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电子病案为现代医院信息化发展的产物,具有便于储存、管理、资源共享等诸多优点,同时也存在着易被篡改和缺乏安全性等弊端。电子病案能否被法律认可已成为制约医院信息化发展的瓶颈,其中保持真实性、原始性则起着至关重要的作用。本文从电子病案的优点及现存问题进行深入分析,并从信息技术、病案管理和法律保障三个层面就如何有效可行地保障电子病案的原始性进行探讨。
Electronic medical record is the product of the development of modern hospital informatization. It has the advantages of convenient storage, management, resource sharing and so on. At the same time, it also has the defects of easy to be tampered with and lack of security. Electronic medical records can be recognized by law has become a bottleneck restricting the development of hospital information, of which to maintain the authenticity of the original play a crucial role. In this paper, the advantages and existing problems of electronic medical records are analyzed in depth, and how to effectively and effectively protect the original features of electronic medical records is discussed from three aspects of information technology, medical record management and legal protection.