Set up and use basic norm in electronic case history

Set up and use basic norm in electronic case history
It is reported (Reporter's grandson Dream) Ministry of Public Health released a few days ago>,Setting-up, use, keeping and managing regulation of the electronic case history of the hospital.
Cure department's relevant introductions of personnel to the policy according to Ministry of Public Health, the electronic case history is different from printing the case history. The former refers to the digitized information of characters, symbol, chart, figure, data, image,etc. that the medical worker uses the information system of medical organization to produce, and can realize the medical records stored, managed, transmitted and reappeared, including (urgent) on the door Examine electronic case history, electronic case history and other electronic medical records in hospital. It is not the electronic case history to use the case history file that the word processor edits, prints.
" the case history writes the basic norm " to record the form as a kind of new case history in electronic case history after implementing from March 1, have already aroused the attention from people. There is security that net friend queries the electronic case history. Once appear medical dispute, how prevent electronic case history from unreasonable to fix, make, suffer from square rights and interests, receive practical assurance? As to this, announce newly>Have carried on the regulation of pertinence. According to " norm ", the electronic case history system should offer identification label and recognition means that have specially to attenbant, set up the corresponding authority, and grade the attenbant's authority, the attenbant is responsible for use of one's own identification label. The medical worker adopts the log-in electronic case history system of identification label to finish every record after operating and confirming, the system should reveal the medical worker electronic signature.
" norm " proposes, the electronic case history system should set up authority and time limit that a medical worker examine, revise, the ones that possess operation of establishing, editing, filing to the electronic case history etc. are traced back to ability. Practise the case history that the medical worker, medical worker in probationary period recorded, should be checked, revised and signed electronically and confirmed by the medical worker in the legal operation of this medical organization. When medical worker revise, electronic the intersection of case history and system should carry on identity discern, keep all previous to revise trace, the intersection of mark and accurate modification time and revise people's information.
Clinic electronic the door in the the case histories ' Urgent) Examine the case history to record, meet and examine a doctor to input and confirm getting and filing, can't revise after filing.
In hospital the electronic case history to leave hospital to file with the patient after the doctors of higher authorities are on the patient leave hospital and verify and confirms, managed in unison by the administrative department of electronic case history after filing.
The information of course of disease recorded on the electronic case history concerns the legal effect, how to guarantee its security? " norm " is clear, the electronic case history system of medical organization should possess system and measure which ensures the data security of the electronic case history, there are data that back up the mechanism, the conditional medical organization should set up the calamity of information system and prepare against the system (such as the disaster resumes the system) ,The emergency preplan that can implement the system while breaking down, guarantee the continuity of the business of the electronic case history.
In addition, when medical worker and administrative staff of relevant hospitals transfer and read, duplicate, print the electronic case history, the medical organization should presume the corresponding authority, set up electronic case history and use the daily record, record to the user, operating time and content. According to the regulation, besides hospital personnel, patient or its agent, dead patient's close relative or its agent, pay basic medical guarantee of expenses, manage and handle organization, patient, authorize safety unit that trust can apply, transfer and read, duplicate the electronic case history for patient, it proves copies such as materials, contract of insurance,etc. to need to retain applicant's effective I.D. copy and legal while applying.
" norm " still points out, when the malpractice dispute happens, should lock the electronic case history in the presence of doctors and patients both sides, and make all the same paper edition and is sealed up for safekeeping, the paper case history materials sealed up for safekeeping are kept by the medical organization.
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