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电子病案在逐步形成一门新的学科,是医院医疗信息化的重要基础,电子病案的实现是一项复杂而又艰巨的工程,应该遵循“全面考虑,周密计划,着眼未来、分步实施”的原则。要考虑到与国际接轨的问题,应该建立一套科学的、严谨的、完整的管理规范,而且要逐步形成行政法规,必须实行分级保密管理,设立查阅、输入、修改和使用的分级授权,以保证电子病案的安全性和使用价值,迫切需要法律依据来规范调整。
The electronic medical record is gradually forming a new discipline, which is an important basis for hospital medical informationization. The realization of electronic medical records is a complex and arduous project. It should follow the principle of “comprehensive consideration, careful planning, focus on the future, and step-by-step implementation”. the rules. In order to take into account international issues, a set of scientific, rigorous and complete management norms should be established, and administrative regulations must be gradually formed. Classified and classified management must be implemented, and graded authorization for inspection, input, modification, and use must be established. To ensure the safety and use value of electronic medical records, there is an urgent need for legal basis to regulate and adjust.