4n !/ in@&%8! (a& # M a& .M a& M a& 1)

Ta'/a N& # P%i8!%a, 10 ! Ca2,a, ! 9&%'i/ia ! C2ia&, In!%8!i&,

P%i8!%a, 10 Ca2,a, ! 9&%'i/ia ! C2ia&, In!%8!i&, 9a,32/in& F!8!nin& T&a/

1

.#

5

*

"

10

T&a/ O%a, Ca2,a,T&a/ Ca2,a,



56/94



5.. 9&%a/ia !n C2ia&, C%6i3&, (32ia&, in!n,i&, M 32ia&, in!%8!i&,): 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a /a $%!,!na3i4n !/ in@&%8! (a& # M a& .M a& M a& 1)

Ta'/a N& 5 P%i8!%a, 10 Ca2,a, ! 9&%a/ia !n C2ia&, C%6i3&,

P%i8!%a, 10 Ca2,a, ! 9&%a/ia !n C2ia&, C%6i3&, 9a,32/in& F!8!nin& T&a/

1

.

#

5

*

"

10

T&a/ O%a, Ca2,a,

T&a/ Ca2,a,



57/94



5. CONSULTA ETERNA

5.1.G#,#!al'a#$

D!,3%i'a /a in@&%8a3i4n B2! ,! ,&/i3ia a 3&nin2a3i4n !ni!n& !n 32!na /&, ,!%i3i&, ! 3&n,2/a 8>i3a g!n!%a/ 3&n,2/a 8>i3a!,$!3ia/i7aa &n3&/&g6a &&n&/&g6a n2%i3i4n ,a/2 $'/i3a = $%&8&3i4n = $%!!n3i4n

11 Di,%i'23i4n ! %!a, !/ ,!%i3i&

R//1 *+&',a

1 R!/a3i&n! /&, $%&g%a8a, ! $%&8&3i4n = $%!!n3i4n $%!,a&, $&% /a &%gani7a3i4n !n !/ 8a%3& ! /a n&%8aiia ig!n!

R//- *+&',a$

1. R!/a3i&n! /&, $%&g%a8a, ! ,a/2 $'/i3a $%!,a&, $&% /a &%gani7a3i4n !n !/ 8a%3& ! /a n&%8aiia ig!n!

R//- *+&',a$

1# R!/a3i&n! /&, $%&g%a8a, ! $%&8&3i4n = $%!!n3i4n i@!%!n!, a /a, &'/iga3i&n!, /!ga/!, B2! a!/ana /a in,i23i4n

R//- *+&',a$



58/94



15 D!,3%i'a /&, 8!3ani,8&, !;i,!n!, $a%a !/ ing%!,& ! $a3i!n!, (?&,$ia/i7a&, = a8'2/a&%i&,) a /&, $%&g%a8a, !$%&8&3i4n = $%!!n3i4n

R//1 > ) *+&',a$

1 D!,3%i'a /&, 8!3ani,8&, ! %!@!%!n3ia in!%na = !;!%na ! $a3i!n!, a /&, $%&g%a8a, ! $%&8&3i4n = $%!!n3i4n

R//1 > ) *+&',a$

1 R!/a3i&n! /&, $%&g%a8a, ! $%&8&3i4n = $%!!n3i4n ,!32na%ia = !%3ia%ia !n 3a,& ! ,!% 2na in,i23i4n ! III =& I+ Ni!/! 3&8$/!ia

R//1 *+&',a

1* D!,3%i'a !/ $%&3!,& ! a!n3i4n !n /&, ,!%i3i&, !: &n3&/&g6a 32ia& $a/iai& = 3/6ni3a !/ &/&%

R//1 *+&',a

1" D!,3%i'a !/ $%&3!,& ! a!n3i4n !n n2%i3i4n $a%a $a3i!n!, a8'2/a&%i&, = ?&,$ia/i7a&,

R//1 *+&',a

ES-P-AS-01-F-005 Pgina 5* ! "# A$%&'a&: 01-0-0*+!%,i&n 0


59/94



5.-. E$ta


60/94



Pa3i!n!, n& a!ni&,!n &&n&/&g6a!,$!3ia/i7aa(S!33i4n F N )T%aa8i!n&, !%8ina&,! &&n&/&g6a(S!33i4n F N *)

T%aa8i!n&, !%8ina&,&n3&/4gi3&, !B2i8i&!%a$ia(S!33i4n F N *)T%aa8i!n&, !%8ina&,

&n3&/4gi3&, !%ai&!%a$ia(S!33i4n F N *)N8!%& ! 3&n,2/a,a8'2/a&%ia, ! n2%i3i4nC&'!%2%a i/ !/$%&g%a8a a8$/ia& !in82ni7a3i4n !n8!n&%!,(S!33i4n F N ")O$&%2nia !n /a!!33i4n ! 3n3!%

3!%i3&2!%in&(S!33i4n F N .0)D! a32!%& 3&n /&, $%&g%a8a, ! $%&8&3i4n = $%!!n3i4n = ! ,a/2 $'/i3a !;i,!n!, !n /a &%gani7a3i4n 3&8$/!! /a ,ig2i!n!in@&%8a3i4n:

SER+ICIO DECONSULTA ETERNA

A& # an!%i&% a /a$%!,!na3i4n !/in@&%8! _____

A& . an!%i&% a /a$%!,!na3i4n !/in@&%8! ____

A& an!%i&% a /a$%!,!na3i4n !/in@&%8! ____

A& 1 an!%i&% a /aP%!,!na3i4n !/in@&%8! ____

A& A32a/ P%!,!na3i4n!/ in@&%8! ______C&%! 8!, an!%i&%:

C28$/i8i!n& !a3iia!, !/ $%&g%a8a



61/94



(%!gi,! !/ n&8'%! !/$%&g%a8a)

(S!33i4n F N .1)

5.0.M!6'l'a

.1 Ca2,a, ! 9&%'i/ia C&n,2/a E;!%na: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a /a$%!,!na3i4n !/ in@&%8! (a& # M a& .M a& M a& 1)

Ta'/a N& P%i8!%a, 10 Ca2,a, ! 9&%'i/ia 9!i3a ! C&n,2/a E;!%na

P%i8!%a, 10 Ca2,a, ! 9&%'i/ia C&n,2/a E;!%na 9!i3a 9a,32/in& F!8!nin& T&a/

1

.

#

5

*

"10

T&a/ O%a, Ca2,a,

T&a/ Ca2,a,

. 9&%'i/ia Sa/2 O%a/: 3&n,&/i! !n /a ,ig2i!n! a'/a /a in@&%8a3i4n 3&%%!,$&ni!n! a /&, # a&, an!%i&%!, a /a $%!,!na3i4n !/in@&%8! (a& # M a& .M a& M a& 1)



62/94



Ta'/a N& * P%i8!%a, 10 Ca2,a, ! 9&%'i/ia ! Sa/2 O%a/

P%i8!%a, 10 Ca2,a, ! 9&%'i/ia !n Sa/2 O%a/ 9a,32/in& F!8!nin& T&a/

1

.

#

5

*"

10

T&a/ O%a, Ca2,a,

T&a/ Ca2,a,

ES-P-AS-01-F-005 Pgina ! "# A$%&'a&: 01-0-0*+!%,i&n 0


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7. LABORATORIO CLNICO BANCO DE SANGRE Y PATOLOGA

7.1.G#,#!al'a#$D!,3%i'a /a in@&%8a3i4n B2! ,! ,&/i3ia a 3&nin2a3i4n:

11 P%&3!,& ! i!ni@i3a3i4n ! 82!,%a, ! !;8!n!, ! /a'&%a&%i& 3/6ni3& =& ?!8&3&8$&n!n!, =& !,$!368!n!,

R//) *+&',a$

1 P%&3!,& $a%a a% %!,$2!,a a ,&/i3i2!, 2%g!n!, ! !;8!n!, ! /a'&%a&%i& 3/6ni3& =& ?!8&3&8$&n!n!, =&!,$!368!n!,

R//) *+&',a$

1. 9!3ani,8&, ! a/!%a, !;i,!n!, $a%a %!,2/a&, 3%6i3&, ! $%2!'a, ! /a'&%a&%i& 3/6ni3& =& 'an3& ! ,ang%! =&$a&/&g6a

R//) *+&',a$



64/94



1# 9a%B2! 3&n 2na !/ %!a & ,!33i&n!, ! /a'&%a&%i& 3/6ni3& B2! $%!,a /a in,i23i4n:

P%2!'a, ! H!8a&/&g6a

P%2!'a, ! In82n&/&g6aP%2!'a, ! 268i3a Sang26n!a

P%2!'a, ! Fa%8a3&/&g6a- T&;i3&/&g6a D%&ga, ! A'2,&

P%2!'a, ! C&$%&$a%a,i&/&g6a

P%2!'a, ! G!n>i3a

P%2!'a, ! 9i3&/&g6a

P%2!'a, !


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7.-. E$ta


66/94



E;8!n!, ! /a'&%a&%i&3/6ni3& $&% $%&g%a8a !

+IH(S!33i4n FN .#) E;8!n!, ! /a'&%a&%i&3/6ni3& $&% $%&g%a8a2'!%32/&,i,(S!33i4n FN .#)O$&%2nia !n /a!n%!ga ! %!,2/a&, !!;8!n!, ! /a'&%a&%i&3/6ni3& 'an3& ! ,ang%!= $a&/&g6a(S!33i4n FN .5)

O$&%2nia !n /aa8ini,%a3i4n !?!8&3&8$&n!n!,(S!33i4n FN .)



67/94



9. IMGENOLOGA PROCEDIMIENTOS DIAGNSTICOS Y TERAPUTICOS

9.1.G#,#!al'a#$

D!,3%i'a /a in@&%8a3i4n B2! ,! ,&/i3ia a 3&nin2a3i4n !ni!n& !n 32!na !n%! &%&, /&, ,ig2i!n!, !;8!n!, =& $%&3!i8i!n&, !:%ai&/&g6a 3&n!n3i&na/ n& 3&n%a,aa %ai&/&g6a 3&n!n3i&na/ 3&n%a,aa 2/%a,&ni& &8&g%a@6a a;ia/ 3&8$2a%i7aa %!,&nan3ia8agn>i3a $%&3!i8i!n&, !n&,34$i3&, !/!3%&@i,i&/&g6a = $%2!'a, ! @2n3i4n $2/8&na%

*11 P%&3!,& ! i!ni@i3a3i4n ! /&, !,2i&, =& $%&3!i8i!n&, %!a/i7a&,

R//) *+&',a

*1 P%&3!,& $a%a a% %!,$2!,a a ,&/i3i2!, ! !,2i&, 2%g!n!, ! !,2i&, =& $%&3!i8i!n&, %!a/i7a&,

R//) *+&',a

*1. 9!3ani,8&, ! a/!%a, !;i,!n!, $a%a %!,2/a&, 3%6i3&, ! /&, !,2i&, =& $%&3!i8i!n&, %!a/i7a&,

R//) *+&',a



68/94



*1# 9a%B2! 3&n 2na !/ i$& ! !,2i&, = $%&3!i8i!n&, iagn4,i3&, = !%a$>2i3&, B2! $%!,a /a in,i23i4n:

Rai&/&g6a 3&n!n3i&na/ n& 3&n%a,aa

Rai&/&g6a 3&n!n3i&na/ 3&n%a,aaU/%a,&ni&

T&8&g%a@6a a;ia/ 3&8$2a%i7aa

R!,&nan3ia 8agn>i3a

P%&3!i8i!n&, !n&,34$i3&,

E/!3%&@i,i&/&g6a

P%2!'a, ! F2n3i4n P2/8&na%

Rai&/&g6a &%a/

O%&, !,$!3i@iB2!:

ES-P-AS-01-F-005 Pgina * ! "# A$%&'a&: 01-0-0*+!%,i&n 0


69/94



9.-.E$ta2i3a,(S!33i4n F N .")



70/94



?. REHABILITACIN

?.1. G#,#!al'a#$

D!,3%i'a /a in@&%8a3i4n B2! ,! ,&/i3ia a 3&nin2a3i4n !ni!n& !n 32!na !n%! &%&, /&, ,ig2i!n!, ,!%i3i&,: !%a$ia @6,i3a !%a$ia&32$a3i&na/ !%a$ia !/ /!ng2a! !%a$ia %!,$i%a&%ia %!?a'i/ia3i4n 3a%ia3a %!?a'i/ia3i4n i,2a/ %!?a'i/ia3i4n $2/8&na%

"11 Di,%i'23i4n ! %!a,

R//1 *+&',a

"1 D!,3%i'a /&, 8!3ani,8&, !;i,!n!, $a%a !/ ing%!,& ! $a3i!n!, (?&,$ia/i7a&, = a8'2/a&%i&,) a /&, ,!%i3i&, !!%a$ia, = %!?a'i/ia3i4n

R//1 *+&',a

?.-.E$ta


71/94



T%aa8i!n&, !%8ina&, !

%!?a'i/ia3i4n 3a%6a3a @a,!II(S!33i4n F N #0)T%aa8i!n&, !%8ina&, !%!?a'i/ia3i4n 3a%6a3a @a,!III(S!33i4n F N #0)

T%aa8i!n&, !%8ina&, !%!?a'i/ia3i4n ! !%a$ia@6,i3a(S!33i4n F N *)

T%aa8i!n&, !%8ina&, !%!?a'i/ia3i4n ! !%a$ia%!,$i%a&%ia(S!33i4n F N *)T%aa8i!n&, !%8ina&, !%!?a'i/ia3i4n ! !%a$ia&32$a3i&na/(S!33i4n F N *)T%aa8i!n&, !%8ina&, !%!?a'i/ia3i4n ! !%a$ia !//!ng2a!(S!33i4n F N *)



72/94



[email protected] INTEGRADAS

[email protected]. G#,#!al'a#$

C&8$/!! /a ,ig2i!n! in@&%8a3i4n:

1011 Di,%i'23i4n ! %!a, = 3&ni3i&n!, @6,i3a, $&% 3aa ,!!

R//1 *+&',a

101 R!/a3i4n ! /&, ,!%i3i&, $%!,a&, $&% 3aa ,!!

R//1 *+&',a



73/94



[email protected]. D'$t!'6(', # *#!$,al *! $##$

C&8$/!! /a ,ig2i!n! in@&%8a3i4n $&% 3aa ,!! an!;an& /a, a'/a, B2! ,!an n!3!,a%ia, ,!gn n28!%& ! ,!!, !;i,!n!,

Ta'/a N& . Di,%i'23i4n $!%,&na/ ,!!10 N8!%& ! %a'aa&%!, a,i,!n3ia/!, = a8ini,%ai&, i,3%i8ina&, B2! /a'&%an !n /a ,!!

P!%,&na/ S!! ________________________ H&%a, 8!,

9>i3&, G!n!%a/!,

En@!%8!%a,

9>i3&, !,$!3ia/i,a, $%!,!n3ia/!,

A2;i/ia%!, ! !n@!%8!%6a A2;i/ia%!, ! ,a/2

T!%a$!2a, %!,$i%a&%i&,

T!%a$!2a, @6,i3&,

T!%a$!2a,

A8ini,%ai&, (a8i,i&n!, = @a32%a3i4n)

A2;i/ia% a8ini,%ai&

Fa32%a&%!,C&82ni3a&%!,

In@&%8a&%!,

O%&,



74/94



[email protected]. E$ta


75/94



(S!33i4n F N)



76/94



SECCIN C. INFRAESTRUCTURA Y GESTION DE TECNOLOGA BIOMDICA

1. G#,#!al'a#$

11 R!/a3i&n! /&, 3in3& (5) $%in3i$a/!, %i!,g&, ! in@%a!,%232%a ! /a &%gani7a3i4n = !,3%i'a /&, 8!3ani,8&, 2i/i7a&, $a%a8ini8i7a% /&, %i!,g&,

R//1 *+&',a

1 R!/a3i&n! /a @!3?a !/ /i8& an/i,i, ! 2/n!%a'i/ia !,3%i'a ,2, %!,2/a&, = a33i&n!, i8$/!8!naa,

R//1 *+&',a



77/94



-. I,f!a#$t!(t!a f


78/94



11 R!gi,%! !n 8!%&, 32a%a&, !/ a%!a @6,i3a &a/ = %!a 3&n,%26a B2! i!n! /a in,i23i4n

R//; *+&',a

1 R!gi,%! !n 8!%&, 32a%a&, !/ a%!a @6,i3a B2! i!n! 3aa ,a/a ! !,$!%a

R//; *+&',a

1. R!gi,%! !n 8!%&, 32a%a&, !/ %!a @6,i3a B2! i!n! !/ ,!%i3i& ! %!ani8a3i4n ! 2%g!n3ia,R//; *+&',a

1# R!gi,%! !n 8!%&, 32a%a&, !/ %!a @6,i3a ! %ai&/&g6a &n! ,! &8a !/ !;a8!n

R//; *+&',a

15 R!gi,%! !n 8!%&, 32a%a&, !/ %!a @6,i3a ! 3aa ,a/a ! 3i%2g6a

R//) *+&',a

1 R!gi,%! !n 8!%&, 32a%a&, !/ %!a @6,i3a ! 3aa ,a/a ! $a%&,

R//


INFORME DE AUTOEVALUACIN


79/94



-.-.Pla,#a(', #:#((', # '"*a(t # 6!a$ # ',f!a#$t!(t!a f3ni3&, !8ii&, $&% !/ !n! !%%i&%ia/ 3&%%!,$&ni!n! = !/9ini,!%i& ! Sa/2 = P%&!33i4n S&3ia/ (!n 3a,& ! %!B2!%i%,!)

R//) *+&',a

Si /a !!323i4n !/ $%&=!3& a,6 /& %!B2i!%! iniB2! /a @!3?a ! !!32&%iaa ! /a /i3!n3ia ! 3&n,%233i4n !;$!ia $&% !/ !n!3&8$!!n!

R//) *+&',a

. R!/a3i&n! /a @!3?a ! /a a$%&'a3i4n !/ $/an ! 3&ning!n3ia $&% !/ !n! !%%i&%ia/ 3&%%!,$&ni!n! = !,3%i'a '%!!8!n! !/8i,8& $%!3i,an& 3&8& ,!%n /&, ai,/a8i!n&, = 3&ni3i&n!, ! ,!g2%ia 2%an! /a !!323i4n ! /a &'%a

R//- *+&',a

# D!,3%i'a !/ i8$a3& a8'i!na/ B2! g!n!%a%a /a !!323i4n ! /a, &'%a, ! a8$/ia3i4n %!8&!/a3i4n %!@&%7a8i!n& =&3&n,%233i4n

R//

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80/94



-.0.S#&!'a

Ta'/a N& .5 Si82/a3%&, ! E8!%g!n3ia,.1 Di/ig!n3i! $a%a /&, /i8&, # a&, /a ,ig2i!n! a'/a %!/a3i&nan& /&, i@!%!n!, i$&, ! ,i82/a3%&, %!a/i7a&, $&% !!8$/&in3!ni& !a32a3i4n !n%! &%&, i,3%i8inan& $&% ,!!, ,i a$/i3aS!! F!3?a ! Si82/a3%& Ti$& ! Si82/a3%& D2%a3i4n

R!gi,%! /&, ,i82/a3%&, %!a/i7a&, !n !/ /i8& a& = @%!n! a 3aa 2n& !,3%i'a /a, &, () $%in3i$a/!, %!3&8!na3i&n!, = !/ ,!g2i8i!n& a/a i8$/!8!na3i4n ! /a, 8i,8a,

N&8'%! = @!3?a !/ ,i82/a3%&R!3&8!na3i&n!, S!g2i8i!n& a R!3&8!na3i&n!,

. D!,3%i'a /a, %!a, ! !;$an,i4n ! a32!%& 3&n /a C/a,i@i3a3i4n T%iag!

ES-P-AS-01-F-005 Pgina *0 ! "# A$%&'a&: 01-0-0*+!%,i&n 0



81/94



R//) *+&',a

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82/94



1. G#,#!al'a#$

C&8$/!! /a in@&%8a3i4n B2! ,! ,&/i3ia a 3&nin2a3i4n:

11 R!gi,%! !/ n8!%& &a/ ! %a'aa&%!, ! /a in,i23i4n B2! %!a/i7an a3iia!, !;3/2,ia8!n! a,i,!n3ia/!, = a3iia!,!;3/2,ia8!n! a8ini,%aia, !n /a, 3&/28na N = . %!,$!3ia8!n! = !n /a 3&/28na N # !/ n8!%& ! %a'aa&%!, B2!3&8$a%! a3iia!, a,i,!n3ia/!, = a8ini,%aia, ,!gn $%&@!,i4n

N& T&a/ ! %a'aa&%!, ! /a &%gani7a3i4nA,i,!n3ia/!,

C&/28na A8ini,%ai&,

C&/28na .

A,i,!n3ia/!, =A8ini,%ai&,

C&/28na #

T&a/C&/28na 5

9>i3&, G!n!%a/!,

9>i3&, E,$!3ia/i,a,

En@!%8!%a,

In,%28!na&%a,

T!%a$!2a, R!,$i%a&%ia,

T!%a$!2a, O32$a3i&na/!,

T!%a$!2a, ! L!ng2a!

P,i34/&g&,

N2%i3i&ni,a,


83/94



A2;i/ia%!, A8ini,%ai&,

A2;i/ia%!, ! A%3?i&

T&a/

1 P&/6i3a = @&%8a, ! 3&n%aa3i4n ! $!%,&na/ ! /a in,i23i4n

R//) *+&',a

1. P&/6i3a, $a%a /a ,!/!33i4n !/ a/!n& ?28an&

R//) *+&',a

1# P&/6i3a, $a%a /a !23a3i4n 3&nin2aa !/ a/!n& ?28an&

R//) *+&',a

15 C/i8a &%gani7a3i&na/ 8&ia3i4n

R//) *+&',a

ES-P-AS-01-F-005 Pgina *. ! "# A$%&'a&: 01-0-0*+!%,i&n 0


84/94



85/94



SECCION E. GESTION DE LA INFORMACIN

1. G#,#!al'a#$


11 P%in3i$a/!, !,a%%&//&, !n !/ /i8& a& !/ ,i,!8a ! in@&%8a3i4n ! /a &%gani7a3i4n (!,%232%a3i4n !/ ,i,!8a !in@&%8a3i4n a$&=& !3n&/4gi3& a/!n& ?28an& in!%,i4n !3&n48i3a)

R//- *+&',a$

1 Aan3!, !n !/ $%&3!,& ! ,i,!8ai7a3i4n ! /a ?i,&%ia 3/6ni3aR//1 *+&',a

1. 9!3ani,8&, $a%a !/ 8an!ni8i!n& = ,&$&%! !/ ?a%Ya%! = ,&@Ya%!

R//1 *+&',a

1# P/an ! 3&ning!n3ia = ,i,!8a, %!2nan!, an! 3a8'i&, = 3a6a, !/ ,i,!8a ! in@&%8a3i4n

R//1 *+&',a

ES-P-AS-01-F-005 Pgina *5 ! "# A$%&'a&: 01-0-0*+!%,i&n 0



86/94



SECCIN F. INDICADORES DE GESTIN

E,a ,!33i4n i!n! /&, ,ig2i!n!, &'!i&,:1 P%!3i,a% /a @&%8a ! 8!i3i4n ! /&, ini3a&%!, ! g!,i4n ,&/i3ia&, !n /a, a'/a, N 5 10 11 15 1* " .0 .1 = ..

in3/2ia, !n /a, ,!33i&n!, A =


87/94



N&8'%! . Gi%& 3a8aD!@ini3i4n &$!%a3i&na/ N8!%& &a/ ! !g%!,&, !n !/ $!%6&& N8!%& &a/ ! 3a8a, i,$&ni'/!, !n !/ 8i,8& $!%6&&

Unia ! 8!ia N8!%&Ni!/!, ! !,ag%!ga3i4n H&,$ia/i7a3i4n &a/ ?&,$ia/i7a3i4n a2/&, ?&,$ia/i7a3i4n $!ia%6a ?&,$ia/i7a3i4n &',!%i3ia

N&8'%! # In@!33i4n in%a?&,$ia/a%iaD!@ini3i4n &$!%a3i&na/ Nmero de pacientes con in@!33i4n n&,&3&8ia/ (in%a?&,$ia/a%ia)!n !/ $!%6&& / Nmero total de

pacientes en !/ 8i,8& $!%6&&) * 100Unia ! 8!ia PorcentajeNi!/!, ! !,ag%!ga3i4n H&,$ia/i7a3i4n &a/ 32ia&, in!n,i&, a2/&, 32ia&, in!n,i&, $!i%i3& 32ia&, in!n,i&,

n!&naa/

N&8'%! 5 Ta,a ! in@!33i4n in%a?&,$ia/a%iaD!@ini3i4n &$!%a3i&na/ (Nmero de pacientes con in@!33i4n in%a?&,$ia/a%ia !n !/ $!%6&& / Nmero total de das

estancia de/&, $a3i!n!, !n !/ 8i,8& $!%6&&) * 1000Unia ! 8!ia Tasa por mil das estanciaNi!/!, ! !,ag%!ga3i4n H&,$ia/i7a3i4n &a/ 32ia&, in!n,i&, a2/&, 32ia&, in!n,i&, $!i%i3& 32ia&, in!n,i&,

n!&naa/

N&8'%! R!ing%!,&, $&% in@!33i4n in%a?&,$ia/a%iaD!@ini3i4n &$!%a3i&na/ (N8!%& &a/ ! $a3i!n!, B2! %!ing%!,an $&% in@!33i4n in%a?&,$ia/a%ia !n !/ $!%6&& N8!%& &a/ !

!g%!,&, ?&,$ia/a%i&, !n !/ 8i,8& $!%6&&) Z 100Unia ! 8!ia PorcentajeNi!/!, ! !,ag%!ga3i4n H&,$ia/i7a3i4n &a/ 32ia&, in!n,i&, a2/&, 32ia&, in!n,i&, $!i%i3& 32ia&, in!n,i&,

n!&naa/ 3i%2g6a

N&8'%! Ta,a ! in@!33i4n ! 6a, 2%ina%ia, a,&3iaa, a ,&na !,i3a/D!@ini3i4n &$!%a3i&na/ (N8!%& ! $a3i!n!, 3&n ,&na !,i3a/ B2! $%!,!na%&n in@!33i4n ! 6a, 2%ina%ia, !n !/ $!%6&&

N8!%& &a/ ! 6a, ! ,&na !,i3a/ !n $a3i!n!, !n !/ 8i,8& $!%6&&) Z 1000Unia ! 8!ia Tasa por 1000 das estanciaNi!/!, ! !,ag%!ga3i4n H&,$ia/i7a3i4n &a/ 32ia&, in!n,i&, a2/&, 32ia&, in!n,i&, $!i%i3& 32ia&, in!n,i&,

n!&naa/

N&8'%! * Ta,a ! n!28&n6a a,&3iaa a/ !ni/a&% (NA+)D!@ini3i4n &$!%a3i&na/ (N8!%& ! $a3i!n!, 3&n n!28&n6a a,&3iaa a/ !ni/a&% !n !/ $!%6&& N8!%& &a/ ! 6a,




88/94

ESTNDARES IPS HOSPITALARIASPARTE 1. PERFIL DE LA INSTITUCIN

VISITA DE OTORGAMIENTO

!ni/a&% !n !/ 8i,8& $!%6&&) Z 1000

Unia ! 8!ia Tasa por 1000 das ventilador

Ni!/!, ! !,ag%!ga3i4n C2ia&, in!n,i&, a2/&, 32ia&, in!n,i&, $!i%i3& 32ia&, in!n,i&, n!&naa/

N&8'%! " Ta,a ! in@!33i4n !/ &%%!n! 3i%32/a&%i&D!@ini3i4n &$!%a3i&na/ (N8!%& ! $a3i!n!, 3&n in@!33i&n!, !/ &%%!n! 3i%32/a&%i& ((in3/2=! 'a3!%!8ia @2ng!8ia =

,!$i3!8ia) a,&3iaa, a /a in%&233i4n ! 3a>!% !n&,& 3!n%a/ !n !/ $!%6&& N8!%& &a/ ! 6a,3a>!% !n&,& 3!n%a/ !n !/ 8i,8& $!%6&&) Z 1000

Unia ! 8!ia Tasa por 1000 das estanciaNi!/!, ! !,ag%!ga3i4n C2ia&, in!n,i&, a2/&, 32ia&, in!n,i&, $!i%i3& 32ia&, in!n,i&, n!&naa/

N&8'%! 10 Pa3i!n!, $!i%i3&, 3&n n!28&n6a, '%&n3&-a,$i%aia,D!@ini3i4n &$!%a3i&na/ (N8!%& ! $a3i!n!, $!i%i3&, 3&n n!28&n6a '%&n3&-a,$i%aia !n !/ $!%6&& T&a/ ! $a3i!n!,

$!i%i3&, !n !/ 8i,8& $!%6&&) Z100Unia ! 8!ia P&%3!na!Ni!/!, ! !,ag%!ga3i4n H&,$ia/i7a3i4n $!ia%6a 32ia&, in!n,i&, $!i%i3& 32ia& in!%8!i& $!i%i3& 32ia&,

in!n,i&, n!&naa/ = 32ia&, in!%8!i& n!&naa/

N&8'%! 11 P%&8!i& ! 3&n%&/!, $%!naa/!,D!@ini3i4n &$!%a3i&na/ S28a&%ia !/ n8!%& ! 3&n%&/!, %!a/i7a&, a /a, 82!%!, g!,an!, 3&n $a%&, a!ni&, !n /a

in,i23i4n !n !/ $!%6&& N8!%& &a/ ! 82!%!, g!,an!, 3&n $a%&, a!ni&, !n /a in,i23i4n !n !/8i,8& $!%6&&

Unia ! 8!ia N8!%&Ni!/!, ! !,ag%!ga3i4n H&,$ia/ i7a3i4n &',>%i3ia

N&8'%! 1 C&'!%2%a ! 3&n%&/ $%!naa/D!@ini3i4n &$!%a3i&na/ (N8!%& ! 82!%!, g!,an!, 3&n 2n na3i8i!n& i& B2! %!3i'i!%&n a!n3i4n $%!naa/ 32a%& & 8,!3!, !n !/ $!%6&& N8!%& &a/ ! 82!%!, g!,an!, 3&n 2n na3i8i!n& i& !n !/ 8i,8& $!%6&&) Z100

Unia ! 8!ia P&%3!na!Ni!/!, ! !,ag%!ga3i4n H&,$ia/ i7a3i4n &',!%i3ia

N&8'%! 1. R!/a3i4n $a%&, agina/!, , $a%&, $&% 3!,%!aD!@ini3i4n &$!%a3i&na/ N8!%& &a/ ! $a%&, agina/!, !n !/ $!%i&& N8!%& &a/ ! $a%&, $&% 3!,%!a !n !/ 8i,8&

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$!%i&&

Unia ! 8!ia N8!%&

Ni!/!, ! !,ag%!ga3i4n H&,$ia/ i7a3i4n &',!%i3ia

N&8'%! 1# A?!%!n3ia a g26a ! $%3i3a 3/6ni3a 8>i3a ! ?!8&%%agia, III %i8!,%! ! g!,a3i4nD!@ini3i4n &$!%a3i&na/ (N8!%& ! ?i,&%ia, 3/6ni3a, !a/2aa, ! $a3i!n!, a!nia, 3&n iagn&,i3& ! ?!8&%%agia, !/ III

%i8!,%! = !a g!,a3i&na/ 8a=&% ! ,!8ana, B2! 328$/!n 3&n /a g26a ! $%3i3a 3/6ni3a 8>i3a!n !/ $!%6&& N8!%& &a/ ! ?i,&%ia, 3/6ni3a, !a/2aa, ! $a3i!n!, a!nia, 3&n iagn&,i3& !?!8&%%agia, !/ III %i8!,%! = !a g!,a3i&na/ 8a=&% ! ,!8ana, !n !/ 8i,8& $!%6&&) Z100

Unia ! 8!ia P&%3!na!Ni!/!, ! !,ag%!ga3i4n H&,$ia/i7a3i4n &',!%i3ia 2%g!n3ia,

N&8'%! 15 A?!%!n3ia a g26a ! $%3i3a 3/6ni3a 8>i3a ! %a,&%n&, ?i$!%!n,i&, ! /a g!,a3i4n

D!@ini3i4n &$!%a3i&na/ (N8!%& ! ?i,&%ia, 3/6ni3a, !a/2aa, ! $a3i!n!, a!nia, 3&n iagn&,i3& ! %a,&%n&,?i$!%!n,i&, ! /a g!,a3i4n = !a g!,a3i&na/ 8a=&% ! ,!8ana, B2! 328$/!n 3&n /a g26a !$%3i3a 3/6ni3a 8>i3a !n !/ $!%6&& N8!%& &a/ ! ?i,&%ia, 3/6ni3a, !a/2aa, ! $a3i!n!,a!nia, 3&n iagn&,i3& ! %a,&%n&, ?i$!%!n,i&, ! /a g!,a3i4n = !a g!,a3i&na/ 8a=&% ! ,!8ana, !n !/ 8i,8& $!%i&&) Z100

Unia ! 8!ia P&%3!na!Ni!/!, ! !,ag%!ga3i4n H&,$ia/i7a3i4n &',!%i3ia 2%g!n3ia,

N&8'%! 1 C&8$/i3a3i4n &',>%i3aD!@ini3i4n &$!%a3i&na/ (N8!%& ! 82!%!, g!,an!, 3&n 3&8$/i3a3i&n!, &',>%i3a, !n !/ $!%6&& T&a/ ! $%&3!i8i!n&,

&',>%i3&, !n !/ 8i,8& $!%6&&) Z 100Unia ! 8!ia P&%3!na!

Ni!/!, ! !,ag%!ga3i4n H&,$ia/i7a3i4n &',!%i3ia 2%g!n3ia,

N&8'%! 1 Ra74n ! 8&%a/ia 8a!%naD!@ini3i4n &$!%a3i&na/ (N8!%& ! 82!%!, 8a!%na, $&% 3a2,a, a%i'2i'/!, a/ !8'a%a7& !n !/ $!%6&& N8!%& &a/ !

na3i&, i&, !n !/ 8i,8& $!%6&&) Z 1000Unia ! 8!ia N8!%&Ni!/!, ! !,ag%!ga3i4n H&,$ia/ i7a3i4n &',!%i3ia

N&8'%! 1* En&8!%ii, $&,$a%&

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D!@ini3i4n &$!%a3i&na/ (N8!%& ! $a3i!n!, 3&n !n&8!%ii, $&,$a%& (agina/ 8, 3!,%!a) !n !/ $!%6&& N8!%& &a/ !$a3i!n!, 3&n $a%&, a!ni&, (agina/ 8, 3!,%!a) !n !/ 8i,8& $!%6&&) Z100

Unia ! 8!ia P&%3!na!Ni!/!, ! !,ag%!ga3i4n H&,$ia/ i7a3i4n &',!%i3ia

N&8'%! 1" Ta,a ! 8&%a/ia $!%inaa/D!@ini3i4n &$!%a3i&na/ (S28a&%ia ! n8!%& ! 82!%!, @!a/!, a%6a, ( & 8, ,!8ana, ! g!,a3i4n) = n8!%& !

82!%!, n!&naa/!, $%!3&3!, (8!n&, ! 6a, ! ia & 8a=&% a 500 g%a8&, ! $!,&) !n !/ $!%6&& T&a/ ! na3i&, i&, !n !/ 8i,8& $!%6&&) Z 1000

Unia ! 8!ia Ta,a $&% 1000Ni!/!, ! !,ag%!ga3i4n H&,$ia/ i7a3i4n &',!%i3ia

N&8'%! 0 R!/a3i4n ! 3&n,2/a, 2%g!n3ia, , 3&n,2/a, ! %iag!D!@ini3i4n &$!%a3i&na/ N8!%& &a/ ! 3&n,2/a, ! 2%g!n3ia, a!nia, !n !/ $!%6&& N8!%& &a/ ! %iag! %!a/i7a&, !n !/

8i,8& $!%6&&Unia ! 8!ia N8!%&Ni!/!, ! !,ag%!ga3i4n U%g!n3ia, a2/&, 2%g!n3ia, $!i%i3a, 2%g!n3ia, &',>%i3a,

N&8'%! 1 R!ing%!,&, a/ ,!%i3i& ! 2%g!n3ia, $&% /a 8i,8a 3a2,a an!, ! ?&%a,D!@ini3i4n &$!%a3i&na/ (N8!%& ! $a3i!n!, B2! %!ing%!,an a/ ,!%i3i& ! 2%g!n3ia, $&% /a 8i,8a 3a2,a an!, ! ?&%a, !n

!/ $!%6&& N8!%& &a/ ! $a3i!n!, %!gi,%a&, !n !/ ,!%i3i& ! 2%g!n3ia, !n !/ 8i,8& $!%6&&) Z100Unia ! 8!ia P&%3!na!Ni!/!, ! !,ag%!ga3i4n U%g!n3ia, a2/&, 2%g!n3ia, $!i%i3a, 2%g!n3ia, &',!%i3a,

N&8'%! Can3!/a3i4n ! 3i%2g6a $%&g%a8aaD!@ini3i4n &$!%a3i&na/ (N8!%& ! 3i%2g6a, $%&g%a8aa, (a8'2/a&%ia, = ?&,$ia/a%ia,) 3an3!/aa, !n !/ $!%6&& N8!%& &a/

! 3i%2g6a, $%&g%a8aa, (a8'2/a&%ia, = ?&,$ia/a%ia,) !n !/ 8i,8& $!%6&&) Z 100Unia ! 8!ia P&%3!na!Ni!/!, ! !,ag%!ga3i4n Ci%2g6a

N&8'%! . Can3!/a3i4n ! 3i%2g6a $&% 3a2,a in,i23i&na/D!@ini3i4n &$!%a3i&na/ (N8!%& ! 3i%2g6a, $%&g%a8aa, (a8'2/a&%ia, = ?&,$ia/a%ia,) 3an3!/aa, $&% 3a2,a in,i23i&na/ !n

!/ $!%i&& N8!%& &a/ ! 3i%2g6a, $%&g%a8aa, (a8'2/a&%ia, = ?&,$ia/a%ia,) !n !/ 8i,8& $!%i&&) Z100

Unia ! 8!ia P&%3!na!

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Ni!/!, ! !,ag%!ga3i4n Ci%2g6a

N&8'%! # Can3!/a3i4n ! 3i%2g6a $&% 3a2,a n& in,i23i&na/D!@ini3i4n &$!%a3i&na/ (N8!%& ! 3i%2g6a, $%&g%a8aa, (a8'2/a&%ia, = ?&,$ia/a%ia,) 3an3!/aa, $&% 3a2,a n& in,i23i&na/!n !/ $!%i&& N8!%& &a/ ! 3i%2g6a, $%&g%a8aa, (a8'2/a&%ia, = ?&,$ia/a%ia,) !n !/ 8i,8&$!%i&&)Z100

Unia ! 8!ia P&%3!na!Ni!/!, ! !,ag%!ga3i4n Ci%2g6a

N&8'%! !/ Ini3a&% 5 R!/a3i4n ! $%&3!i8i!n&, !/!3i&, , $%&3!i8i!n&, n& !/!3i&,D!@ini3i4n &$!%a3i&na/ N8!%& ! $%&3!i8i!n&, !/!3i&, !n !/ $!%6&& N8!%& ! $%&3!i8i!n&, n& !/!3i&, !n !/ 8i,8&

AutoevaluaciónOtorgamientoIPShospitalariaParte1

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