电子病历发布与预防医患纠纷的可行性研究

Kaihuan Yu, Y. Xiong, Chang Mao
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引用次数: 0

摘要

摘要电子病历的发布是指在整个诊疗过程中实时为患者发布医疗服务记录,这不仅有助于医疗机构规范医务人员的诊疗活动,提升病历质量,而且尊重患者的知情同意权和患者的自决权。增加医患之间的相互信任,有助于减少和处理医疗纠纷的风险。因此,电子病案内容的发布是必然的。但在发布过程中,应加强对医务人员信息发布及相关法律法规的培训,并提出建立电子病历质量控制体系的建议及实施步骤。
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Feasibility Study on Publication of Electronic Medical Records and Prevention of Doctor-Patient Disputes
AbstractThe publication of electronic medical records involves the medical services record being published for patients in real time during the entire diagnostic and treatment process, which not only helps the medical institutions standardize the diagnosis and treatment activities of medical staff and upgrade the quality of medical records, but also respects the patient's right of informed consent and the patient's right of self-determination, increases the mutual trust between doctors and patients, and helps to reduce and deal with risks in medical disputes. Therefore, the publication of electronic medical record content is inevitable. However, in the publication process, the training provided to the medical staff regarding information publication and the relevant laws and regulations, should be strengthened, and suggestions for establishing a quality control system for electronic medical records and the steps to implement them, are put forward.
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