DRCHANSIOPAN陈少斌医生家庭医学专科医生.ppt

DR CHANSIOPAN陈少斌医生家庭医学专科医生 F H K A M FamilyMedicine 香港医学专科学院院士 家庭医学 Notanexpertinmedicalrecord 非医疗记录专家 PURPOSEOFMEDICALRECORD医疗记录的作用 Longitudinalhistorypatient shealth病人健康情况Providecontinuityofcare持续照顾Anticipatorycare疾病预防Communications资讯交流Educational Research教育和研究Auditing qualityassurance审查和品质保证 Billing收费记录MEDICALLEGAL有关医学的法律问题 BASICINFORMATION基本资讯 Personal个人资料Pasthistory病历Socialhistory社康背景Occupation职业 OTHERINFORMATION其他资讯 Immunization疫苗注射Developmentalhistory成长史Problemlist现有 持续医疗问题Medicationlist药物记录Psychological心理Familyhistory家族严重疾病历史Allergy敏感 SOAPnote Subjective主观 病者所言whatyouheardObjective客观 医者观yourfindingsAssessment诊断及评估yourconclusionPlan治疗计划youplanofmanagement MEDICALLEGAL有关医学的法律问题 USA medicalrecorddatabelongtopatient病历属於病人所有UK belongtoNHS病历属於国家卫生组织HK datainallmedicalrecordbelongtopatient patienthasabsoluterighttoassessallhis herdata Doctorcanchargereasonablehandlingfee 病历资料属於病人所有 病人有绝对权力提取个人资料 医生可以合理地收费 PIC 香港医务委员会 Medicalcomplaint firstactionwillrequestthedefendanttoproducephotocopyofthe ORIGINAL medicalrecordoftheincidence 医疗事故投诉 医务委员会先要求当事人提交相关医疗病历副本Medicalrecord shouldbekept indefinitely 病历应该 永远 保留 EMBINHONGKONG ITSURVEYHKMA 90 doctorusecomputer40 hadClinicManagementPackage90 doctorinterestedinHAtrainingcoursetoassesshospitaldataAlreadyinplaceinprivatehospital CanossaHospitalNonoftheprogramareinter operative EMR electronicmedicalrecord willbeamustinthefuture将来会成为必须Userfriendliness是否容易使用Whentostart应何时开始Addingoldrecords加入旧记录Interoperability共容性Digitalphoto scanner数码相片与扫描Confidentiality保密Reliability BACKUP绝对需要另存档案Legalconsideration法律责任 PERSONALEXPERIENCE Over10yearsexperience 3generationsofEMR forDOStowindowBugsininitialphase thingswillgetbetterVirus alwaysaseriousthreatNewersoftware hardwarenotalwayscompatiblewitholdonee g Windowxpvs98 printeretcTechnicalsupportveryimportantThereisgoingtobemoreproblemsthanyoucanthinkof AlwaysBACKUPyourdata ADVANTAGES Carriesyourrecordhomeinamem stickGoodforHongKongwhereofficerentup youmove printaddresslabelstooEasyretrievalofrecord matterofsecondsParticularlygoodinDRUGALLERGYAccountkeepingandauditingDigitalphoto video scanning