全科醫(yī)學(xué) 第5講 Practice Management學(xué)習(xí)課件

Chapter22

PracticeManagementTwentyyearsagoandnowRefP418北京在職醫(yī)生將可開私人診所

（2014年02月28日）

北京今年（5月）將鼓勵社會資本進入健康服務(wù)業(yè)，醫(yī)生將可獲準開辦私人診所，并有望跨省多點執(zhí)業(yè)。醫(yī)生開診所審批流程簡單北京今年還將發(fā)布首都地區(qū)社會辦醫(yī)指南，把北京市衛(wèi)生資源情況向社會發(fā)布，包括公立私立醫(yī)院如何布局，人員、床位基本情況，以此幫助投資者決策，“比如什么地方可以辦醫(yī)療機構(gòu)，提供什么服務(wù)?！贝送?，還包括社會辦醫(yī)過程中需要提供什么樣的材料、需要什么樣的手續(xù)，政策法規(guī)等。醫(yī)生執(zhí)業(yè)有望不受地點限制將支持醫(yī)療機構(gòu)開展全日制與非全日制醫(yī)生區(qū)別聘用合同、薪酬待遇等改革探索，鼓勵非全日制醫(yī)生以固定時間到基層、其他醫(yī)院兼職工作護士將提供社會護理服務(wù)OldmanagementcomparetotheNewOLDNEWACUTE(severe,urgent,care)Nurse/doctor,sameday,immediatePA(physicalassistant)-decidewhatisthenext,prescribtion/doctorCHRONIC(nonurgent,routineappointment)NoneNoneROUTINE(waitinwaitroom,15minutes)Prevention,telphonecalls,PEE-mail,testresultsRETURNVISIT(everythreemonths)Dependentondisease(hypertension)E-mailschedulingofnextappointmentdependingontestresults

PaymentOldNewFeeforserviceA.H.A(affordablehealthcareact)InsurancefromemployerinsurancefromindividualPrepaidgovernmentManagedcare(HMO,IPA,capitation)Gatekeeper(aprimarydoctororpersonwhodecidesifpatientsneedspecialistsorhospitalization)Notlimitedtothedoctors.NeedsOldNewvitalsignsCOPD-pneumococcalvacTargetingtheDisabilityHPVimmunizionforwhosexualactiveIncreasingmigrantinfectiousdiseaseHomevisitTransportationtotheclinicFlushotsChangingviralsubtypesPsycho-socialdiseaseAPAmanualpsychiatricdisease2013SinglepatientsMoreindigenthealthcareMigrantsMigrantsw/o(without)careincreasingPAPsmearsbydoctorDonebyPA,plannedparenthood-typeoutpatientclinicsPatient’sdemandsOldNewTelephoneconsultationsinternetmedicalinformationOfficevisitsforacuteconditionsmediadrugpromotion(riskofradiation,cost)RequestforhomevisitsOfficevisitsforpreventioncareRequestsforrepeatprescriptionscare-giversEmergencyandnightcallsinformedconsentEvaluationOldNewAdirectapproachtothepatientelectronicrecordsPeriodicassessmentsofpracticeproceduresSOAPaspectsofmanagement,prescribing,referral,performanceAuditofrecords,monitorsuchanduseofMeasuresomethinghemoglobinA1ccholesterol,HDLcholesterol(ref-standardsofmedicalcareindiabetes-2010.Diabetescare,33(suppCreatingspaceInChinaInwest100patientseachmorningVitalsignsbynurseAppointments<1nurse/doctorVitalsignsbynurse>1nurse/doctorIV(intravenous)NoneCortisoneNoneexceptforasthmaacuteallergyAngrypatientsandrelativeskilldoctorsMedicalInsuranceObjectivesInChinaInwest100patientseachmorningVitalsignsbynurseappointments<1nurse/doctorVitalsignsbynurse>1nurse/doctorIV(intravenous)noneCortisonenoneexceptforasthmaacuteallergyObjectivesoldnewEducationACS(Americancancersociety)postersReferralsNonewpatients-whenPhysicalexaminationlifestylechange-scienceObesitymanagementSmokingcessationNursesReceptionistOfficemanagementBusinessmanagerVisitNumberscontrolManagecareInChinaInthewesternYearlyphysicalexamNotcosteffectiveMammographyfrequency(ageandfrequencyunknown)ChestX-ray/notcosteffectiveRoutineUltrasound/yearNoCTriskofradiationSmokersSmokingcontrolDiseaseorientedfullmeetingtreatmentobjectivesVarenicycline(酒石酸伐尼克蘭片)–veryexpensiveVarenicyclineEachcasehasitslessonAlessenmaybe,butitalways,learntUnderstandingofthediseasecomeswithanintelligentstudyofascoreofcasesKnowledgeandwisdomaredifferent[zhishi]vs[zhihui]CasestudyPrioritiesUrgency-acutevschronicS-symptomsO-objectiveA-assessmentP-planS-symptomsHistorygivesdiagnosis-70%ChiefcomplaintanddurationOccupationEthnicityListening-saynothingO-objectivePEminimumisvitalsigns-weight,height,BMI,pulse,bloodpressure,respirationandtemperatureNurseDoctorexamineseffectpartsCompetePETakesfiveminutesIfneurology–mentalstatusexamineorientation-whoandwheredateyearnameofthepresidentcalculateA-assessmentAssessmentdifferentialdiagnosisassignmenttoanatomyorsymptomorganicvsb