在临床医学中怎样用药.ppt

1,Chapter1:HealthCareDeliverySystemsFeipeiLaiNationalTaiwanUniversity,2,HealthCareDeliverySystems,HistoryofMedicineandHealthcareDeliveryContinuumofCareHealthCareFacilityOwnershipHealthCareFacilityOrganizationalStructureLicensure,Regulation,andAccreditation,3,Introduction,Healthcaredeliveryhasbeengreatlyimpactedbyescalatingcosts,resultinginmedicalnecessityrequirements,reviewofappropriatenessofadmissions,andrequirementforadministrationofqualityandeffectivetreatments.,4,MRXO,在臨床醫學中，進行手術時同時使用磁振造影並整合各種影像技術是目前最熱門的醫療概念。新式的未來手術室中，安裝有全球首套MRXO解決方案，即完全整合磁振造影(MR)、光及電腦斷層掃描(CT)系統，大幅減少病患危險並簡化醫師的手續，可望提高手術成功率。這項由日本東海大學、飛利浦醫療系統事業部合力推動的未來手術室，已經由日本東海大學的松前教授、津具醫師、山本醫師共同在手術室同時使用MR(磁振造影)和X光影像技術，來進行神經外科手術。,5,MRXO,在未來手術室中執行手術，可依執刀醫師與病患狀況，在數分鐘內將病患從手術台搬移到磁振造影、電腦斷層掃描或光診斷系統，增加手術精密度與成功率。在磁振造影和電腦斷層掃描區域有拉門。,6,HistoryofMedicinenursesandancillarystaffarein-houseandimmediatelyavailabletoinitiateresuscitativemeasures.,20,Traumacenters,LevelIV:criticallyinjuredpatientswhorequirespecialtycarearetransferredtoahigherleveltraumasystemhospitalinaccordancewithpre-establishedcriteria.,21,Tertiarycare,BurncentertreatmentCardiothoracicandvascularsurgeryInpatientcareforAIDSpatientsMagneticresonanceimaging(MRI)NeonatologylevelIIIunitservicesNeurosurgeryOrgantransplant,22,Tertiarycare,PediatricsurgeryPositronemissionstomography(PET)RadiationoncologyServicesprovidedtoapersonwithahigh-riskpregnancyServicesprovidedtoapersonwithcancerState-designatedtraumacentersTraumasurgery,23,Positronemissionstomography(PET),buildsimagesbydetectingenergygivenoffbydecayingradioactiveisotopes.Isotopesareatomsofanelementwiththesamenumberofprotons(positivelychargedparticles)inthenucleus,butadifferentnumberofneutrons(neutralparticles).Becauseradioactiveisotopesareunstable,astheydecay,theythrowoffpositronsthatcollidewithelectronsandproducegammaraysthatshootoffinnearlyoppositedirections.,24,PET/abt/sidebars/pet.shtml,PETsystemsusethepathsofthetwodetectedgammaraystodeterminetheoriginatingcollisionpoint,aprocesscalledelectroniccollimation(瞄準).Thescannersuseacircularseriesofgammaray-detectorstoenvelopethepatientsobothgammascanbedetectedsotheinstrumentcanuseelectroniccollimationtopredictwheretheenergysignaloriginated.Thissignalisthenconvertedintoathree-dimensionalimageslice.,25,台灣醫院分類,診所地區醫院(497/2005)區域醫院(80/2005,65/2006,64/2007)醫學中心(23/2005,18/2006,19/2007,14/2009),26,醫學中心,在衛生局登記開放的急性一般病床與急性精神病床合計須達五百床以上至少應能提供家庭醫學、內、外、婦產、兒、骨、神經外、泌尿、耳鼻喉、眼、皮膚、神經、精神、復健、麻醉、放射線、病理、核醫、牙等十九科之診療服務。,27,醫學中心,專任主治醫師人數(包括主任在內)每八床應有一名。專任護理人員每2床至少1名。加護病房：每床2.5名。手術室：每班每台2.5名。手術恢復室：每班每床0.5名。產房及待產室：每床2名。嬰兒室：每床0.4名。急診室：觀察室每床0.5名；診療室每12人次1名。門診：每班每診療室0.5名。血液透析室：每4人次1名。行政、教學、研究及其他護理人員(如院內感染控制、公衛、供應中心等護理人員)另計，應佔總人數百分之六。應有受過感染控制訓練之專任護理人員，每300床應設1名。,28,醫學中心,藥事人員每40床至少1名。每60張門診處方至少1名。特殊藥品處方每15張至少1名。藥事人員總數至少四分之三為藥師。藥事人員至少有4名負責藥品管理諮詢及臨床等工作。,29,區域醫院,應設置250床位以上急性病病床數每床所擁有的樓地板面積應在50平方公尺以上每9床至少應擁有一名主治醫師每2.5床至少應擁有一名護理人員等。至少應能提供家庭醫學、內、外、婦產、兒、骨、耳鼻喉、眼、精神、復健、麻醉、放射線、病理、牙等十四科之診療服務。,30,區域醫院Nurse,加護病房：每床2名。手術室：每班每台2名。手術恢復室：每班每床0.5名。產房及待產室：每床1.2名。嬰兒室：每床0.4名。急診室：觀察室每床0.5名；診療室每12人次1名。門診：每班每診療室0.5名。血液透析室：每4人次1名。行政、教學、研究及其他護理人員(如院內感染控制、公衛、供應中心等護理人員)另計，應佔總人數百分之四。應有受過感染控制訓練之專任護理人員，每300床應設1名。,31,區域醫院,藥事人員每50床至少1名。每70張門診處方至少1名。特殊藥品處方每15張至少1名。藥事人員總數至少四分之三為藥師。藥事人員中，至少有2名負責藥品管理諮詢及臨床等工作。,32,地區醫院,在衛生局登記開放的急性一般病床需20床以上，急性一般病床及急性精神病床合計249床（含）以下。,33,地區醫院,專任員工總人數每床應有1名。專任主治醫師人數以及專任護理人員應符合醫療機構設置標準。藥事人員每50床至少1名。每80張門診處方至少1名。每增加100張處方應增加1名。應有藥師1人以上。,34,評鑑分級,設施總樓地板面積病房設施安全設備及一般設備保險病床比率,35,評鑑分級,人員員工總人數醫師總數麻醉科醫師放射線科醫師核醫科醫師病理科醫師復健科醫師精神科醫師護理藥事醫事檢驗醫用放射線技術復健技術精神科社會工作營養師病歷管理,36,評鑑分級,醫療業務及設備醫療業務急性病床數診療科別急診業務手術及麻醉作業產房嬰兒室加護病房藥事作業檢驗作業輸血作業放射線診療作業病理作業復健醫療作業精神科核子醫學牙科特殊醫療服務醫務社會服務工作營養部門病歷部門社區衛生服務員工健康檢查,37,評鑑分級,品質保證醫療品質審查感染控制人體試驗藥事作業品質護理服務品質檢驗作業品質管制輸血作業品質管制病理作業品質管制放射線診療品質管制核子醫學品質管制病歷管理醫院管理業務醫病關係之促進,38,評鑑分級,指定項目評估住院診斷處置用藥手術病歷寫作,39,評鑑分級,教學訓練教學師資教學訓練與研究設備教學訓練活動與其他醫院(醫學院)交流合作情形研究情形及論文發表教學進修研究經費,40,新制教學醫院評鑑基準,教學資源教學訓練計畫與成果研究執行與成果臨床師資培育及繼續教育學術交流與社區功能及角色管理行政,41,財團法人醫院評鑑暨醫療品質策進會,.tw/Identify.asp?catid=23,42,HealthCareFacilityOwnership,Government(not-for-profit)25%Proprietary(for-profit)15%Voluntary(not-for-profit)60%,43,MedicalStaff,Intern:aphysicianinthefirstyearofgraduatemedicaleducation,whichordinarilyimmediatelyfollowscompletionofthefour-yearmedicalcurriculum.Resident:aphysicianwhohascompletedaninternshipandisengagedinaprogramoftrainingdesignedtoincreasehisorherknowledgeoftheclinicaldisciplinesofmedicine,surgery,oranyoftheotherspecialfieldsthatprovideadvancedtraininginpreparationforthepracticeofaspecialty.,44,MedicalStaff,Chiefresident:aphysicianwhoisinhisfinalyearofresidencyorintheyearaftertheresidencyhasbeencompleted.VisitingStaff(VS):主治醫師,45,HealthCareFacilityOrganizationalStructure,GoverningboardAdministrationMedicalstaffDepartments,services,andcommitteesContractedservices,46,Governingboard,Thegoverningboard(boardoftrustees,boardofgovernors,boardofdirectors)serveswithoutpay,anditsmembershipisrepresentedbyprofessionalsfromthebusinesscommunity.,47,Administration,Servesasliaisonbetweenthemedicalstaffandgoverningboardandisresponsiblefordevelopingastrategicplanforsupportingthemissionandgoalsoftheorganization.CEO:chiefexecutiveofficeCFO:chieffinancialofficerCIO:chiefinformationofficerCOO:chiefoperatingofficer,48,Medicalstaff,Consistsoflicensedphysiciansandotherlicensedprovidersaspermittedbylaw(e.g.,nursepractitionersandphysicianassistants)whoaregrantedclinicalprivileges.,49,physicianassistants,Examine,diagnose,andtreatpatientsunderthedirectsupervisionofaphysician.,50,Medicalstaffmembershipcategories,Active:deliversmosthospitalmedicalservices,performssignificantorganizationalandadministrativemedicalstaffdutiesAssociate:advancementtoactivecategoryisbeingconsideredConsultingCourtesy:admitsanoccasionalpatienttothehospitalHonorary,51,52,Hospitaldepartments,Services,andCommittees,53,NTUHDepartments,秘書室總務室企劃管理室病歷資訊管理室醫療事務室社會工作室公共事務室工務室資訊室圖書室安全衛生室警衛隊會計室人事室教學部醫學工程部,54,NTUHDepartments,內科部外科部骨科部婦產部小兒部神經部精神部耳鼻喉部眼科部泌尿部皮膚部牙科部復健部家庭醫學部麻醉部影像醫學部核子醫學部檢驗醫學部病理部藥劑部護理部營養部綜合診療部醫學研究部基因醫學部門診部急診醫學部腫瘤醫學部創傷醫學部老年醫學部環境及職業醫學部,55,NTUHDepartments,品質管理中心資財管理中心健康管理中心肝炎研究中心形體美容醫學研究中心國家級卓越臨床驗與研究中心,56,抗老及健康諮詢中心心臟衰竭中心乳房醫學中心感染控制中心運動醫學中心過敏免疫中心臨床心理中心健康教育中心睡眠中心國際醫療中心,57,TheJohnsHopkinsHospital,AllergyandClinicalImmunologyAnesthesiology/CriticalCareMedicineCardiologyDermatology(Skin)EmergencyMedicineEndocrinology內分泌學Gastroenterology胃腸病學Gynecologythisfunctionisusuallyperformedbycredentialedindividuals.CodersassignICD-9-CMcodestoinpatientcasesandCurrentProceduralTerminology(CPT),HealthCareProcedureCodingSystem(HCPCS)LevelII(National),andICD-9-CMcodestooutpatient,emergencydepartment,andphysicianofficecases.,71,Cancerregistry,Performedbyindividualswhoarecredentialedascertifiedtumorregistrarsandincludeusingcomputerizedregistrysoftwaretoconductlifetimefollow-uponeachcancerpatient,electronicallytransmitdatatostateandnationalagenciesforuseatlocal,regional,state,andnationallevels,andgeneratereportsandinformationforrequestingentities.,72,CurrentProceduralTerminology(CPT),PublishedannuallybytheAmericanMedicalAssociationandcodesare5-digitnumbersassignedtoambulatoryproceduresandservices.E.g.90663Influenzavirusvaccine,pandemicformulation,73,ICD-9-CM,TheInternationalClassificationofDiseases,Ninthrevision,ClinicalModificationisusedintheUnitedStatestocollectinformationaboutdiseasesandinjuriesandtoclassifydiagnosesandprocedures.NationalCenterforHealthStatistics(NCHS).,74,1.INFECTIOUSANDPARASITICDISEASES(001-139)TUBERCULOSIS(010-018)Includes:infectionbyMycobacterium分枝桿菌tuberculosis(human)(bovine牛)Excludes:congenitaltuberculosis(771.2)lateeffectsoftuberculosis(137.0-137.4)Thefollowingfifth-digitsubclassificationisforusewithcategories010-018:0unspecified1bacteriologicalorhistological組織學的examinationnotdone2bacteriologicalorhistologicalexaminationunknown(atpresent)3tuberclebacilli結核桿菌found(insputum)bymicroscopy4tuberclebacillinotfound(insputum)bymicroscopy,butfoundbybacterialculture5tuberclebacillinotfoundbybacteriologicalexamination,buttuberculosisconfirmedhistologically6tuberclebacillinotfoundbybacteriologicalorhistologicalexamination,buttuberculosisconfirmedbyothermethodsinoculation預防接種ofanimals,75,010PrimarytuberculousinfectionRequiresfifthdigit.Seebeginningofsection010-018forcodesanddefinitions.011PulmonarytuberculosisRequiresfifthdigit.Seebeginningofsection010-018forcodesanddefinitions.Useadditionalcodetoidentifyanyassociatedsilicosis矽肺病(502)012OtherrespiratorytuberculosisRequiresfifthdigit.Seebeginningofsection010-018forcodesanddefinitions.Excludes:respiratorytuberculosis,unspecified(011.9)013Tuberculosisofmeninges腦脊膜andcentralnervoussystemRequiresfifthdigit.Seebeginningofsection010-018forcodesanddefinitions.,76,014Tuberculosisofintestines腸,peritoneum腹膜,andmesentericglands腸系膜腺Requiresfifthdigit.Seebeginningofsection010-018forcodesanddefinitions.015TuberculosisofbonesandjointsRequiresfifthdigit.Seebeginningofsection010-018forcodesanddefinitions.Useadditionalcodetoidentifymanifestation,as:tuberculous:Arthropathy關節病(711.4)Necrosis壞死ofbone(730.8)Osteitis骨炎(730.8)Osteomyelitis骨髓炎(730.8)Synovitis滑膜炎(727.01)Tenosynovitis腱鞘炎(727.01),77,016Tuberculosisofgenitourinary泌尿生殖器的systemRequiresfifthdigit.Seebeginningofsection010-018forcodesanddefinitions.017TuberculosisofotherorgansRequiresfifthdigit.Seebeginningofsection010-018forcodesanddefinitions.018Miliary粟粒狀的tuberculosisIncludes:tuberculosis:Disseminated彌散性Generalized全身性的miliary,whetherofasinglespecifiedsite,multiplesites,orunspecifiedsitePolyserositis漿膜炎,78,HCPCS,TheHealthCareProcedureCodingSystemiscomprisedofLevelI(CPT)andLevelII(National)codes.LevelIIHCPCScodesaredevelopedbytheCentersforMedicareMedicare,Medicaid,andprivatehealthinsurersuseHCPCSprocedureandmodifiercodesforclaimsprocessing.,84,/medicare/hcpcs/,A1001007DRESSINGFORONEWOUNDDressingforonewoundC2002070120020701NA2001007DRESSINGFORTWOWOUNDSDressingfortwowoundsC02002070120020701NA3001007DRESSINGFORTHREEWOUNDSDressingforthreewoundsC02002070120020701N,85,Abstracting,Performedtoentercodesandotherpertinentinformationutilizingcomputersoftware.Togeneratestatisticalreportsanddisease/procedureindexes,whichareusedforadministrativedecision-makingandquality-managementpurposes.,86,Incompleterecordprocessing,Includestheassemblyandanalysisofdischargedpatientrecords.Afterapatientisdischargedfromanursingunit,therecordisretrievedandreportsareassembledaccordingtoahospital-andmedicalstaff-approvedorderofassembly.,87,Medicaltranscription,Involvestheaccurateandtimelytranscriptionofdictatedreports.,88,Recordcirculation,Includestheretrievalofpatientrecords,forthepurposeof:InpatientreadmissionScheduledandunscheduledoutpatientclinicvisitsAuthorizedquality-managementstudiesEducationandresearch,89,Licensure,RegulationandAccreditation,CodeofFederalRegulations(CFR)FederalRegisterAlegalnewspaperpublishedeverybusinessdaybytheNationalArchivesandRecordsAdministration(NARA)inpaperform,microfiche,andonline.AccreditationStandardsandSurveys,90,Regulation,Aregulationisaninterpretationofalawthatiswrittenbytheresponsibleregulatoryagency.E.g.theConditionsofParticipation(CoP)areregulationswrittenbytheCentersforMedicare&MedicaidServices(CMS).Congresswritesandpassesanact,thePresidentsignstheactintolaw,andCMSinterpretsthelawcreatingaregulation.,91,Accreditation,Avoluntaryprocessthatahealthcarefacilityororganizationundergoestodemonstratethatithasm