《电子病历应用管理规范》实施的相关法律问题的探讨

Investigation on the Implementation of Relevant Legal issues of the "Application of Electronic Medical Records Management Standard"

电子病历已普遍应用于各级医疗机构,对提高医疗效率、减轻医师负担等方面起到了重要的作用。通过《电子病历应用管理规范(试行)》解读,讨论电子病历的证据能力、证据类属和特征;电子病历在应用过程中对患者隐私权、知情同意权的侵犯等法律风险;与电子病历密切相关的电子签名配套的法律支持等问题,提出应当完善相关法律法规、加强监督管理机制,从而推动电子病历在医院信息化时代依法有序发展。

Electronic medical records have been widely used in medical institutions at all levels, and play an important role in improving medical efficiency and reducing the burden of doctors. ＂Through the application of electronic medical records management standard（Trial）＂ interpretation, discussion of electronic medical records, which belongs to the category of evidence ability and characteristics; the electronic medical record in the application process of patient privacy, the right of informed consent of the infringement of legal risk; electronic signature lacks the necessary legal support is closely related with the electronic medical record, put forward perfect the relevant laws and regulations, strengthen supervision and management mechanism, so as to promote the orderly development of electronic medical records in the hospital information age according to law.