| 电子病案的原始性问题及解决方法探讨 |
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| 引用本文： | 曾清华,徐臻.电子病案的原始性问题及解决方法探讨[J].中国病案,2011,12(11):29-31. |
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| 作者姓名： | 曾清华 徐臻 |
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| 作者单位： | 1. 南昌大学第二附属医院病案室,南昌市,330006
2. 南昌大学第二附属医院心内科,南昌市,330006 |
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| 基金项目： | 2008年江西省卫生厅科技计划资助项目 |
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| 摘 要： | 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。
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| 关 键 词： | 电子病案 信息技术 法律凭证 |
Discussion of Primitiveness Problems and Solutions of Electronic Medical Records |
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| Zeng Qinghua,Xu Zhenyan.Discussion of Primitiveness Problems and Solutions of Electronic Medical Records[J].Chinese Medical Record,2011,12(11):29-31. |
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| Authors: | Zeng Qinghua Xu Zhenyan |
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| Affiliation: | Zeng Qinghua,Medical Records Department of the Second Affiliated Hospital of Nanchang University,Xu Zhenyan,Cardiology Department of the Second Affiliated Hospital of Nanchang University,Nanchang 330006,Jiangxi Province,China |
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| Abstract: | Electronic medical record,modern hospital information development product,has advantages as ease storage,management and resource sharing,and also has corrupt practices such as susceptible to distorting and lack of security.This article provides insight analysis of the advantages and problems of electronic medical records and discuss how to effectively protect the primitiveness of electronic medical record in three parts of information technology,medical record management and legal protection. |
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| Keywords: | Electronic medical record Primitiveness keeping |
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