知情同意书无纸化系统的设计与实现  

Design and implementation of a paperless system for informed consent

作　　者：俞静[1] 姜胜耀[1] YU Jing;JIANG Shengyao(Information Center,Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine,Shanghai 200025,China)

机构地区：[1]上海交通大学医学院附属瑞金医院信息中心,上海200025

出　　处：《中国数字医学》2023年第9期33-38,共6页China Digital Medicine

摘　　要：目的:知情同意权是在医疗过程中患者的一项基本权利。基于知情同意书需要患者和医务人员共同参与的特点,建立一套知情同意书无纸化的解决方案。方法:对临床的知情同意书进行调研,分析业务流程,借助5G网络、手写设备、CA认证等主流的信息化技术,设计、开发一套无纸化知情同意系统。结果:无纸化知情同意流程的改造,为全面病案无纸化的开展打下了患者端技术基础。为医院和患者知情同意沟通搭起了畅通、友好的信息桥梁。结论:无纸化知情同意书对提高医疗满意度起到重要的作用,对系统的便捷性、真实性、安全性提出了更高的要求,手写板建立便捷、友好的用户体系;电子签名保障病案的真实性和合法性;5G网络对信息传输中的安全性进行保障。Objective The right of informed consent is a basic right of patients in the medical process and also an important guarantee to safeguard the rights of patients.Based on the feature that informed consent requires the joint participation of both patients and medical staff,to establish a set of solutions for paperless informed consent,so as to realize comprehensive paperless medical records.Methods Clinical informed consent forms were investigated,the business process was analyzed,and a paperless informed consent system was designed and developed with the help of mainstream information technology such as 5G network,handwriting devices,and CA certification.Results The transformation of the paperless informed consent process has laid a technological foundation on the patient side for the comprehensive paperless development of medical records,which builds a smooth and friendly information bridge for hospital-patient informed consent communication.Conclusion Paperless informed consent plays an important role in improving medical satisfaction and puts forward higher requirements for the convenience,authenticity,and security of the system.The handwriting tablet establishes a convenient and friendly user system.Electronic signature ensures the authenticity and legality of medical records and the 5G network ensures the security of information during transmission.

关 键 词：无纸化 知情同意书 电子签名 法律效力 

分 类 号：R197.3[医药卫生—卫生事业管理] R319[医药卫生—公共卫生与预防医学]