" basic norm of the electronic case history " will be implemented next month The strict case history is revised

" basic norm of the electronic case history " will be implemented next month The strict case history is revised
Channel of Jiangxi, March 16 (Xinhuanet) according to the news of department of public health of Jiangxi Province, every large hospital will implement in Jiangxi Province successively from April 1 " basic norm of the electronic case history ".
It is reported electronic case history record standardization. The norm requires, the electronic case history should use Chinese and medical terminology, demand to state accurately, the sentence is clear and coherent, the punctuation mark is correct. Recording date should use Aeabic numeral, recording time should be adopted for 24 hours and made.
In the management of the electronic case history, will implement differentiated control to the attenbant's authority, protect the patient's personal secrets. The hospital will set up the high grade case history system, security should reach protection system of grades and standard of national information security. While operating the electronic case history system, the attenbant will set up the corresponding authority. The medical worker wants the log-in system, need to adopt the identification label. Forbid anyone to distort, forge, hide, grab, steal and destroy the electronic case history. Once the patient's electronic case history is set up, can't revise after filing. Unlike past paper case history, it will also keep and back up the case history data. The hospital will resume the test in backing up the data regularly, will guarantee the electronic case history data will not be revised.
Because electronic case history intelligent, copying the case history procedure will present changing. According to the regulation, copying the case history should be applied for first. The applicant also can be agent or close relative,etc. except that it is me. After copying or duplicating the case history, it proves the seal that the medical organization should put on on the case history copying, or offer and already lock the case history electronic edition that can't be changed.
In addition, when the malpractice dispute happens, should be in the presence of doctors and patients both sides, lock the electronic case history and make all the same paper edition and is sealed up for safekeeping, the paper case history materials sealed up for safekeeping are kept by the medical organization.
(The source of this text: Www.xinhuanet.com)
|