PPT-DR.CHANSIOPAN陈少斌医生家庭医学专科医生.pptVIP

DR. CHAN SIO PAN陈少斌医生 家庭医学专科医生 F.H.K.A.M. (Family Medicine) 香港医学专科学院院士(家庭医学) *Not an expert in medical record *非医疗记录专家 PURPOSE OF MEDICAL RECORD医疗记录的作用 Longitudinal history patient’s health 病人健康情况 Provide continuity of care 持续照顾 Anticipatory care 疾病预防 Communications 资讯交流 Educational Research 教育和研究 Auditing quality assurance 审查和品质保证 *Billing 收费记录 MEDICAL LEGAL 有关医学的法律问题 BASIC INFORMATION基本资讯 Personal 个人资料 Past history 病历 Social history 社康背景 Occupation 职业 OTHER INFORMATION其他资讯 Immunization 疫苗注射 Developmental history 成长史 Problem list 现有/持续 医疗问题 Medication list 药物记录 Psychological 心理 Family history 家族严重疾病历史 Allergy 敏感 SOAP note Subjective 主观 -病者所言 what you heard Objective 客观 -医者观 your findings Assessment 诊断及评估 your conclusion Plan 治疗计划 you plan of management MEDICAL LEGAL有关医学的法律问题 USA – medical record data belong to patient 病历属於病人所有 UK – belong to NHS 病历属於国家卫生组织 HK - data in all medical record belong to patient, patient has absolute right to assess all his/her data. Doctor can charge reasonable handling fee. 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 Medical complaint - first action will request the defendant to produce photocopy of the ‘ORIGINAL’ medical record of the incidence. 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 Medical record – should be kept ‘indefinitely’ 病历应该”永远”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 plac