CAJ | 학술논문

病历是病人在医院进行诊疗活动历史的原始记录,是记录病人医疗信息的历史档案.随着医院现代化建设的发展和电子计算机技术的迅速普及,电子病历逐步取代纸质病历,在病人信息的收集、储存、分析、传递和利用中得到广泛实施,显示出纸质病历所不能比拟的优越性.一方面,人民健康需求不断提高,要求加快电子病历的实施,彻底淘汰纸质病历;一方面,电子病历的法律效力被质疑,纸质病历还应保留.为此,需要针对电子病历的实施难点采取有效对策.难点是:电子病历的原始性难以鉴定,不能具有纸质病历同等法律效力;措施是:解决电子病历具有纸质病历同等法律效力,采用双套制保存纸质病历.
병력시병인재의원진행진료활동역사적원시기록,시기록병인의료신식적역사당안.수착의원현대화건설적발전화전자계산궤기술적신속보급,전자병력축보취대지질병력,재병인신식적수집、저존、분석、전체화이용중득도엄범실시,현시출지질병력소불능비의적우월성.일방면,인민건강수구불단제고,요구가쾌전자병력적실시,철저도태지질병력;일방면,전자병력적법률효력피질의,지질병력환응보류.위차,수요침대전자병력적실시난점채취유효대책.난점시:전자병력적원시성난이감정,불능구유지질병력동등법률효력;조시시:해결전자병력구유지질병력동등법률효력,채용쌍투제보존지질병력.
Medical record is the original record of patients’ treatment in hospital ,and it is the history file that recorded the pa -tients’ information .In pace with the development of hospital modernization and wide spreading of computer technology ,electric med-ical record take the place of paper record progressively ,and showed many adventages that paper record could not achieved in patients ’ information collection ,saving ,analyzing ,communication and utilizing .On the one hand ,as the constantly increasing of people’s health need ,there is a requirement to accelerate the implementation of electric record and eliminating paper record .On the other hand ,the legal effect of electric record was still remain suspicious ,paper record should be retained continually .Thus ,relevant effec-tive countermeasures should carry out to ensure the implementation of electric record .The difficulties is the primitive character of electric record is difficult to identify and cannot possess the same legal effect as paper record .So our countermeasures are to solve the problems that to make electric record possess the same legal effect as paper record ,and save paper record as “double set mode” at the same .