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目的探讨纸质病案信息形成合法性的基础及特性,以明确电子病案的合法性。方法对纸质病案和电子病案功能等同相关因素进行对比分析,找出共性与特性。结果依据现行法律、法规,同时通过对电子病案信息形成过程进行严格控制和管理,可有效夯实电子病案应用的合法性基础。结论实现无纸化的电子病案是完全有可能的。
Objective To explore the basis and characteristics of the legitimacy of paper medical information in order to clarify the legitimacy of electronic medical records. Methods Comparative analysis of paper-based medical records and electronic medical records functional equivalence to find commonalities and characteristics. Results Based on the current laws and regulations, and strictly controlled and managed the formation process of electronic medical record information, the legal basis of electronic medical record application can be effectively compacted. Conclusion It is entirely possible to achieve a paperless electronic medical record.