醫(yī)師助理、專(zhuān)科護(hù)理師及外傷護(hù)士在醫(yī)療及法律的定位與角色【精選】課件

醫(yī)師助理、專(zhuān)科護(hù)理師及外傷護(hù)士在醫(yī)療及法律的定位與角色高雄醫(yī)學(xué)大學(xué)附設(shè)中和紀(jì)念醫(yī)院急診部外傷科 郭良基醫(yī)師助理、專(zhuān)科護(hù)理師及外傷護(hù)士在醫(yī)療及法律的定位與角色高雄1名詞釋義醫(yī)師助理（Physicianassistant）專(zhuān)科護(hù)理師（AdvancedPracticeRegisteredNurses(APRNs)）外傷護(hù)士（Traumanurse）名詞釋義醫(yī)師助理（Physicianassistant）2醫(yī)療業(yè)務(wù)與醫(yī)療行為醫(yī)師法及醫(yī)療法並未規(guī)定醫(yī)療業(yè)務(wù)之範(fàn)圍?！阜惨灾委煛⒊C正或預(yù)防人體疾病、傷害、殘缺或保健為直接目的，所為的診察、診斷及治療，或基於診察、診斷結(jié)果，以治療為目的，所為的處方或用藥等行為的一部或全部的總稱(chēng)為醫(yī)療行為?！梗ò耸荒暌辉铝招l(wèi)署醫(yī)字第一零零一一六二號(hào)）「施術(shù)或處置」（八十一年七月三十一日衛(wèi)署醫(yī)字第八一五三四六三號(hào)函釋?zhuān)┽t(yī)療業(yè)務(wù)與醫(yī)療行為醫(yī)師法及醫(yī)療法並未規(guī)定醫(yī)療業(yè)務(wù)之範(fàn)圍。3護(hù)理人員之業(yè)務(wù)護(hù)理人員法第二十四條：健康問(wèn)題之護(hù)理評(píng)估預(yù)防保健之護(hù)理措施護(hù)理指導(dǎo)及諮詢醫(yī)療輔助行為醫(yī)療輔助行為應(yīng)在醫(yī)師之指示下行之。護(hù)理人員之業(yè)務(wù)護(hù)理人員法第二十四條：4醫(yī)療輔助行為－I侵入性檢查之護(hù)理侵入性治療、處置之護(hù)理各項(xiàng)手術(shù)全程護(hù)理分娩全程護(hù)理放射線檢查、治療之護(hù)理化學(xué)治療之護(hù)理氧氣療法、光線療法之護(hù)理醫(yī)療輔助行為－I侵入性檢查之護(hù)理5醫(yī)療輔助行為－II恢復(fù)室、加護(hù)病房（含精神科保護(hù)室）、洗腎室急診病人全程護(hù)理住院病人、暫留病人口服藥物之投與生命徵象監(jiān)視器的監(jiān)視住院病人生命徵象測(cè)量與評(píng)估其他經(jīng)衛(wèi)生主管機(jī)關(guān)認(rèn)定的醫(yī)療輔助行為（八十二年六月二十九日衛(wèi)署醫(yī)字第八二四六零三四號(hào)函）醫(yī)療輔助行為－II恢復(fù)室、加護(hù)病房（含精神科保護(hù)室）、洗腎室6醫(yī)師助理醫(yī)師助理7醫(yī)師助理臺(tái)灣：不合法。醫(yī)療法第五十八條：醫(yī)療機(jī)構(gòu)不得置臨床助理執(zhí)行醫(yī)療業(yè)務(wù)。美國(guó)：合法。美國(guó)CNN之最佳工作一百名中排名第五（醫(yī)師：第三十，律師：第三十七）醫(yī)師助理臺(tái)灣：不合法。8醫(yī)師助理之資格至少兩年之大學(xué)教育。美國(guó)有超過(guò)135個(gè)的課程，其中有超過(guò)90個(gè)提供碩士學(xué)位，其餘多為學(xué)士學(xué)位。NationalCommissiononCertificationofPhysicianAssistants(NCCPA)醫(yī)師助理之資格至少兩年之大學(xué)教育。9醫(yī)師助理之工作範(fàn)圍－I在醫(yī)師監(jiān)督下，提供診斷、治療、及預(yù)防保健服務(wù)。詢問(wèn)病史、檢查及治療病患、開(kāi)立並判讀實(shí)驗(yàn)室檢查及X光、作出診斷?？芍委熭p微外傷，縫合及石膏副木固定。紀(jì)錄progressnotes、病人衛(wèi)教及諮詢、開(kāi)立及執(zhí)行治療。在48州及DC，醫(yī)師助理可以開(kāi)立藥物處方。醫(yī)師助理之工作範(fàn)圍－I在醫(yī)師監(jiān)督下，提供診斷、治療、及預(yù)防保10醫(yī)師助理之工作範(fàn)圍－II醫(yī)師助理可用電話，或到醫(yī)院或護(hù)理之家診視病人後，向其監(jiān)督醫(yī)師回報(bào)。在部分地區(qū)，醫(yī)師助理可能是主要的醫(yī)療照護(hù)提供者。大多數(shù)醫(yī)師助理是一般內(nèi)科、小兒科、及家醫(yī)科。醫(yī)師助理之工作範(fàn)圍－II醫(yī)師助理可用電話，或到醫(yī)院或護(hù)理之家11美國(guó)醫(yī)師助理之薪資2004年五月調(diào)查：平均年收入$69,410。2004年：全職的醫(yī)師助理medianincome為$74,264/年；第一年畢業(yè)生之medianincome為$64,536/年。美國(guó)醫(yī)師助理之薪資2004年五月調(diào)查：平均年收入$69,4112專(zhuān)科護(hù)理師專(zhuān)科護(hù)理師13專(zhuān)科護(hù)理師臺(tái)灣：合法。護(hù)理人員法第七條之一第三項(xiàng)：護(hù)理師經(jīng)完成專(zhuān)科護(hù)理師訓(xùn)練，並經(jīng)中央主管機(jī)關(guān)甄審合格者，得請(qǐng)領(lǐng)專(zhuān)科護(hù)理師證書(shū)。專(zhuān)科護(hù)理師分科及甄審辦法第二條：護(hù)理師依本辦法所定之分科完成專(zhuān)科護(hù)理師訓(xùn)練者，得參加各該專(zhuān)科護(hù)理師之甄審。衛(wèi)生署醫(yī)療網(wǎng)第五期計(jì)畫(huà)：規(guī)劃專(zhuān)科護(hù)理師制度，提昇護(hù)理人力及功能。美國(guó)：合法。專(zhuān)科護(hù)理師臺(tái)灣：合法。14APRNs之資格擁有碩士以上學(xué)位的RN（RegisteredNurses），接受考試及格之後，由各學(xué)會(huì)授與證書(shū)。APRNs之資格擁有碩士以上學(xué)位的RN（Registered15AdvancedPracticeRegisteredNurses(APRNs)AdvancedPracticeNurses(APNs)CertifiedNurseMidwife(CNM)ClinicalNurseSpecialist(CNS)CertifiedRegisteredNurseAnesthetist(CRNA)NursePractitioner(NP)AdvancedPracticeRegisteredN16CNSCRNACNMNPAPNsCNSCRNACNMNPAPNs17NP之資格取得RN之後，有以下五種學(xué)歷之一，可以參加考試。社區(qū)學(xué)院所授與之藝術(shù)相關(guān)學(xué)位醫(yī)院為主的計(jì)畫(huà)，授與3年的學(xué)位證書(shū)大學(xué)所授與之護(hù)理學(xué)學(xué)士(BSN)大學(xué)所授與之護(hù)理學(xué)碩士學(xué)位(MSN)

大學(xué)所授與之護(hù)理學(xué)博士學(xué)位

NP之資格取得RN之後，有以下五種學(xué)歷之一，可以參加考試。18在2015年，所有的NP訓(xùn)練計(jì)畫(huà)都將到達(dá)博士級(jí)(DNP,DrNP)！在2015年，所有的NP訓(xùn)練計(jì)畫(huà)都將到達(dá)博士級(jí)(DNP,19NP的工作範(fàn)圍－I依需要與醫(yī)師和其他醫(yī)療專(zhuān)業(yè)人士合作，包括轉(zhuǎn)診。提供病患健康行為，自我照護(hù)技能和治療選擇的諮詢及教育。診斷和治療急性病，傳染病和外傷。診斷、治療及監(jiān)控慢性病(例如糖尿病，高血壓)。書(shū)寫(xiě)病歷並執(zhí)行理學(xué)檢查。開(kāi)立處方用藥。NP的工作範(fàn)圍－I依需要與醫(yī)師和其他醫(yī)療專(zhuān)業(yè)人士合作，包括轉(zhuǎn)20NP的工作範(fàn)圍－II開(kāi)立、執(zhí)行、並判讀檢查報(bào)告(例如實(shí)驗(yàn)室檢查，X光，心電圖)。開(kāi)立物理療法和復(fù)健處方。提供產(chǎn)前檢查及家庭計(jì)畫(huà)服務(wù)。提供完整兒童照護(hù)，包括篩檢和免疫注射。提供成年人健康維持照護(hù)，包括每年體格檢查。執(zhí)行簡(jiǎn)單的小手術(shù)(如皮膚切片，縫合，石膏副木固定)。NP的工作範(fàn)圍－II開(kāi)立、執(zhí)行、並判讀檢查報(bào)告(例如實(shí)驗(yàn)室檢21NP的發(fā)照單位（國(guó)家級(jí)）NP-C(NursePractitioner-Certified;ifcertifiedbytheAANP－AmericanAcademyofNursePractitioners)APRN,BC(AdvancedPracticeRegisteredNurse,BoardCertified;ifcertifiedbytheANCC－AmericanNursesCredentialingCenter)NP的發(fā)照單位（國(guó)家級(jí)）NP-C(NursePracti22NP的發(fā)照單位（不同專(zhuān)科別）CPNP(PediatricNPwhencertifiedbythePediatricNursingCertificationBoard(PNCB)AmericanAssociationofCritical-CareNursesAmericanPsychiatricNursingAssociationBoardofCertificationforEmergencyNursingNationalCertificationBoardofPediatricNursePractitionersandNursesNationalCertificationCorporationfortheObstetric,Gynecologic,andNeonatalNursingSpecialtiesOncologyNursingCertificationCorporationAmericanHolisticNursesAssociationNP的發(fā)照單位（不同專(zhuān)科別）CPNP(Pediatric23NP的分科ACNP(AcuteCareNP)AHN(HolisticNP)ANP(AdultNP)FNP(FamilyNP)GNP(GeriatricNP)NNP(NeonatalNP)PMHNP(PsychiatricMentalHealthNP)PNP(PediatricNP)WHNP(Women'sHealthNP)NP的分科ACNP(AcuteCareNP)24RN的薪資2004年五月調(diào)查：平均年收入$52,330Employmentservices $63,170Generalmedicalandsurgicalhospitals $53,450Homehealthcareservices $48,990Officesofphysicians $48,250Nursingcarefacilities $48,220RN的薪資2004年五月調(diào)查：平均年收入$52,33025臺(tái)灣專(zhuān)科護(hù)理師之分科專(zhuān)科護(hù)理師分科及甄審辦法第三條：專(zhuān)科護(hù)理師之分科如下：一、內(nèi)科二、外科三、其他經(jīng)中央主管機(jī)關(guān)指定之分科。臺(tái)灣專(zhuān)科護(hù)理師之分科專(zhuān)科護(hù)理師分科及甄審辦法第三條：專(zhuān)科護(hù)理26內(nèi)科及外科專(zhuān)科護(hù)理師訓(xùn)練課程綱要

（臺(tái)灣專(zhuān)科護(hù)理師之資格）94年11月25日衛(wèi)署醫(yī)字第0940219048號(hào)令一、訓(xùn)練期間，至少六個(gè)月。二、訓(xùn)練內(nèi)容，包括學(xué)科課程與臨床訓(xùn)練。三、學(xué)科課程，應(yīng)有一六O小時(shí)以上，其範(fàn)圍包括如下：（一）醫(yī)療品質(zhì)。（二）法規(guī)與倫理。（三）專(zhuān)業(yè)課程。內(nèi)科及外科專(zhuān)科護(hù)理師訓(xùn)練課程綱要

（臺(tái)灣專(zhuān)科護(hù)理師之資格）927專(zhuān)業(yè)課程應(yīng)包含專(zhuān)科護(hù)理師執(zhí)業(yè)模式及照護(hù)品質(zhì)、健康評(píng)估及臨床決策、進(jìn)階藥理學(xué)、進(jìn)階生理病理學(xué)、實(shí)驗(yàn)診斷及判讀、健康促進(jìn)與疾病預(yù)防、個(gè)案諮商、健康問(wèn)題診斷與處置、內(nèi)外科健康照護(hù)、案例分析等科目。專(zhuān)業(yè)課程應(yīng)包含專(zhuān)科護(hù)理師執(zhí)業(yè)模式及照護(hù)品質(zhì)、健康評(píng)估及臨床決28臨床訓(xùn)練範(fàn)圍四、臨床訓(xùn)練範(fàn)圍包括如下：（一）內(nèi)（外）科病人照護(hù)。（二）急重癥病人照護(hù)。（三）末期病人照護(hù)。臨床訓(xùn)練範(fàn)圍四、臨床訓(xùn)練範(fàn)圍包括如下：29臨床訓(xùn)練範(fàn)圍之訓(xùn)練重點(diǎn)協(xié)助住院病人身體理學(xué)檢查之初步評(píng)估及病情詢問(wèn)。協(xié)助填具檢驗(yàn)單、特殊檢查單、會(huì)診單、轉(zhuǎn)診單及診斷證明等各項(xiàng)臨床單據(jù)。協(xié)助記錄住院病人病情及各項(xiàng)檢查、檢驗(yàn)結(jié)果。協(xié)助醫(yī)師為臨床處置。簡(jiǎn)易之傷口處置、導(dǎo)管更換。協(xié)助處理住院病人或其家屬醫(yī)療諮詢及病情之說(shuō)明。臨床訓(xùn)練範(fàn)圍之訓(xùn)練重點(diǎn)協(xié)助住院病人身體理學(xué)檢查之初步評(píng)估及病30臺(tái)灣專(zhuān)科護(hù)理師之工作範(fàn)圍臺(tái)灣專(zhuān)科護(hù)理師之工作範(fàn)圍31外傷護(hù)士外傷護(hù)士32外傷護(hù)士臺(tái)灣：無(wú)法規(guī)規(guī)定。美國(guó)：合法。外傷護(hù)士臺(tái)灣：無(wú)法規(guī)規(guī)定。33TN之資格美國(guó)：RN接受過(guò)外傷訓(xùn)練課程，並經(jīng)測(cè)驗(yàn)合格，即可獲得。AdvancedTraumaCareforNurses(ATCN)－SocietyofTraumaNurses

TraumaNursingCoreCourse(TNCC)CourseinAdvancedTraumaNursing–II(CATN-II)－EMERGENCYNURSESASSOCIATION(ENA)

TN之資格美國(guó)：RN接受過(guò)外傷訓(xùn)練課程，並經(jīng)測(cè)驗(yàn)合格，即可獲34臺(tái)灣TN之資格參加TNTP課程，並經(jīng)測(cè)驗(yàn)及格。ETTC？ATLS？急診加護(hù)護(hù)理人員能力鑑定考試（BCCRN）？臺(tái)灣TN之資格參加TNTP課程，並經(jīng)測(cè)驗(yàn)及格。35外傷護(hù)士之職責(zé)外傷護(hù)士之職責(zé)36TraumaNurses＝EmergencyNursesTraumaNurses＝EmergencyNurses37TNCC課程表－IEpidemiology,biomechanicsandmechanismsofinjuryInitialassessmentShockBrainandcraniofacialtraumaThoracicandnecktraumaAbdominaltraumaSpinalcordandvertebralcolumntraumaMusculoskeletaltraumaBurntraumaTraumaandpregnancyPediatrictraumaGeriatrictraumaPsychosocialaspectsoftraumacareStabilization,transferandtransportTNCC課程表－IEpidemiology,biomech38TNCC課程表－IISkillStationsTraumanursingprocessAirwayandventilationinterventionsSpinalimmobilizationChesttraumaandtractionsplintingTNCC課程表－IISkillStations39ATCN課程表－IInitialAssessment&Management*AirwayandVentilatoryManagement*Shock*ThoracicTrauma*AbdominalTrauma*RotationinPracticalSkillsStations:Airway&VentilatoryManagement,HemorrhagicShockandInitialAssessment,MRDSTeamVideoATCN課程表－IInitialAssessment&40ATCN課程表－IIHeadTrauma*SpineandSpinalCordTrauma*MusculoskeletalTrauma*RotationinPracticalSkillsStations:SpineandExtremityInjury,PediatricTraumaandHeadTraumaInjuriesduetoBurnsandCold*TraumainExtremesofAgeTraumainWomen*TransfertoDefinitiveCare*WrittenExamination&TriageCaseScenariosInitialAssessmentSkillsStationsLecturesbyATLS?facultyindicatedby*.Practicalskillsstations&testingbyATCN?facultyATCN課程表－IIHeadTrauma*41臺(tái)灣TNTP課程表－I外傷護(hù)理、外傷制度、與緊急醫(yī)療網(wǎng)EMS/TraumaSystem/TraumaNursing外傷評(píng)估處置與外傷休克護(hù)理呼吸道處置與護(hù)理(包含住院後)胸腹部之外傷護(hù)理(包含住院後)頭頸與脊椎之外傷護(hù)理(包含住院後)肢體外傷(骨骼肌肉血管)之護(hù)理臺(tái)灣TNTP課程表－I外傷護(hù)理、外傷制度、與緊急醫(yī)療網(wǎng)EMS42臺(tái)灣TNTP課程表－II燒燙傷、吸入性灼傷與電擊傷之護(hù)理特殊傷患外傷－兒童、孕婦、老人外傷病人的運(yùn)送與轉(zhuǎn)院外傷病患之加護(hù)照護(hù)壓力適應(yīng)、危機(jī)處理與創(chuàng)傷後癥候群外傷團(tuán)隊(duì)合作/外傷護(hù)理倫理與法律問(wèn)題臺(tái)灣TNTP課程表－II燒燙傷、吸入性灼傷與電擊傷之護(hù)理43臺(tái)灣TNTP課程表－IIISkillStations建立安全呼吸道/外科手術(shù)建立呼吸道/喉罩式呼吸道外傷護(hù)理流程：早期創(chuàng)傷評(píng)估及創(chuàng)傷休克處置；輸液治療、骨盆骨折胸部創(chuàng)傷：含心包膜穿刺術(shù)、胸管放置術(shù)、固定及胸瓶護(hù)理骨骼、肌肉、肢體外傷/血管外傷頭頸部、脊椎外傷外傷病患與家屬心理支持、危機(jī)處理腹部外傷、腹部超音波與腹膜灌洗術(shù)、腹壓測(cè)量外傷病人急救處置情境模擬臺(tái)灣TNTP課程表－IIISkillStations44PAv.NPv.TNPA(臺(tái))PA(美)NP(臺(tái))NP(美)TN(臺(tái))TN(美)法規(guī)非法有有有無(wú)有資格至少兩年大學(xué)160小時(shí)訓(xùn)練RN及碩士學(xué)位訓(xùn)練課程訓(xùn)練課程工作範(fàn)圍執(zhí)行大多數(shù)醫(yī)療業(yè)務(wù)同護(hù)理師？執(zhí)行大多數(shù)醫(yī)療業(yè)務(wù)？同護(hù)理師？PAv.NPv.TNPA(臺(tái))PA(美)NP(臺(tái))N45WhatkindofNPsandTNsdoweneed?WhatkindofNPsandTNsdowe46ThanksforYourAttention!ThanksforYourAttention!47jUlWoZq!s&v(x+A1C4F6H9KbMePgRiUlWnZq!s&v(x+A1C4F6H8KbMdPgRiUlWnZ8JaLdOfQiTkVmYp#r%u*w-z0B3E5G8JaLcOfQhTkVmYp#r%u*w-z0B2E5G7JaLcOfQhTkVmYp#r$u*w)z0B2E5G7JaLcOfQhSkVmXp#r$u*w)z0B2E5G7IaLcNfQhSkVmXp#r$u*w)y0B2D5G7IaLcNfQhSkVmXo#r$t*w)y0B2D5G7IaLcNeQhSjVC3F6H8KbMdOgRiTlWnYq!s%v(x-A1C3E6H8JbMdOgRiTlWnYq!s%u(x-z1C3E6H8JbMdOgRiTkWnYp!s%u(x-zdOfQiTkVnYp#r%u*w-z0B3E5G8JaLdOfQhTkVmYp#r%u*w-z0B3E5G7JaLcOfQhTkVmYp#r%u*w)z0B2E5G7JaLcOfQhTkVmXp#r$u*w)z0B2E5G7JaLcNfQhSkVmXp#r$u*w)z0B2D5G7IaLcN(y+A1D4F6I9KbMePgRjUlWoZq!t&v(y+A1C4F6H9KbMePgRjUlWoZq!t&v(x+A1C4F6H9KbMePgRjUlWnZq!s&v(x+A1C4F6H9KbMdPgRiUlWnZq!s&v(x+A1C3F6H8KbMdPgRiUlWnZq!s%v(x-A1C3F6H8KbMdPgRiTlWnYq!s%v(x-A1C3F6H8JbMdOgRiTlWnYq!s%LcNeQhSjVmXo#r$t*w)y+B2D4G7I9LcNeQhSjVmXoZr$t&w)y+B2D4G7I9LcNePhSjUmXoZr$t&w)y+B2D4F7I9KcNePhSjUmXoZr$t&v)y+A2D4F7I9KcNePhSjUlXoZq$t&v)y+A2D4F7I9KbNePgSjUlXoZq$t&v)y+A1D4F6I9KbNePgSjUlXoZq!t&v(y+ATkWnYp!s%u(x-z1C3E5H8JaMdOfRiTkWnYp!s%u*x-z0C3E5H8JaMdOfRiTkVnYp#s%u*x-z0C3E5H8JaLdOfQiTkVnYp#s%u*x-z0B3E5G8JaLdOfQiTkVnYp#r%u*w-z0B3E5G8JaLdOfQhTkVmYp#r%u*w-z0B3E5G7JaLcOfQhTkVmYp#r%u*MePgRjUlWoZq!t&v(x+A1C4F6H9KbMePgRjUlWnZq!s&v(x+A1C4F6H9KbMdPgRiUlWnZq!s&v(x+A1C3F6H8KbMdPgRiUlWnZq!s%v(x-A1C3F6H8KbMdPgRiTlWnYq!s%v(x-A1C3F6H8Jr$t*w)y0B2D4G7I9LcNeQhSjVmXo#r$t*w)y+B2D4G7I9LcNeQhSjVmXoZr$t&w)y+B2D4G7I9LcNePhSjUmXoZr$t&w)y+B2D4F7I9KcNePhSjUmXoZr$t&v)y+A2D4F7I9KcNePhSjUlXoZq$t&v)y+A2D4F7I9KbNeP8JbMdOgRiTlWnYq!s%u(x-z1C3E6H8JbMdOgRiTkWnYp!s%u(x-z1C3E6H8JaMdOfRiTkWnYp!s%u(x-z0C3E5H8JaMdOfRiTkWnYp#s%u*NePhSjUlXoZq$t&v)y+A2D4F7I9KbNePgSjUlXoZq$t&v)y+A1D4F6I9KbNePgSjUlXoZq!t&v(y+A1D4F6I9KbNcNePhSjUmXoZr$t&w)y+A2D4F7I9KcNePhSjUmXoZq$t&v)y+A2D4F7I9KcNePgSjUlXoZq$t&v)y+A2D4F6I9#s%u*x-z0C3E5G8JaLdOfQiTkVnYp#s%u*w-z0B3E5G8JaLdOfQiTiTkWnYp!s%u(x-z1C3E5H8JaMdOfRiTkWnYp!s%u*x-z0C3E5H8JaMdOfRiTkVnYp#s%u*x-z0C3E5H8JaLdOfQiTkVnYp#s%u*x-z0B3E5G8JaLdOfQiTkVnYp#r%u*w-z0B3E5G8JaLdOfQhTkVmYp#r%u*w-z0B3E5G7JaLcOfQ+A2D4F7I9KcNePhSjUlXoZq$t&v)y+A2D4F7I9KbNePgSjUlXoZq$t&v)y+A1D4F6I9KbNs%u(x-z1C3E6H8JbMdOfRiTkWnYp!s%u(x-z1C3E5H8JaMdOfRiTkWnYp!s%u*x-z0C3E5HoZq$t&v)y+A2D4F7I9KcNePgSjUlXoZq$t&v)y+A2D4F7I9KbNePgSjUlXoZq$t&v)y+A1D4F6I9KbNePgSjUlXoZq!t&v(y+A1D4F6I9KbNePgRjUlWoZq!t&v(y+A1D4F6H9KbMePgRjUlWoZq!t&vOfQiTkVnYp#s%u*x-z0C3E5G8JaLdOfQiTkVnYp#s%u*w-z0B3E5G8JaLdOfQiTkVnYp#r%u*w-z0B3E5G8JaLdOfQhTkVmYp#r%u*w-z0B3E5G7JaLcOfQhTkVmYp#r%u*w)z0B2E5G7Ja!s&v(x+A1C4F6H9KbMePgRiUlWnZq!s&v(x+A1C4F6H8KbMdPgRiUlWnZq!s&v(x-A1C3F6H8KbMdP(x-z0C3E5H8JaMdOfRiTkWnYp#s%u*x-z0C3E5H8JaMdOfQiTkVnYp#s%u*x-z0C3E5H8JaLdOfQiTkVnYp#s%u*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郭良基醫(yī)師助理、專(zhuān)科護(hù)理師及外傷護(hù)士在醫(yī)療及法律的定位與角色高雄49名詞釋義醫(yī)師助理（Physicianassistant）專(zhuān)科護(hù)理師（AdvancedPracticeRegisteredNurses(APRNs)）外傷護(hù)士（Traumanurse）名詞釋義醫(yī)師助理（Physicianassistant）50醫(yī)療業(yè)務(wù)與醫(yī)療行為醫(yī)師法及醫(yī)療法並未規(guī)定醫(yī)療業(yè)務(wù)之範(fàn)圍?！阜惨灾委?、矯正或預(yù)防人體疾病、傷害、殘缺或保健為直接目的，所為的診察、診斷及治療，或基於診察、診斷結(jié)果，以治療為目的，所為的處方或用藥等行為的一部或全部的總稱(chēng)為醫(yī)療行為?！梗ò耸荒暌辉铝招l(wèi)署醫(yī)字第一零零一一六二號(hào)）「施術(shù)或處置」（八十一年七月三十一日衛(wèi)署醫(yī)字第八一五三四六三號(hào)函釋?zhuān)┽t(yī)療業(yè)務(wù)與醫(yī)療行為醫(yī)師法及醫(yī)療法並未規(guī)定醫(yī)療業(yè)務(wù)之範(fàn)圍。51護(hù)理人員之業(yè)務(wù)護(hù)理人員法第二十四條：健康問(wèn)題之護(hù)理評(píng)估預(yù)防保健之護(hù)理措施護(hù)理指導(dǎo)及諮詢醫(yī)療輔助行為醫(yī)療輔助行為應(yīng)在醫(yī)師之指示下行之。護(hù)理人員之業(yè)務(wù)護(hù)理人員法第二十四條：52醫(yī)療輔助行為－I侵入性檢查之護(hù)理侵入性治療、處置之護(hù)理各項(xiàng)手術(shù)全程護(hù)理分娩全程護(hù)理放射線檢查、治療之護(hù)理化學(xué)治療之護(hù)理氧氣療法、光線療法之護(hù)理醫(yī)療輔助行為－I侵入性檢查之護(hù)理53醫(yī)療輔助行為－II恢復(fù)室、加護(hù)病房（含精神科保護(hù)室）、洗腎室急診病人全程護(hù)理住院病人、暫留病人口服藥物之投與生命徵象監(jiān)視器的監(jiān)視住院病人生命徵象測(cè)量與評(píng)估其他經(jīng)衛(wèi)生主管機(jī)關(guān)認(rèn)定的醫(yī)療輔助行為（八十二年六月二十九日衛(wèi)署醫(yī)字第八二四六零三四號(hào)函）醫(yī)療輔助行為－II恢復(fù)室、加護(hù)病房（含精神科保護(hù)室）、洗腎室54醫(yī)師助理醫(yī)師助理55醫(yī)師助理臺(tái)灣：不合法。醫(yī)療法第五十八條：醫(yī)療機(jī)構(gòu)不得置臨床助理執(zhí)行醫(yī)療業(yè)務(wù)。美國(guó)：合法。美國(guó)CNN之最佳工作一百名中排名第五（醫(yī)師：第三十，律師：第三十七）醫(yī)師助理臺(tái)灣：不合法。56醫(yī)師助理之資格至少兩年之大學(xué)教育。美國(guó)有超過(guò)135個(gè)的課程，其中有超過(guò)90個(gè)提供碩士學(xué)位，其餘多為學(xué)士學(xué)位。NationalCommissiononCertificationofPhysicianAssistants(NCCPA)醫(yī)師助理之資格至少兩年之大學(xué)教育。57醫(yī)師助理之工作範(fàn)圍－I在醫(yī)師監(jiān)督下，提供診斷、治療、及預(yù)防保健服務(wù)。詢問(wèn)病史、檢查及治療病患、開(kāi)立並判讀實(shí)驗(yàn)室檢查及X光、作出診斷?？芍委熭p微外傷，縫合及石膏副木固定。紀(jì)錄progressnotes、病人衛(wèi)教及諮詢、開(kāi)立及執(zhí)行治療。在48州及DC，醫(yī)師助理可以開(kāi)立藥物處方。醫(yī)師助理之工作範(fàn)圍－I在醫(yī)師監(jiān)督下，提供診斷、治療、及預(yù)防保58醫(yī)師助理之工作範(fàn)圍－II醫(yī)師助理可用電話，或到醫(yī)院或護(hù)理之家診視病人後，向其監(jiān)督醫(yī)師回報(bào)。在部分地區(qū)，醫(yī)師助理可能是主要的醫(yī)療照護(hù)提供者。大多數(shù)醫(yī)師助理是一般內(nèi)科、小兒科、及家醫(yī)科。醫(yī)師助理之工作範(fàn)圍－II醫(yī)師助理可用電話，或到醫(yī)院或護(hù)理之家59美國(guó)醫(yī)師助理之薪資2004年五月調(diào)查：平均年收入$69,410。2004年：全職的醫(yī)師助理medianincome為$74,264/年；第一年畢業(yè)生之medianincome為$64,536/年。美國(guó)醫(yī)師助理之薪資2004年五月調(diào)查：平均年收入$69,4160專(zhuān)科護(hù)理師專(zhuān)科護(hù)理師61專(zhuān)科護(hù)理師臺(tái)灣：合法。護(hù)理人員法第七條之一第三項(xiàng)：護(hù)理師經(jīng)完成專(zhuān)科護(hù)理師訓(xùn)練，並經(jīng)中央主管機(jī)關(guān)甄審合格者，得請(qǐng)領(lǐng)專(zhuān)科護(hù)理師證書(shū)。專(zhuān)科護(hù)理師分科及甄審辦法第二條：護(hù)理師依本辦法所定之分科完成專(zhuān)科護(hù)理師訓(xùn)練者，得參加各該專(zhuān)科護(hù)理師之甄審。衛(wèi)生署醫(yī)療網(wǎng)第五期計(jì)畫(huà)：規(guī)劃專(zhuān)科護(hù)理師制度，提昇護(hù)理人力及功能。美國(guó)：合法。專(zhuān)科護(hù)理師臺(tái)灣：合法。62APRNs之資格擁有碩士以上學(xué)位的RN（RegisteredNurses），接受考試及格之後，由各學(xué)會(huì)授與證書(shū)。APRNs之資格擁有碩士以上學(xué)位的RN（Registered63AdvancedPracticeRegisteredNurses(APRNs)AdvancedPracticeNurses(APNs)CertifiedNurseMidwife(CNM)ClinicalNurseSpecialist(CNS)CertifiedRegisteredNurseAnesthetist(CRNA)NursePractitioner(NP)AdvancedPracticeRegisteredN64CNSCRNACNMNPAPNsCNSCRNACNMNPAPNs65NP之資格取得RN之後，有以下五種學(xué)歷之一，可以參加考試。社區(qū)學(xué)院所授與之藝術(shù)相關(guān)學(xué)位醫(yī)院為主的計(jì)畫(huà)，授與3年的學(xué)位證書(shū)大學(xué)所授與之護(hù)理學(xué)學(xué)士(BSN)大學(xué)所授與之護(hù)理學(xué)碩士學(xué)位(MSN)

大學(xué)所授與之護(hù)理學(xué)博士學(xué)位

NP之資格取得RN之後，有以下五種學(xué)歷之一，可以參加考試。66在2015年，所有的NP訓(xùn)練計(jì)畫(huà)都將到達(dá)博士級(jí)(DNP,DrNP)！在2015年，所有的NP訓(xùn)練計(jì)畫(huà)都將到達(dá)博士級(jí)(DNP,67NP的工作範(fàn)圍－I依需要與醫(yī)師和其他醫(yī)療專(zhuān)業(yè)人士合作，包括轉(zhuǎn)診。提供病患健康行為，自我照護(hù)技能和治療選擇的諮詢及教育。診斷和治療急性病，傳染病和外傷。診斷、治療及監(jiān)控慢性病(例如糖尿病，高血壓)。書(shū)寫(xiě)病歷並執(zhí)行理學(xué)檢查。開(kāi)立處方用藥。NP的工作範(fàn)圍－I依需要與醫(yī)師和其他醫(yī)療專(zhuān)業(yè)人士合作，包括轉(zhuǎn)68NP的工作範(fàn)圍－II開(kāi)立、執(zhí)行、並判讀檢查報(bào)告(例如實(shí)驗(yàn)室檢查，X光，心電圖)。開(kāi)立物理療法和復(fù)健處方。提供產(chǎn)前檢查及家庭計(jì)畫(huà)服務(wù)。提供完整兒童照護(hù)，包括篩檢和免疫注射。提供成年人健康維持照護(hù)，包括每年體格檢查。執(zhí)行簡(jiǎn)單的小手術(shù)(如皮膚切片，縫合，石膏副木固定)。NP的工作範(fàn)圍－II開(kāi)立、執(zhí)行、並判讀檢查報(bào)告(例如實(shí)驗(yàn)室檢69NP的發(fā)照單位（國(guó)家級(jí)）NP-C(NursePractitioner-Certified;ifcertifiedbytheAANP－AmericanAcademyofNursePractitioners)APRN,BC(AdvancedPracticeRegisteredNurse,BoardCertified;ifcertifiedbytheANCC－AmericanNursesCredentialingCenter)NP的發(fā)照單位（國(guó)家級(jí)）NP-C(NursePracti70NP的發(fā)照單位（不同專(zhuān)科別）CPNP(PediatricNPwhencertifiedbythePediatricNursingCertificationBoard(PNCB)AmericanAssociationofCritical-CareNursesAmericanPsychiatricNursingAssociationBoardofCertificationforEmergencyNursingNationalCertificationBoardofPediatricNursePractitionersandNursesNationalCertificationCorporationfortheObstetric,Gynecologic,andNeonatalNursingSpecialtiesOncologyNursingCertificationCorporationAmericanHolisticNursesAssociationNP的發(fā)照單位（不同專(zhuān)科別）CPNP(Pediatric71NP的分科ACNP(AcuteCareNP)AHN(HolisticNP)ANP(AdultNP)FNP(FamilyNP)GNP(GeriatricNP)NNP(NeonatalNP)PMHNP(PsychiatricMentalHealthNP)PNP(PediatricNP)WHNP(Women'sHealthNP)NP的分科ACNP(AcuteCareNP)72RN的薪資2004年五月調(diào)查：平均年收入$52,330Employmentservices $63,170Generalmedicalandsurgicalhospitals $53,450Homehealthcareservices $48,990Officesofphysicians $48,250Nursingcarefacilities $48,220RN的薪資2004年五月調(diào)查：平均年收入$52,33073臺(tái)灣專(zhuān)科護(hù)理師之分科專(zhuān)科護(hù)理師分科及甄審辦法第三條：專(zhuān)科護(hù)理師之分科如下：一、內(nèi)科二、外科三、其他經(jīng)中央主管機(jī)關(guān)指定之分科。臺(tái)灣專(zhuān)科護(hù)理師之分科專(zhuān)科護(hù)理師分科及甄審辦法第三條：專(zhuān)科護(hù)理74內(nèi)科及外科專(zhuān)科護(hù)理師訓(xùn)練課程綱要

（臺(tái)灣專(zhuān)科護(hù)理師之資格）94年11月25日衛(wèi)署醫(yī)字第0940219048號(hào)令一、訓(xùn)練期間，至少六個(gè)月。二、訓(xùn)練內(nèi)容，包括學(xué)科課程與臨床訓(xùn)練。三、學(xué)科課程，應(yīng)有一六O小時(shí)以上，其範(fàn)圍包括如下：（一）醫(yī)療品質(zhì)。（二）法規(guī)與倫理。（三）專(zhuān)業(yè)課程。內(nèi)科及外科專(zhuān)科護(hù)理師訓(xùn)練課程綱要

（臺(tái)灣專(zhuān)科護(hù)理師之資格）975專(zhuān)業(yè)課程應(yīng)包含專(zhuān)科護(hù)理師執(zhí)業(yè)模式及照護(hù)品質(zhì)、健康評(píng)估及臨床決策、進(jìn)階藥理學(xué)、進(jìn)階生理病理學(xué)、實(shí)驗(yàn)診斷及判讀、健康促進(jìn)與疾病預(yù)防、個(gè)案諮商、健康問(wèn)題診斷與處置、內(nèi)外科健康照護(hù)、案例分析等科目。專(zhuān)業(yè)課程應(yīng)包含專(zhuān)科護(hù)理師執(zhí)業(yè)模式及照護(hù)品質(zhì)、健康評(píng)估及臨床決76臨床訓(xùn)練範(fàn)圍四、臨床訓(xùn)練範(fàn)圍包括如下：（一）內(nèi)（外）科病人照護(hù)。（二）急重癥病人照護(hù)。（三）末期病人照護(hù)。臨床訓(xùn)練範(fàn)圍四、臨床訓(xùn)練範(fàn)圍包括如下：77臨床訓(xùn)練範(fàn)圍之訓(xùn)練重點(diǎn)協(xié)助住院病人身體理學(xué)檢查之初步評(píng)估及病情詢問(wèn)。協(xié)助填具檢驗(yàn)單、特殊檢查單、會(huì)診單、轉(zhuǎn)診單及診斷證明等各項(xiàng)臨床單據(jù)。協(xié)助記錄住院病人病情及各項(xiàng)檢查、檢驗(yàn)結(jié)果。協(xié)助醫(yī)師為臨床處置。簡(jiǎn)易之傷口處置、導(dǎo)管更換。協(xié)助處理住院病人或其家屬醫(yī)療諮詢及病情之說(shuō)明。臨床訓(xùn)練範(fàn)圍之訓(xùn)練重點(diǎn)協(xié)助住院病人身體理學(xué)檢查之初步評(píng)估及病78臺(tái)灣專(zhuān)科護(hù)理師之工作範(fàn)圍臺(tái)灣專(zhuān)科護(hù)理師之工作範(fàn)圍79外傷護(hù)士外傷護(hù)士80外傷護(hù)士臺(tái)灣：無(wú)法規(guī)規(guī)定。美國(guó)：合法。外傷護(hù)士臺(tái)灣：無(wú)法規(guī)規(guī)定。81TN之資格美國(guó)：RN接受過(guò)外傷訓(xùn)練課程，並經(jīng)測(cè)驗(yàn)合格，即可獲得。AdvancedTraumaCareforNurses(ATCN)－SocietyofTraumaNurses

TraumaNursingCoreCourse(TNCC)CourseinAdvancedTraumaNursing–II(CATN-II)－EMERGENCYNURSESASSOCIATION(ENA)

TN之資格美國(guó)：RN接受過(guò)外傷訓(xùn)練課程，並經(jīng)測(cè)驗(yàn)合格，即可獲82臺(tái)灣TN之資格參加TNTP課程，並經(jīng)測(cè)驗(yàn)及格。ETTC？ATLS？急診加護(hù)護(hù)理人員能力鑑定考試（BCCRN）？臺(tái)灣TN之資格參加TNTP課程，並經(jīng)測(cè)驗(yàn)及格。83外傷護(hù)士之職責(zé)外傷護(hù)士之職責(zé)84TraumaNurses＝EmergencyNursesTraumaNurses＝EmergencyNurses85TNCC課程表－IEpidemiology,biomechanicsandmechanismsofinjuryInitialassessmentShockBrainandcraniofacialtraumaThoracicandnecktraumaAbdominaltraumaSpinalcordandvertebralcolumntraumaMusculoskeletaltraumaBurntraumaTraumaandpregnancyPediatrictraumaGeriatrictraumaPsychosocialaspectsoftraumacareStabilization,transferandtransportTNCC課程表－IEpidemiology,biomech86TNCC課程表－IISkillStationsTraumanursingprocessAirwayandventilationinterventionsSpinalimmobilizationChesttraumaandtractionsplintingTNCC課程表－IISkillStations87ATCN課程表－IInitialAssessment&Management*AirwayandVentilatoryManagement*Shock*ThoracicTrauma*AbdominalTrauma*RotationinPracticalSkillsStations:Airway&VentilatoryManagement,HemorrhagicShockandInitialAssessment,MRDSTeamVideoATCN課程表－IInitialAssessment&88ATCN課程表－IIHeadTrauma*SpineandSpinalCordTrauma*MusculoskeletalTrauma*RotationinPracticalSkillsStations:SpineandExtremityInjury,PediatricTraumaandHeadTraumaInjuriesduetoBurnsandCold*TraumainExtremesofAgeTraumainWomen*TransfertoDefinitiveCare*WrittenExamination&TriageCaseScenariosInitialAssessmentSkillsStationsLecturesbyATLS?facultyindicatedby*.Practicalskillsstations&testingbyATCN?facultyATCN課程表－IIHeadTrauma*89臺(tái)灣TNTP課程表－I外傷護(hù)理、外傷制度、與緊急醫(yī)療網(wǎng)EMS/TraumaSystem/TraumaNursing外傷評(píng)估處置與外傷休克護(hù)理呼吸道處置與護(hù)理(包含住院後)胸腹部之外傷護(hù)理(包含住院後)頭頸與脊椎之外傷護(hù)理(包含住院後)肢體外傷(骨骼肌肉血管)之護(hù)理臺(tái)灣TNTP課程表－I外傷護(hù)理、外傷制度、與緊急醫(yī)療網(wǎng)EMS90臺(tái)灣TNTP課程表－II燒燙傷、吸入性灼傷與電擊傷之護(hù)理特殊傷患外傷－兒童、孕婦、老人外傷病人的運(yùn)送與轉(zhuǎn)院外傷病患之加護(hù)照護(hù)壓力適應(yīng)、危機(jī)處理與創(chuàng)傷後癥候群外傷團(tuán)隊(duì)合作/外傷護(hù)理倫理與法律問(wèn)題臺(tái)灣TNTP課程表－II燒燙傷、吸入性灼傷與電擊傷之護(hù)理91臺(tái)灣TNTP課程表－IIISkillStations建立安全呼吸道/外科手術(shù)建立呼吸道/喉罩式呼吸道外傷護(hù)理流程：早期創(chuàng)傷評(píng)估及創(chuàng)傷休克處置；輸液治療、骨盆骨折胸部創(chuàng)傷：含心包膜穿刺術(shù)、胸管放置術(shù)、固定及胸瓶護(hù)理骨骼、肌肉、肢體外傷/血管外傷頭頸部、脊椎外傷外傷病患與家屬心理支持、危機(jī)處理腹部外傷、腹部超音波與腹膜灌洗術(shù)、腹壓測(cè)量外傷病人急救處置情境模擬臺(tái)灣TNTP課程表－IIISkillStations92PAv.NPv.TNPA(臺(tái))PA(美)NP(臺(tái))NP(美)TN(臺(tái))TN(美)法規(guī)非法有有有無(wú)有資格至少兩年大學(xué)160小時(shí)訓(xùn)練RN及碩士學(xué)位訓(xùn)練課程訓(xùn)練課程工作範(fàn)圍執(zhí)行大多數(shù)醫(yī)療業(yè)務(wù)同護(hù)理師？執(zhí)行大多數(shù)醫(yī)療業(yè)務(wù)？同護(hù)理師？PAv.NPv.TNPA(臺(tái))PA(美)NP(臺(tái))N93WhatkindofNPsandTNsdoweneed?WhatkindofNPsandTNsdowe94ThanksforYourAttention!ThanksforYourAttention!95jUlWoZq!s&v(x+A1C4F6H9KbMePgRiUlWnZq!s&v(x+A1C4F6H8KbMdPgRiUlWnZ8JaLdOfQiTkVmYp#r%u*w-z0B3E5G8JaLcOfQhTkVmYp#r%u*w-z0B2E5G7JaLcOfQhTkVmYp#r$u*w)z0B2E5G7JaLcOfQhSkVmXp#r$u*w)z0B2E5G7IaLcNfQhSkVmXp#r$u*w)y0B2D5G7IaLcNfQhSkVmXo#r$t*w)y0B2D5G7IaLcNeQhSjVC3F6H8KbMdOgRiTlWnYq!s%v(x-A1C3E6H8JbMdOgRiTlWnYq!s%u(x-z1C3E6H8JbMdOgRiTkWnYp!s%u(x-zdOfQiTkVnYp#r%u*w-z0B3E5G8JaLdOfQhTkVmYp#r%u*w-z0B3E5G7JaLcOfQhTkVmYp#r%u*w)z0B2E5G7JaLcOfQhTkVmXp#r$u*w)z0B2E5G7JaLcNfQhSkVmXp#r$u*w)z0B2D5G7IaLcN(y+A1D4F6I9KbMePgRjUlWoZq!t&v(y+A1C4F6H9KbMePgRjUlWoZq!t&v(x+A1C4F6H9KbMePgRjUlWnZq!s&v(x+A1C4F6H9KbMdPgRiUlWnZq!s&v(x+A1C3F6H8KbMdPgRiUlWnZq!s%v(x-A1C3F6H8KbMdPgRiTlWnYq!s%v(x-A1C3F6H8JbMdOgRiTlWnYq!s%LcNeQhSjVmXo#r$t*w)y+B2D4G7I9LcNeQhSjVmXoZr$t&w)y+B2D4G7I9LcNePhSjUmXoZr$t&w)y+B2D4F7I9KcNePhSjUmXoZr$t&v)y+A2D4F7I9KcNePhSjUlXoZq$t&v)y+A2D4F7I9KbNePgSjUlXoZq$t&v)y+A1D4F6I9KbNePgSjUlXoZq!t&v(y+ATkWnYp!s%u(x-z1C3E5H8JaMdOfRiTkWnYp!s%u*x-z0C3E5H8JaMdOfRiTkVnYp#s%u*x-z0C3E5H8JaLdOfQiTkVnYp#s%u*x-z0B3E5G8JaLdOfQiTkVnYp#r%u*w-z0B3E5G8JaLdOfQhTkVmYp#r%u*w-z0B3E5G7JaLcOfQhTkVmYp#r%u*MePgRjUlWoZq!t&v(x+A1C4F6H9KbMePgRjUlWnZq!s&v(x+A1C4F6H9KbMdPgRiUlWnZq!s&v(x+A1C3F6H8KbMdPgRiUlWnZq!s%v(x-A1C3F6H8KbMdPgRiTlWnYq!s%v(x-A1C3F6H8Jr$t*w)y0B2D4G7I9LcNeQhSjVmXo#r$t*w)y+B2D4G7I9LcNeQhSjVmXoZr$t&w)y+B2D4G7I9LcNePhSjUmXoZr$t&w)y+B2D4F7I9KcNePhSjUmXoZr$t&v)y+A2D4F7I9KcNePhSjUlXoZq$t&v)y+A2D4F7I9KbNeP8JbMdOgRiTlWnYq!s%u(x-z1C3E6H8JbMdOgRiTkWnYp!s%u(x-z1C3E6H8JaMdOfRiTkWnYp!s%u(x-z0C3E5H8JaMdOfRiTkWnYp#s%u*NePhSjUlXoZq$t&v)y+A2D4F7I9KbNePgSjUlXoZq$t&v)y+A1D4F6I9KbNePgSjUlXoZq!t&v(y+A1D4F6I9KbNcNePhSjUmXoZr$t&w)y+A2D4F7I9KcNePhSjUmXoZq$t&v)y+A2D4F7I9KcNePgSjUlXoZq$t&v)y+A2D4F6I9#s%u*x-z0C3E5G8JaLdOfQiTkVnYp#s%u*w-z0B3E5G8JaLdOfQiTiTkWnYp!s%u(x-z1C3E5H8JaMdOfRiTkWnYp!s%u*x-z0C3E5H8JaMdOfRiTkVnYp#s%u*x-z0C3E5H8JaLdOfQiTkVnYp#s%u*x-z0B3E5G8JaLdOfQiTkVnYp#r%u*w-z0B3E5G8JaLdOfQhTkVmYp#r%u*w-z0B3E5G7JaLcOfQ+A2D4F7I9KcNePhSjUlXoZq$t&v)y+A2D4F7I9KbNePgSjUlXoZq$t&v)y+A1D4F6I9KbNs%u(x-z1C3E6H8JbMdOfRiTkWnYp!s%u(x-z1C3E5H8JaMdOfRiTkWnYp!s%u*x-z0C3E5HoZq$t&v)y+A2D4F7I9KcNePgSjUlXoZq$t&v)y+A2D4F7I9KbNePgSjUlXoZq$t&v)y+A1D4F6I9KbNePgSjUlXoZq!t&v(y+A1D4F6I9KbNePgRjUlWoZq!t&v(y+A1D4F6H9KbMePgRjUlWoZq!t&vOfQiTkVnYp#s%u*x-z0C3E5G8JaLdOfQiTkVnYp#s%u*w-z0B3E5G8JaLdOfQiTkVnYp#r%u*w-z0B3E5G8JaLdOfQhTkVmYp#r%u*w-z0B3E5G7JaLcOfQhTkVmYp#r%u*w)z0B2E5G7Ja!s&v(x+A1C4F6H9KbMePgRiUlWnZq!s&v(x+A1C4F6H8KbMdPgRiUlWnZq!s&v(x-A1C3F6H8KbMdP(x-z0C3E5H8JaMdOfRiTkWnYp#s%u*x-z0C3E5H8JaMdOfQiTkVnYp#s%u*x-z0C3E5H8JaLdOfQiTkVnYp#s%u*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