The Hebei patient diagnoses the illness to have " The electronic case history " Forbid altering forging

The Hebei patient diagnoses the illness to have " The electronic case history " Forbid altering, forging
The Hebei patient diagnoses the illness to have " The electronic case history " Forbid altering, forging
The reporter learnt from the department of public health of Hebei, managed in order to standardize the electronic case history of medical organization yesterday, safeguarded doctors and patients' legitimate rights and interests of both sides, was made and issued by the department of public health of the province <>Have already played and sent to health authority and relevant medical organization of every city, and demand to abide by. As to patient, the implementation of the electronic case history means that it is more convenient, more swift to see the doctor. " regulations " require clearly, the electronic case history system should meet protection system of the grade of national information security and standard, forbid altering, forging, hiding, grabing, stealing and destroying the electronic case history. It is more convenient for the electronic case history to let the patient diagnose the illness So-called " electronic case history " Refer to the medical worker while medical treatment is movable, use the medical record material of digitization of characters, symbol, chart, figure, data, image,etc. that the information system of medical organization produces, and can realize the medical records stored, managed, transmitted and reappeared, it is a kind of record form of the case history. The electronic case history includes the door ' Urgent) Examine electronic case history, electronic case history and other electronic medical records in hospital. Meanwhile, the electronic case history should presume whether the data share annotating, reserve the interface with medical systems of regional electron such as resident's electronic file,etc., realize progressively case history data, resident's health information area share. "As to patient, the implementation of the electronic case history means that it is more convenient, more swift to see the doctor. " The person in charge of a provincial hospital says, at present, go to the hospital to see the doctor, ~s links of wanting the process to register, go to a doctor, pay the fees, fetch medicines at least etc., some difficult and complicated cases patients also need to be checked. And once implement " The electronic case history " And then, the patient's mode of seeking medical advice will change greatly, namely register according to a card, diagnose, fetch medicine,etc., can realize, go on synchronously, at the time of subsequent visit next time such as patient, the doctor only needs to turn on the computer, information will be " very clear " that the one ahead seeks medical advice ,The patient needn't repeat many times. The relevant persons in charge of department of public health of Hebei say, the electronic case history is one of the cores of information construction of the hospital, it will accelerate information to transmit, can realize the information sharing between different medical organizations, utilize medical resources effectively, the hospitalization cost which reduce the patient is born, and can realize that changes the place of examination, grades medical treatment, tele-medicine and personnel training,etc. bidirectionally through resource-sharing. Forbid altering, forging, hiding the electronic case history " regulations " are pointed out, electronic the intersection of case history and system should set up personal the intersection of information and database for patient ' Including the name, gender, date of birth, nationality, marital status, job, office, address, effective identity document number, social security number or medical insurance number, telephone number, clinic case history number, in hospital case history number, image and last materials number,etc. specially) ,Authorize, only annotate numbers and guarantee to correspond to the patient's all previous medical records. Meanwhile, electronic the intersection of case history and system should set up corresponding function, realize the same the intersection of patient and personal the intersection of information and producing automatically until case history record, in order to guarantee information such as patient's name, gender, age are not input repeatedly again, offer the convenience to medical work. " regulations " require clearly, the electronic case history system should meet protection system of the grade of national information security and standard, accord with the relevant regulation of " liability for tort of the People's Republic of China ", and have corresponding legal effects. Forbid altering, forging, hiding, grabing, stealing and destroying the electronic case history. The department of public health of the province requires, the electronic case history system should also serve quality controlling, health care of the case history at the same time information and data statistical analysis and medical insurance premium are verified and offered technical support, including the classified inquiry of the hospitalization cost, the operation is managed in grades, the clinical route is managed, quality control of single number, in hospital day equally, average day in hospital in front of the skill, the intersection of berth and rate of utilization, reasonable administration control and medicine account for the intersection of gross income and proportion medical quality control and statistics to control index, utilize the systematic advantage to establish the system of medical quality examination, raise working efficiency, guarantee medical quality, the behavior of making a diagnosis of the norm, improve the management level of the hospital. In front of the electronic case history, how to protect patient's personal secrets? Require clearly in " regulations ", the medical organization should set up the information security security system of electronic case history, presume medical worker and administrative staff of relevant hospitals transfer and read, duplicate, print the corresponding authority of the electronic case history, set up electronic case history and use the daily record, record to the user, operating time and content. Without permission, no individual or unit may transfer and read, duplicate the electronic case history without authorization. Meanwhile, the medical organization should set up institute's tertiary quality control systems of grade, section, persons who write, control in real time the quality network of electronic case history. To at present can't yet electronize or must retain paper medical information material of document ' Surgery letter of consent,etc. need patient or medical materials,etc. that relative write comments and sign one's name) for instance Should take measures, make information it include in the electronic case history and keep after the datumization, and keep the original paper. Could the patient copy the electronic case history? According to " regulations"'s request, medical organization should accept following personnel or organization, copy or duplicate electronic the intersection of case history and application of materials: Patient or its agent; Dead patient's close relative or its agent; Pay the basic medical guarantee of the expenses for the patient and manage and handle the organization; The patient authorizes the safety unit that trusted. " regulations " especially require, after the case history materials copied or duplicated are checked by the applicant, it proves the seal that the medical organization should put on on the paper edition of electronic case history, or offer and already lock the case history electronic edition that can't be changed. When the malpractice dispute happens, how to keep the electronic case history? " regulations " point out, when the malpractice dispute happens, should lock the electronic case history and make all the same paper edition and is sealed up for safekeeping in the presence of doctors and patients both sides, the case history materials sealed up for safekeeping are kept by the medical organization. (Wang FengWei Li XueNing)


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