病案记录的使用与法律风险的规避  

The Use of the Medical Record and the Circumvention of the Risks in Legal Affairs

作　　者：张舒 任然 金以东 刘爱民[2] 胡燕生[3] 聂铁屏[4] 

机构地区：[1]中西亚通(北京)咨询有限公司 [2]北京协和医院 [3]首都医科大学附属北京朝阳医院 [4]天津第一中心医院

出　　处：《中国病案》2008年第1期4-8,共5页Chinese Medical Record

摘　　要：目的对病案记录使用过程中法律明确禁止和限制的情形加以界定。方法通过对我国病案记录现状的调查以及相关法律法规的进行分析比较。结果病案记录使用过程之中在数据供应、数据使用、国家机密、个人隐私、商业机密、知识产权、互联网机密信息保护等7个方面需要符合27部法律和法规的规定。住院病案首页中有30个字段涉及法律和法规的限定。结论在除去法律明确禁止和限制的内容以及字段之外,应该积极开放病案记录中的其他内容以促进病案记录的科学使用,推动医学科学事业的进步和发展。By a Large Scale Matrix Analysis on the front sheets of the medical records and 27 relevant laws and regulations, the authors find that there are seven aspects, including data supply, data application, national secret, privacy protection, business confidentiality, intellectual property, the Internet confidential information protection, which should be accordance with 27 laws and regulations. In the front sheets of the medical record, the uses of 30 fields are defined and protected by the laws and regulations. Finally, through the review of the relevant laws the author defines the scope in using medical record information to set a solid basis for the safe and legal application of the medical record.

关 键 词：病案 法律 住院病案首页 隐私 

分 类 号：R197.3[医药卫生—卫生事业管理]