在临床医学中PPT课件.ppt

在临床医学中在临床医学中2Health Care Delivery SystemsnHistory of Medicine and Health care DeliverynContinuum of CarenHealth Care Facility OwnershipnHealth Care Facility Organizational StructurenLicensure,Regulation,and Accreditation3IntroductionnHealth care delivery has been greatly impacted by escalating costs,resulting in medical necessity requirements,review of appropriateness of admissions,and requirement for administration of quality and effective treatments.4MRXOn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。n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。5MRXOn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。6History of Medicine&Health Care DeliverynHistory of medicinenEvolution of health care delivery in the United States7History of medicinenIn 1994,scientists discovered the genes responsible for many cases of hereditary colon cancer,inherited breast cancer,and the most common type of kidney cancer.8Evolution of health care delivery in the United Statesn1991 The Workgroup on Electronic Data Interchange(WEDI)was created to reduce health care administrative costs through implementation of the electronic data interchange(EDI),which uses national standards to transmit data for reimbursement purposes.9Evolution of health care delivery in the United Statesn1996 The Health Insurance Portability and Accountability Act(HIPAA)was passed.nIt mandates administrative simplification regulations that govern privacy,security,and electronic transaction standards for health care information.10Evolution of health care delivery in the United Statesn1996 The Healthcare Integrity and Protection Data Bank(HIPDB)was created which combats fraud and abuse in health insurance and health care delivery by alerting users to conduct a comprehensive review of a practitioners,providers,or suppliers past actions.11Healthcare Integrity and Protection Data BanknAccess to information in the HIPDB is available to entities that meet the eligibility requirements defined in Section 1128E of the Social Security Act and the HIPDB regulations.In order to access information,eligible entities must first register with the Data Bank.nHIPDB information is not available to the general public.However,information in a form that does not identify any particular entity or practitioner is available.12Healthcare Integrity and Protection Data Banknhttp:/www.npdb-hipdb.hrsa.gov/nEstimates of annual losses due to health care fraud range from 3 to 10percent of all health care expenditures-between$30billion and$100billion based on estimated 1997 expenditures of over$1 trillion and 2.5 trillion for 2009.13Continuum of CarenA complete range of programs and services is called a continuum of care,with the type of health care indicating the health care services provided.nPrimary carenSecondary carenTertiary care14Primary care servicesnInclude preventive and acute care,are referred to as the point of first care,and are provided by a general practitioner or other health professional who has the first contact with a patient seeking medical treatment,including general dental,ophthalmic 眼科的,and pharmaceutical services.15Primary care servicesnAnnual physical examinationsnEarly detection of diseasenFamily planningnHealth educationnImmunizationsnTreatment of minor illnesses and injuriesnVision and hearing screening16Secondary care servicesnProvided by medical specialists or hospital staff members to a patient whose primary care was provided by a general practitioner who first diagnosed or treated the patient.17Tertiary care servicesnProvided by specialized hospitals equipped with diagnostic and treatment facilities not generally available at hospitals other than primary teaching hospital or Level I,II,III or IV trauma centers.18Trauma centersnLevel I:provides the highest level of comprehensive care for severely injured adult and pediatric patients with complex,multi-system trauma.nLevel II:broad range of sub-specialists are on-call and promptly available to provide consultation or care.19Trauma centersnLevel III:physicians are advanced trauma life support(ATLS)trained and experienced in caring for traumatically injured patients;nurses and ancillary staff are in-house and immediately available to initiate resuscitative measures.20Trauma centersnLevel IV:critically injured patients who require specialty care are transferred to a higher level trauma system hospital in accordance with pre-established criteria.1、病毒性肝炎：、病毒性肝炎：由病毒造成的肝炎按照其病毒系列不同分为甲、乙、丙、丁、戊和庚共六种类型病毒性肝炎。能引起肝脏细胞肿胀，是世界上流传广泛，危害很大的传染病之一。1908 年，才发现病毒也是肝炎的致病因素之一。1947 年，将原来的传染性肝炎（infectioushepatitis）称为甲型肝炎（HepatitisA,HA）；血清性肝炎（serumhepatitis）称为乙型肝炎（HepatitisB,HB）。1965 年人类首次检测到乙型肝炎的表面抗原。我国经济和科学技术日益发展，学术文化领域百家争鸣，（df高血压958心脏病983u6 糖尿病87fr）特别是思想家的革新精神，为中医学理论的创新和突破性进展，提供了有利的文化背景。宋代陈无择著三因极一病证方论一书，（45传染病q566 丙肝964jo乙肝28jgsx甲肝gh）提出三因学说；并产生了最具盛名四大学派，刘完素倡导火热论；张从正力倡“攻邪论”；李杲提出“内伤脾胃，百病由生”的理论；朱震亨创造性地阐明了相火的演变规律。编辑本段明清时期（df肺25s血液f369血小板t5172 红血球gdf55m 白血球fd2）是中医学理论综合汇编、深化发展，临床各科辨证体系丰富、提高阶段。如明代楼英的医学纲目和王肯堂的证治准绳，清代吴谦等编著的医宗金鉴和陈梦雷主编的古今图书集成医部全录等。王清任著医林改错，注重实证研究，（df高血压958心脏病983u6 糖尿病87fr）纠正了古医籍中关于解剖知识的某些错误，肯定了“脑主思维”，发展了瘀血理论。温病学说的形成和发展，标志着中医理论的创新与突破，吴有性著温疫论，叶天士著温热病篇，吴鞠通著温病条辨等，在药物学研究方面，（45传染病q566 丙肝964jo乙肝28jgsx甲肝gh）李时珍著的本草纲目，总结了16世纪以前我国药物学研究的成就。医的诊察疾病能参考现代医学的微观分析，将辨证与辨病相结合，实现宏观与微观的统一，使中医诊断客观化，即把分析与综合相结合的方法引入中医理、法、方、药的研究，使二者有机结合，互相借鉴、补充，避免各自的片面性、局限性，这将有利于中西医学的优势互补，“和而不同”，多元发展。近年来，中医药在防治非典、禽流感和艾滋病方面发挥的独特作用也证实了二者的有机结合，具有肯定的临床疗效。编辑本段东西方医学交融不管是中医学还是西医学，从二者现有的思维方式的发展趋势来看，均是走向现代系统论思维，中医药学理论与现代科学体系之间具有系统同型性，属于本质相同而描述表达方式不同的两种科学形式。可望在现代系统论思维上实现交融或统一，成为中西医在新的发展水平上实现交融或统一的支撑点，希冀籍此能给中医学以至生命科学带来良好的发展机遇，进而对医学理论带来新的革命。编辑本段现代中医史上个世纪末,本世纪初，1996 年,清华学界对中医气本质，经络实质，阴阳，五行，藏象，中医哲学观等都有了新的全面整体创造性的认识和解说。如，邓宇等发现的:气是流动着的信息能量物质的混合统一体；分形分维的经络解剖结构；数理阴阳；中医分形集：分形阴阳集阴阳集的分形分维数，五行分形集五行集的分维数；分形藏象五系统暨心系统、肝系统、脾系统、肺系统、肾系统；中医三个哲学观新提出的第三哲学观：相似观分形论等。还包括近代针灸经络的发展史,近代中医气的进展简史,中西医结合史,中医中药史等.六种类型的病毒性肝炎遗传因子不同，除乙型肝炎遗传因子是DNA外，其余几型肝炎遗传因子均为RNA。其中甲型肝炎的传播途径是粪口传播，乙型肝炎的传播途径是血液传播、性传播和母婴传播。疫苗。2、酒精性肝炎：、酒精性肝炎：酒精性肝炎早期可无明显症状，但肝脏已有病理改变，发病前往往有短期内大量饮酒史，有明显体重减轻，食欲不振，恶心，呕吐，全身倦怠乏力，发热，腹痛及腹泻，上消化道出血及精神症状。体征有黄疸，肝肿大和压痛，同时有脾肿大，面色发灰，腹水浮肿及蜘蛛痣，食管静脉曲张。从实验室检查看，有贫血和中性白细胞增多，红细胞容积测定（MCV）大于95FL,血清胆红素增高，可达17.1moL/L 或以上，转氨酶中度升高，常大于2.0，测定线粒体AST（mAST）及其与总AST（tAST）的比值，其升高可达12.5+5.2%。并有-GT，谷氨酸脱氢酶和碱性磷酸酶活力增高，凝血酶原时间延长。此外，病毒性肝炎还有丙型肝炎、丁型肝炎、戊型肝炎和庚型肝炎。过去被定为己型肝炎病毒的病毒现在被确定为乙型肝炎病毒的一个属型，因此己型肝炎不存在。在病毒肝炎的疫苗，A型、B型、D型的疫苗已研发成功；C型、E型、F型的目前无编辑本段宋金元时期精品课件文档，欢迎下载，下载后可以复制编辑。更多精品文档，欢迎浏览。22Tertiary carenBurn center treatmentnCardiothoracic and vascular surgerynInpatient care for AIDS patientsnMagnetic resonance imaging(MRI)nNeonatology level III unit servicesnNeurosurgerynOrgan transplant23Tertiary carenPediatric surgerynPositron emissions tomography(PET)nRadiation oncologynServices provided to a person with a high-risk pregnancynServices provided to a person with cancernState-designated trauma centersnTrauma surgery24Positron emissions tomography(PET)nbuilds images by detecting energy given off by decaying radioactive isotopes.nIsotopes are atoms of an element with the same number of protons(positively charged particles)in the nucleus,but a different number of neutrons(neutral particles).nBecause radioactive isotopes are unstable,as they decay,they throw off positrons that collide with electrons and produce gamma rays that shoot off in nearly opposite directions.25PETnPET systems use the paths of the two detected gamma rays to determine the originating collision point,a process called electronic collimation(瞄準).nThe scanners use a circular series of gamma ray-detectors to envelope the patient so both gammas can be detected so the instrument can use electronic collimation to predict where the energy signal originated.nThis signal is then converted into a three-dimensional image slice.26台灣醫院分類n診所n地區醫院(497/2005)n區域醫院(80/2005,65/2006,64/2007)n醫學中心(23/2005,18/2006,19/2007,14/2009)27醫學中心n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n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。28醫學中心n專任主治醫師人數(包括主任在內)每八床應有一名。n專任護理人員每2床至少1名。n加護病房：每床2.5名。n手術室：每班每台2.5名。n手術恢復室：每班每床0.5名。n產房及待產室：每床2名。n嬰兒室：每床0.4名。n急診室：觀察室每床0.5名；n診療室每12人次1名。n門診：每班每診療室0.5名。n血液透析室：每4人次1名。n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。n應有受過感染控制訓練之專任護理人員，每300床應設1名。29醫學中心n藥事人員每40床至少1名。n每60張門診處方至少1名。n特殊藥品處方每15張至少1名。n藥事人員總數至少四分之三為藥師。n藥事人員至少有4名負責藥品管理諮詢及臨床等工作。30區域醫院n應設置 250 床位以上急性病病床數n每床所擁有的樓地板面積應在 50 平方公尺以上n每 9 床至少應擁有一名主治醫師n每 2.5 床至少應擁有一名護理人員等。n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。31區域醫院 Nursen加護病房：每床 2名。n手術室：每班每台 2名。n手術恢復室：每班每床 0.5名。n產房及待產室：每床 1.2名。n嬰兒室：每床 0.4名。n急診室：觀察室每床 0.5名；n診療室每 12人次 1名。n門診：每班每診療室 0.5名。n血液透析室：每 4人次 1名。n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。n應有受過感染控制訓練之專任護理人員，每 300床應設 1名。32區域醫院n藥事人員每 50床至少 1名。n每 70張門診處方至少 1名。n特殊藥品處方每 15張至少 1名。n藥事人員總數至少四分之三為藥師。n藥事人員中，至少有 2名負責藥品管理諮詢及臨床等工作。33地區醫院n在衛生局登記開放的急性一般病床需 20床以上，n急性一般病床及急性精神病床合計 249床（含）以下。34地區醫院n專任員工總人數每床應有 1名。n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。n藥事人員每 50床至少 1名。n每 80張門診處方至少 1名。n每增加 100張處方應增加 1名。n應有藥師 1人以上。35評鑑分級n設施n總樓地板面積n病房設施n安全設備及一般設備n保險病床比率36評鑑分級n人員n員工總人數 醫師總數n麻醉科醫師 放射線科醫師n核醫科醫師 病理科醫師n復健科醫師 精神科醫師n護理 藥事n醫事檢驗 醫用放射線技術n復健技術 精神科n社會工作 營養師n病歷管理37評鑑分級n醫療業務及設備n醫療業務 急性病床數n診療科別 急診業務n手術及麻醉作業 產房n嬰兒室 加護病房n藥事作業 檢驗作業n輸血作業 放射線診療作業n病理作業 復健醫療作業n精神科 核子醫學n牙科 特殊醫療服務n醫務社會服務工作 營養部門n病歷部門 社區衛生服務n員工健康檢查38評鑑分級n品質保證n醫療品質審查n感染控制n人體試驗n藥事作業品質n護理服務品質n檢驗作業品質管制n輸血作業品質管制n病理作業品質管制n放射線診療品質管制n核子醫學品質管制n病歷管理n醫院管理業務n醫病關係之促進39評鑑分級n指定項目評估n住院 n診斷 n處置 n用藥 n手術 n病歷寫作40評鑑分級n教學訓練n教學師資 n教學訓練與研究設備 n教學訓練活動 n與其他醫院(醫學院)交流合作情形 n研究情形及論文發表 n教學進修研究經費41新制教學醫院評鑑基準新制教學醫院評鑑基準n教學資源n教學訓練計畫與成果n研究執行與成果n臨床師資培育及繼續教育n學術交流與社區功能及角色n管理行政42財團法人醫院評鑑暨醫療品質策進會nhttp:/www.tjcha.org.tw/Identify.asp?catid=2343Health Care Facility OwnershipnGovernment(not-for-profit)25%nProprietary(for-profit)15%nVoluntary(not-for-profit)60%44Medical StaffnIntern:a physician in the first year of graduate medical education,which ordinarily immediately follows completion of the four-year medical curriculum.nResident:a physician who has completed an internship and is engaged in a program of training designed to increase his or her knowledge of the clinical disciplines of medicine,surgery,or any of the other special fields that provide advanced training in preparation for the practice of a specialty.45Medical StaffnChief resident:a physician who is in his final year of residency or in the year after the residency has been completed.nVisiting Staff(VS):主治醫師46Health Care Facility Organizational StructurenGoverning boardnAdministrationnMedical staffnDepartments,services,and committeesnContracted services47Governing boardnThe governing board(board of trustees,board of governors,board of directors)serves without pay,and its membership is represented by professionals from the business community.48Administration nServes as liaison between the medical staff and governing board and is responsible for developing a strategic plan for supporting the mission and goals of the organization.nCEO:chief executive officenCFO:chief financial officernCIO:chief information officernCOO:chief operating officer49Medical staffnConsists of licensed physicians and other licensed providers as permitted by law(e.g.,nurse practitioners and physician assistants)who are granted clinical privileges.50physician assistantsnExamine,diagnose,and treat patients under the direct supervision of a physician.51Medical staff membership categoriesnActive:delivers most hospital medical services,performs significant organizational and administrative medical staff dutiesnAssociate:advancement to active category is being considerednConsultingnCourtesy:admits an occasional patient to the hospitalnHonorary5253Hospital departments,Services,and Committees54Health Information DepartmentnDepartment administrationnCancer registrynCoding and abstractingnImage processingnIncomplete record processingnMedical transcriptionnRecord circulationnRelease of information processing5556CodingnInvolves assigning numeric and alphanumeric codes to diagnoses,procedures,and services;this function is usually performed by credentialed individuals.nCoders assign ICD-9-CM codes to inpatient cases and Current Procedural Terminology(CPT),Health Care Procedure Coding System(HCPCS)Level II(National),and ICD-9-CM codes to outpatient,emergency department,and physician office cases.57Cancer registrynPerformed by individuals who are credentialed as certified tumor registrars and include using computerized registry software to conduct lifetime follow-up on each cancer patient,electronically transmit data to state and national agencies for use at local,regional,state,and national levels,and generate reports and information for requesting entities.58Current Procedural Terminology(CPT)nPublished annually by the American Medical Association and codes are 5-digit numbers assigned to ambulatory procedures and services.nE.g.90663 Influenza virus vaccine,pandemic formulation59ICD-9-CMnThe International Classification of Diseases,Ninth revision,Clinical Modification is used in the United States to collect information about diseases and injuries and to classify diagnoses and procedures.nNational Center for Health Statistics(NCHS).60http:/ AND PARASITIC DISEASES(001-139)nTUBERCULOSIS(010-018)nIncludes:ninfection by Mycobacterium 分枝桿菌 tuberculosis(human)(bovine 牛)nExcludes:ncongenital tuberculosis(771.2)nlate effects of tuberculosis(137.0-137.4)nThe following fifth-digit subclassification is for use with categories 010-018:n0 unspecifiedn1 bacteriological or histological 組織學的 examination not donen2 bacteriological or histological examination unknown(at present)n3 tubercle bacilli 結核桿菌 found(in sputum)by microscopyn4 tubercle bacilli not found(in sputum)by microscopy,but found by bacterial culturen5 tubercle bacilli not found by bacteriological examination,but tuberculosis confirmed histologicallyn6 tubercle bacilli not found by bacteriological or histological examination,but tuberculosis confirmed by other methods inoculation 預防接種 of animals61http:/ Primary tuberculous infectionnRequires fifth digit.See beginning of section 010-018 for codes and definitions.n011 Pulmonary tuberculosisnRequires fifth digit.See beginning of section 010-018 for codes and definitions.nUse additional code to identify any associated silicosis矽肺病(502)n012 Other respiratory tuberculosisnRequires fifth digit.See beginning of section 010-018 for codes and definitions.nExcludes:nrespiratory tuberculosis,unspecified(011.9)n013 Tuberculosis of meninges 腦脊膜 and central nervous systemnRequires fifth digit.See beginning of section 010-018 for codes and definitions.62http:/ Tuberculosis of intestines 腸,peritoneum 腹膜,and mesenteric glands 腸系膜腺nRequires fifth digit.See beginning of section 010-018 for codes and definitions.n015 Tuberculosis of bones and jointsnRequires fifth digit.See beginning of section 010-018 for codes and definitions.nUse additional code to identify manifestation,as:ntuberculous:nArthropathy 關節病(711.4)nNecrosis 壞死of bone(730.8)nOsteitis 骨炎(730.8)nOsteomyelitis 骨髓炎(730.8)nSy