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目前电子病历系统已经在各大医疗机构普遍使用,但是各类医院所使用的电子病历系统各不相同,我国已经在二零一零年二月十二日由卫生部组织制定了《电子病历基本规范(试行)》并开始试行,对电子病历系统做出了初步的要求,规定了电子病历系统应具备的使用条件与管理规范,但对电子病历所包含的电子数据如何保全并未提及。由于电子病历所承载的电子数据在发生医患纠纷时起着证据证明的重要作用,所以对于电子病历法律效力的问题与如何对电子病历所包含的电子数据保全尤为重要。本文期望从法律和技术交叉为电子病历保全与认证提供微薄的借鉴意义。
At present, the electronic medical record system has been widely used in major medical institutions. However, the electronic medical record systems used in various hospitals are different. China has formulated the Basic Electronic Medical Record on February 12, 2010 by the Ministry of Health (Trial) "and began trial implementation of the electronic medical record system to make the initial requirements, the provisions of the electronic medical record system should have the conditions of use and management practices, but the electronic medical records contained in the electronic data is not mentioned how to preserve. As electronic data carried in EHRs plays an important role in evidence-based disputes in the event of medical disputes, the issue of the legal validity of EHRs and how electronic data is kept in EHRs are of particular importance. This article expects to provide a meager reference for the preservation and certification of electronic medical records from the cross of law and technology.