电子护理文书质量缺陷中潜在的法律问题分析与对策  

Legal Problem Analysis and Solution in the Defect in Quality of the Electronic Clinical Document

作　　者：申燕勤[1] SHEN Yan-qin （Affiliated Zhongshan Hospital,Zhongshan University,Zhongshn 528403,China）

机构地区：[1]中山大学附属中山医院,广东中山528403

出　　处：《医学信息》2010年第4期803-805,共3页Journal of Medical Information

摘　　要：目的提高临床护理质量，减少电子护理文书质量缺陷，保证病案信息的法律依据的准确性。方法对2009年1至6月电子护理文书质量缺陷中潜在的法律问题进行分析。结果电子护理文书质量缺陷影响了病案记载内容的客观性、真实性和严肃的法律性。结论强化护理人员法律意识教育，从法律角度认识记录病案信息的重要性，进而规范临床护理与护理文书书写。Objective There are three issues to be addressed in this thesis. Firstly, improve the quality of clinical care. Secondly, reduce defect in quality of electronic clinic documents. Thirdly, ensure the accuracy of the medical reports as legal grounds. Method Analysis has been undertaken to identify and solve the potential legal problems raised by defects quality of the electronic clinic document. Result It is obviously, according to the analysis conducted by author＇s research, that the quality defect in electronic document has negative impacts toward the objectivity, authenticity and serious legality of the information of the medical report. Conclusion it is important to enhance the education of legal consciousness towards the paramedics, and it is essential to recognize that, from the legal point of view, the importance of the information of the medical report. And hence, one can regulate the clinical care and the writing of the clinic document.

关 键 词：电子护理文书缺陷 法律问题 规范护理文书书写 

分 类 号：R47[医药卫生—护理学;医药卫生—临床医学]