患者电子签名系统的构建与应用

Construction and application of patient electronic signature system

目的:推进医院病历无纸化,实现知情告知类文书患者电子签名管理。方法:分析患者知情文书的签署现状以及患者签名电子化的关键点,设计适合我院临床实际的多终端患者电子签名系统,提供实名认证、电子签名、时间戳及数据存证等服务。结果:自2022年7月上线至2022年10月底,共完成27种病历类型共8278份电子病历的签署,实现了患者签名无纸化。其中,手机端和平板端签署量各占约50%,青年人和中年人对手机签署的接纳程度更高,而老年人则倾向于使用平板签署。结论:该系统可以保证患者签署后的电子病历真实完整、合法可信,提高病案工作效率,推动病历无纸化,降低医院运行成本。

Objective To promote the paperless medical records in hospitals,and realize the management of electronic signatures of patients with informed documents.Methods By analyzing the current status of patients informed documents signing and the key points of electronic signature of patients,a multi-terminal patient electronic signature system suitable for the clinical practice in our hospital was designed to provide services such as real-name authentication,electronic signature,time stamp and data storage services.Results From July 2022 to the end of October 2022,a total of 8,278 EMRs(electronic medical records)of 27 types were signed,and paperless patient signatures were realized.Among them,the number of signatures on mobile phones and tablets accounted for about 50%each,with young and middle-aged people being more receptive to mobile phone signatures,while the elderly tended to tablet signatures.Conclusion This system can ensure the authenticity,integrity,legitimacy and credibility of the EMRs signed by patients,improve the efficiency of medical record work,promote paperless medical records and reduce the operating costs of the hospital.