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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。
Objective To define the conditions that are explicitly prohibited and restricted by law in the use of medical records. Methods Through the investigation of the current status of medical records in China and the analysis and comparison of relevant laws and regulations. Results The use of medical record records requires the compliance with 27 laws and regulations in seven areas: data supply, data use, state secrets, personal privacy, trade secrets, intellectual property rights, and protection of Internet confidential information. There are 30 fields on the front page of inpatient medical records involving the limits of laws and regulations. Conclusion In addition to the content and fields that are explicitly prohibited and restricted by law, other contents in the medical record should be actively opened to promote the scientific use of medical record and promote the advancement and development of medical science.