电子处方的法律效力探讨

Legal Validity of Electronic Prescription

目的探讨医疗机构内部电子处方的法律效力。方法从处方的定义、处方承载的管理意义、确认电子处方的合法性等方面分析电子处方的法律效力。结果互联网医院的电子处方可由医院信息系统自动生成,其法律地位已在有关文件中确立,但在实体医疗机构内部尚处于模糊地带。国内外相关文件对处方的定义均强调“药物治疗指令”的定义核心,而非以“处方标准”格式为要件。结论随着医院电子病历系统建设的升级,作为门(急)诊病历基本组成部分的处方,电子处方的法律效力理应与纸质处方相同。医务人员在符合《电子病历基本规范》的电子病历系统完成并显示可靠电子签名的处方,即为与纸质处方法律效力相同的电子处方。

Objective To investigate the legal validity of electronic prescription in medical institutions.Methods The legal validity of electronic prescription was analyzed from the definition of prescription,management significance of prescription and the confirmation of the legitimacy of electronic prescription.Results The electronic prescription in the Internet hospital could be automatically generated by the hospital information system(HIS),and its legal status had been established in relevant documents,but it was still in a fuzzy area within the entity medical institutions.The definition of prescription in the relevant documents at home and abroad emphasized the definition core of″drug treatment instruction″,rather than taking the format of″prescription standard″as the important condition.Conclusion As a basic part of outpatient(emergency)medical records,the legal validity of electronic prescription should be the same as that of paper prescription with the upgrading of the construction of hospital electronic medical record system.A prescription completed by medical staff in an electronic medical record system that complied with the Basic Norms of Electronic Medical Records and displayed a reliable electronic signature was an electronic prescription with the same legal validity as a paper prescription.