随着医院电子计算机网络建设的发展,通称的“电子病案”已在一些医院形成。但如何确保电子病案信息安全,保持其病案的原始性、真实性是要引起人们高度重视的课题。笔者认为,除了采取安全技术措施外,从管理角度看应注意以下几点: 1 明确责任权限从电子病案的形成开始就要责任分明。病人的经管医师应对该病案负有全责,一个病人有多人参与诊治,有科主任,高级、中级、初级人员,还有进修、实习人员等。因此,要注意划清参与人员的责任范围,一份病案只能一人负全责。一般来讲,不相关人员不能进入其他人员的责 With the development of hospital electronic computer networks, the so-called “electronic medical record” has been formed in some hospitals. However, how to ensure the safety of electronic medical record information and maintain the original and authenticity of medical records is a subject that needs to be given high priority. The author believes that, in addition to take safety technical measures, from the management point of view should pay attention to the following points: A clear responsibility authority From the beginning of the formation of electronic medical records should have a clear responsibility. The patient’s supervising physician should bear full responsibility for the medical record. One patient has more than one person involved in the diagnosis and treatment. Chiefs, senior, intermediate and junior staff, as well as further studies and internships, etc. Therefore, we should pay attention to draw the scope of responsibility of participants, a medical record can only be one person responsible. In general, unrelated individuals can not enter the responsibility of other personnel