电子病历公开与防范医患纠纷可行性探讨  

Feasibility Study of Public Disclosure of Electronic Medical Records and the Medical Disputes Prevention

作　　者：余开焕[1] 熊勇[1] 毛昌[1] 

机构地区：[1]武汉大学人民医院,武汉市430060

出　　处：《中国病案》2014年第1期44-45,共2页Chinese Medical Record

摘　　要：电子病历公开是在整个诊疗过程中实时向患者公开医疗服务工作记录,不仅有助于医疗机构规范医护人员的诊疗行为,提高病案质量,也充分体现尊重患者的知情权和选择权,增进医患的互信,有利于防范和处理医患纠纷。因此,电子病历内容公开是必然的,但在公开的过程中,应加强对医务人员在信息公开法律法规方面的培训,建立电子病历质量控制体系和分步实施的建议。Electronic Medical Records publicity （EMRP）is real-time open records of medical services in whole diagnosis and treatment process to patients. EMRP of medical institutions can not only help them perfect diagnosis and treatment actions of paramedics, upgrade quality of medical records, but also respect patient＇s right of informed consent and patients＇ right of self-determination, increase mutual trust between doctors and patients, reduce mid evade risks in medical disputes. This paper puts forward the following suggestions： establishing a training system of EMRP laws and regulations for medical personnel, strengthening a quality control system of Electronic Medical Records and executing of EMRP step by step.

关 键 词：医疗机构 电子病历 医患纠纷 

分 类 号：R197.3[医药卫生—卫生事业管理]