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DR. CHAN SIO PAN 陈少斌医生 家庭 医 学专科 医生

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

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DR. CHAN SIO PAN 陈少斌医生 家庭 医 学专科 医生

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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) 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

  2. 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

  3. BASIC INFORMATION基本资讯 • Personal 个人资料 • Past history 病历 • Social history 社康背景 • Occupation 职业

  4. 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

  5. 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

  6. 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。

  7. 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

  8. 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 • Non of the program are inter-operative

  9. EMR- electronic medical record • will be a must in the future 将来会成为必须 • User friendliness 是否容易使用 • When 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

  10. 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 serious 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.

  11. ADVANTAGES • Carries your record home in a mem. stick • Good for Hong Kong where office rent up- you move – print address labels too • Easy retrieval of record- matter of seconds • Particularly good in DRUG ALLERGY • Account keeping and auditing • Digital photo/video & scanning

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