电子病历实施的难点及其对策  

The Difficulties and Countermeasures of the Implementation of Electric Medical Record

作　　者：崔新莉[1] 董毓贵[1] 

机构地区：[1]江苏省连云港市第一人民医院,连云港市222002

出　　处：《中国病案》2013年第2期38-41,共4页Chinese Medical Record

摘　　要：病历是病人在医院进行诊疗活动历史的原始记录,是记录病人医疗信息的历史档案。随着医院现代化建设的发展和电子计算机技术的迅速普及,电子病历逐步取代纸质病历,在病人信息的收集、储存、分析、传递和利用中得到广泛实施,显示出纸质病历所不能比拟的优越性。一方面,人民健康需求不断提高,要求加快电子病历的实施,彻底淘汰纸质病历;一方面,电子病历的法律效力被质疑,纸质病历还应保留。为此,需要针对电子病历的实施难点采取有效对策。难点是:电子病历的原始性难以鉴定,不能具有纸质病历同等法律效力;措施是:解决电子病历具有纸质病历同等法律效力,采用双套制保存纸质病历。Medical record is the original record of patients＇ treatment in hospital, and it is the history file that recorded the pa- tients＇ information. In pace with the development of hospital modernization and wide spreading of computer technology, electric med- ical record take the place of paper record progressively, and showed many adventages that paper record could not achieved in patients＇ information coUection, saving, analyzing, communication and utilizing. On the one hand, as the constantly increasing of people＇ s health need, there is a requirement to accelerate the implementation of electric record and eliminating paper record. On the other hand, the legal effect of dectric record was stir remain suspicious, paper record should be retained continually. Thus, rdevant effec- tive countermeasures should carry out to ensure the implementation of electric record. The difficulties is the primitive character of electric record is difficult to identify and cannot possess the same legal effect as paper record. So our countermeasures are to solve the problems that to make electric record possess the same legal effect as paper record, and save paper record as ＂double set mode＂ at the same.

关 键 词：电子和纸质病历 法律效力 双套制 

分 类 号：R197.324[医药卫生—卫生事业管理]