对我国电子病历管理办法起草若干问题的思考

The Thinking of Drafting Managerial Rule of Electronic Medical Recorder in China

我国电子病历的大规模推行,有待于电子病历管理办法的出台。文章提出了我国电子病历管理办法起草的四项基本原则:与国际通行规则保持一致,不偏重任何技术,依赖“功能等同”方法,跟踪计算机技术的最新发展。同时,文章运用功能等同法,结合对电子病历参与人和病历管理流程的研究,形成了我国电子病历管理办法起草的综合思路。文章构思了电子病历管理办法的基本内容,包括:电子病历实施当事人、电子病历建立与修改、电子签字与电子病历、电子病历保存、电子病历交换、电子病历安全等。

Electronic Medical Recorder(EMR)can be promoted in more hospitals i n China until managerial rule of EMR of China is published.This paper puts forw ard four basic principles of drafting managerial rule of electronic medical reco rder of China:consisting with health organization of United Nations.Not laying particular stress on any kind technology,relying on functional equivalent appr oach.And following the newest technology of computer.At same time,the paper u sce“functional equivalent approach”,combines with the research of participato r of EMR and managerial flow,and forms integrated thought of drafting EMR of Ch ina.The paper designs basic contents of EMR managerial rule:participator of EM R.Setting up and amending of EMR,electronis signature and EMR,saving of EMR, interchanging of EMR,safety of EMR.