DR.CHANSIOPAN陳少斌醫(yī)生家庭醫(yī)學(xué)專科醫(yī)生

1、DR. CHAN SIO PAN陳少斌醫(yī)生 家庭醫(yī)學(xué)?？漆t(yī)生F.H.K.A.M. (Family Medicine)香港醫(yī)學(xué)?？茖W(xué)院院士(家庭醫(yī)學(xué))*Not an expert in medical record*非醫(yī)療記錄專家PURPOSE OF MEDICAL RECORD醫(yī)療記錄的作用 Longitudinal history patients health 病人健康情況 Provide continuity of care 持續(xù)照顧 Anticipatory care 疾病預(yù)防 Communications 資訊交流 Educational & Research 教育和研究 A

2、uditing & quality assurance 審查和品質(zhì)保證 *Billing 收費(fèi)記錄 MEDICAL LEGAL 有關(guān)有關(guān)醫(yī)醫(yī)學(xué)的法律問(wèn)題學(xué)的法律問(wèn)題BASIC INFORMATION基本資訊 Personal 個(gè)人資料 Past history 病歷 Social history 社康背景 Occupation 職業(yè)OTHER INFORMATION其他資訊 Immunization 疫苗注射 Developmental history 成長(zhǎng)史 Problem list 現(xiàn)有/持續(xù) 醫(yī)療問(wèn)題 Medication list 藥物記錄 Psychological 心理 F

3、amily history 家族嚴(yán)重疾病歷史 Allergy 敏感SOAP note Subjective 主觀 -病者所言 what you heard Objective客觀 -醫(yī)者觀 your findings Assessment 診斷及評(píng)估 your conclusion Plan治療計(jì)劃 you plan of management MEDICAL LEGAL有關(guān)醫(yī)學(xué)的法律問(wèn)題 USA medical record data belong to patient 病歷屬於病人所有 UK belong to NHS 病歷屬於國(guó)家衛(wèi)生組織 HK - data in all medical

4、 record belong to patient, patient has absolute right to assess all his/her data. Doctor can charge reasonable handling fee. 病歷資料屬於病人所有，病人有絕對(duì)權(quán)力提取個(gè)人資料。醫(yī)生可以合理地收費(fèi)。PIC 香港醫(yī)務(wù)委員會(huì) Medical complaint - first action will request the defendant to produce photocopy of the ORIGINAL medical record of the incidence

5、. 醫(yī)療事故投訴 -醫(yī)務(wù)委員會(huì)先要求當(dāng)事人提交相關(guān)醫(yī)療病歷副本 Medical record should be kept indefinitely 病歷應(yīng)該”永遠(yuǎn)”保留EMB IN HONG KONG IT SURVEY HKMA 90% doctor use computer 40% had Clinic Management Package 90% doctor interested in HA training course to assess hospital data Already in place in private hospital , Canossa Hospital N

6、on of the program are inter-operativeName of Clinic Management Package UsedThe CMSsystem of theHA20%ClinicSmart4%Tailor madesoftware17%Others15%Missing3%ClinicSolution29%HKMA CMS2.012%EMR- electronic medical record will be a must in the future 將來(lái)會(huì)成為必須 User friendliness 是否容易使用 When to start 應(yīng)何時(shí)開(kāi)始 Add

7、ing old records 加入舊記錄 Interoperability 共 容性 Digital photo & scanner 數(shù)碼相片與掃描 Confidentiality 保密 Reliability BACK UP 絕對(duì)需要另存檔案 Legal consideration 法律責(zé)任PERSONAL EXPERIENCE Over 10 years experience, 3 generations of EMR for DOS to window Bugs in initial phase, things will get better Virus always a se

8、rious threat Newer software/hard ware not always compatible with old one e.g. Window xp vs 98, printer etc Technical support very important There is going to be more problems than you can think of. Always BACK UP your data.ADVANTAGES Carries your record home in a mem. stick Good for Hong Kong where office rent up- you move print address labels too Easy retriev