新型冠状病毒肺炎时期住院病案的签名

The Signature of the Inpatient Medical Record Writing of the Corona Virus Disease 2019

2019年新型冠状病毒肺炎疫情特殊时期,减少纸质病案的污染是病案管理的重点,其突出问题是患者和医师需要签字的病历内容必须在病区产生并收回保管。为解决这个问题,探讨仅针对未使用电子签名的基层医院减少纸质病历在隔离病区的产生,进一步从源头遏制纸质病历在隔离病区受到污染。新冠肺炎患者住院病历的书写应更加注重基础资料的收集、病程的完整记录以及特殊病案的标识,保证特殊病案资料的完整准确。为减少纸质病案在隔离病区的流通和污染,医院可在与上级部门沟通申报的情况下对新冠肺炎病历签名的时效性和签名授权予以调整,采用医师补签、患者授权代签或患者免签等方案。传染病诊治中临床注重防与控,其病案中的签名可特事特办。疫情的出现也督促应进一步加大医院信息化的建设,基层医院应适当加大力度应用电子签名,大型综合医院应向更为科学严谨的无纸化病案发展。

In the special period of the Corona Virus Disease 2019 outbreak in 2019,how to reduce the contamination of paper medical records is the focus of medical record management,and the outstanding problem is that the medical records signed by patients and physicians must be produced in the ward and recalled for storage.In order to solve this problem,this paper discusses ways to reduce the generation of paper medical records in isolation ward by means of doctors're-signing,patient authorization,and patient visa-free in primary hospitals that do not use electronic signature,and further prevent the contamination of paper medical records in isolation ward from the source.More attention should be paid to the collection of basic data,the complete record of course of disease and the identification of special medical records in the writing of medical records of patients with Corona Virus Disease 2019,so as to ensure the completeness and accuracy of special medical records.In order to reduce the circulation and pollution of paper medical records in the isolated ward,the hospital can adjust the timeliness and signature authorization of the medical records of Corona Virus Disease 2019 under the condition of communication and declaration with the superior departments,and adopt such schemes as doctor's reissuance,patient authorization or patient visa exemption.In the diagnosis and treatment of infectious diseases,clinical attention is paid to prevention and control.The emergence of the epidemic situation also urges that the construction of hospital informatization should be further strengthened,grassroots hospitals should appropriately increase the application of electronic signature,and large general hospitals should develop toward more scientific and rigorous paperless medical records.