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 place in private hospital , Canossa Hospital

– Non of the program are inter-operative

Name of Clinic Management Package Used

The CMSsystem of the

HA20%

ClinicSmart4%

Tailor madesoftware

17%

Others15%

Missing3%

ClinicSolution29%

HKMA CMS2.0

12%

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

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.

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