无纸化电子病历管理制度研究

Research on management system of paperless electronic medical record

论述开展无纸化电子病历（electronic medical record，EMR）管理制度研究的意义，指出在建设无纸化EMR管理过程中面临的病历真实性、法律效力、雷同性、安全性以及缺漏错误等问题。针对问题进行解决方案的分析，提出制定安全管理制度、对病历质量进行全程监控、加强归档后的管理、制定备份和恢复机制、完善保密和授权制度、健全借阅管理、执行复印制度、加强对电子签名管理、实行惟一编号管理、强化人员综合素质培养等措施。

This paper discussed on the importance of management system of paperless electronic medical record and pointed out that we would encountered lots of problems during the construction of paperless electronic medical record management system including authenticity, legal effect, similarity, safety, mistakes and missing of medical records. This paper analyzed these problems and proposed corre- sponding countermeasures including developing safety management system, whole-process monitoring of medical record quality, enhancing archive management, developing backup and recovery mechanisms, improving secrecy and authorization system, promoting borrowing management, performing copy system, strengthening electronic signature management, implementing unique number management and enhanc- ing overall quality of personnel