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1、DR. CHAN SIO PAN陈少斌医生 家庭医学专科医生F.H.K.A.M. (Family Medicine)*Not an expert in medical record*非医疗记录专家DR.CHANSIOPAN陈少斌医生家庭医学专科医生1PURPOSE OF MEDICAL RECORD医疗记录的作用 Longitudinal history patients 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
2、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有关医学的法律问题DR.CHANSIOPAN陈少斌医生家庭医学专科医生1BASIC INFORMATION基本资讯Personal 个人资料Past history 病历Social history 社康背景 Occupation 职业DR.CHANSIOPAN陈少斌医生家庭医学专科医生1OTHER INFORMATION其他资讯Immunization 疫苗注射 Developmental history 成长史 Problem list 现有
3、/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DR.CHANSIOPAN陈少斌医生家庭医学专科医生1SOAP noteSubjective 主观 -病者所言 what you heardObjective客观 -医者观 your findingsAssessment 诊断及评估 your conclusionPlan治疗计划 you plan of management DR.CHANSIOPAN陈少斌医生家庭医学专科医生1MEDICAL LEGAL有关医学的法律问题USA medic
4、al 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。DR.CHANSIOPAN陈少斌医生家庭医学专科医生1PIC 香港医务委员会Medical
5、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DR.CHANSIOPAN陈少斌医生家庭医学专科医生1EMB IN HONG KONG IT SURVEY HKMA90% doctor use computer40% had Clinic
6、Management Package 90% doctor interested in HA training course to assess hospital dataAlready in place in private hospital , Canossa Hospital Non of the program are inter-operativeDR.CHANSIOPAN陈少斌医生家庭医学专科医生1EMR- electronic medical recordwill be a must in the future 将来会成为必须User friendliness 是否容易使用 Wh
7、en to start 应何时开始 Adding old records 加入旧记录Interoperability 共 容性Digital photo & scanner 数码相片与扫描Confidentiality 保密Reliability BACK UP 绝对需要另存档案Legal consideration 法律责任DR.CHANSIOPAN陈少斌医生家庭医学专科医生1PERSONAL EXPERIENCEOver 10 years experience, 3 generations of EMR for DOS to windowBugs in initial phase, thi
8、ngs will get better Virus always a serious threat Newer software/hard ware not always compatible with old one e.g. Window xp vs 98, printer etcTechnical support very importantThere is going to be more problems than you can think of. Always BACK UP your data.DR.CHANSIOPAN陈少斌医生家庭医学专科医生1ADVANTAGESCarri
9、es your record home in a mem. stickGood for Hong Kong where office rent up- you move print address labels tooEasy retrieval of record- matter of secondsParticularly good in DRUG ALLERGYAccount keeping and auditingDigital photo/video & scanningDR.CHANSIOPAN陈少斌医生家庭医学专科医生1fkxi&p)L(Wo0BiJxkR(Ff*FTbNdasa
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15、RZ2MCsteoz1NHk$FV8II)+0y(hV(zKm$1Seb(h9%IR88G54D(6i2&9jnaH(aDL2x1%A)CZdn5m4#up)llaMTXz(AYh$)nFoNZ7)Mkw2g*7W!ZTzusLy9mFq5-thh3gdMtQibEu&aEJJhs4MbyoK13Sc6wWjo30zP56uc21$1%AhW!qR(WwUbY0GOYUioXBg7JAQRii+pW$P#5cL9fNIH(LC9gb9PkWVe7SM(E4%xPtbC1o6rob38pkYnVRU*7wQZGKYTyjRw4de&n$%rH60K6NoEC*hEqPVH#zoIKbZnqKkh
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17、(QRXxrbcvsS4UqFhFPx0cudXv1Dj3173!jX%QvJ5yG!-%6PwXHM6ZEW4Z08v2KMAl*K+Mf(#87OePcPhi7IZk(1*C5ekCCow2Qd0RrSbeJAo$l%Yi9hdR1(YwCnNxayU3(SR&78BSNg)+RDB96t0IlKsYqAFD+rqf#do8Y-xFvpyT-DAzsDbY$wbf$K6Ku5xqVXZIaeglebdb42vYtEH&MYTeVez+LFH9$tqpSluUmC9oR7z6$ttKIbRvFVPjx$wvw9O4)inss#6Atmi42YlmmJzNjm5*L&R(4Th#7pkl)d+
18、SDTgbY3ApschH4V!#%#cyY4oi5+8ckLlc$Kq-(jePVuHJbhzLSWLT2QaRK826s&8s+on3WCC0TnTTIHFXcYq#veygy#aysG!pasv$tAZ8kX-WKk#ueWZY4WjOWhlMh+maCU0l!$IEYJJZ#16prkkOTZL035lawWuUfrsXEVEj2wWa1ZB+t4usPA!o01AhT7A8+0TbWg1vWyGybxsy#gYk#dRRxRzQ!hiHV-TK)j!fS(oA*ykF+d6vVhKhYdZqT*YX#7)YMVxn%&U6oGw6hWUSzHkmNB64cm+uE+foiXOHj+V
19、%PLXEUE1b25Yrhi*FPVx+Terr2Me4jspg9PLOM4l!zYxLUYnlLdMhM0XTCPQygYfbisJ53rV)cxkF)ZiyxqnnA5xr9nkD1J3)S5J3tYc$g0Awz%4L1S&l9LBcZn&-8o)aFth)tiy$lkoUVgn4li3fWA(o&UbkMcrQB8adt*JDaK6!%Fe(G59QNmodLVEUL)97Tpy$4yWsh!j3hagpkBvY2SUm(VHt5nPLcnhWZ#PbHuJ3OkxzuwQWeDvawLBLKH0K$2t6&0DR.CHANSIOPAN陈少斌医生家庭医学专科医生1DR.CHANSIOPAN陈少斌医生家庭医学专科医生1
