Electronic case history of two hospitals of pilot project of Shandong Any modification will be recorded

Electronic case history of two hospitals of pilot project of Shandong Any modification will be recorded
Recently, Ministry of Public Health issues>,Set up, make comparisons detailed regulation to electronic the intersection of case history and function of system among them. Since October of 2010, in launch electronic the intersection of case history and pilot project while being national Ministry of Public Health. Since pilot project of the electronic case history, a lot of people are afraid the case history will be distorted arbitrarily. To this, what has made in detail has avoided the measure in the regulation. In reality, can accomplish these? What advantages does electronic case history have? The 4th,participate in while interviewing reporter at this point the Shandong that the two hospitals of pilot project - Qianfo Mount hospital.
This time can understand doctor write anything
On the 4th, the reporter just met old man Zhang copying the case history in Qianfo Mount hospital. Old man Zhang from Liaocheng works as a temporary labourer in Jinan, the unexpected fracture because on the building site for the previous period, the hospital has done the operation in Qianfo Mount. "Use in order to submit an expense account, too in order to leave a bottom, come over to take the case history today. " "The case history that saw the doctor in the past, I can not understand at all, actually words recognized were not many, in addition, the word that the doctor writes is in a mess, no matter take the list of medicine, or one of this case history, can't understand. " Old man Zhang says loudly, the present case history is printed out, words are all very clear, " well recognize " . In fact, except say good-bye to " book from heaven " Beyond, " the electronic case history have mainly standardized writing the form of the case history. " Vice President of Qianfo Mount hospital Xu Min introduces, though the paper case history has strict writing the norm, but some project have sometimes, doctor may write, but implement in electronic case history " the half structured case history " ,All projects must be filled out, " even only fill out a ' not have ' word " . Writing the form and making the strict regulation to electronic case history of norm announced newly this time, the case history wants " " basic norm when writing in case history " and according to Ministry of Public Health>Requirement,last the functions of materials " .
The intersection of case history and the record modification any
Except say good-bye to " The book from heaven " Case history, compare in the traditional case history, the electronic case history has also improved the speed of seeking medical advice greatly, have saved patient time. "The doctor's network was linked with the registration office, dispensary, so long as the doctor has written a prescription, the prescription of the ward can be printed at the same time. When the patient reaches the dispensary, medicine is finished preparing early. " Xu Min introduces. It is convenient that the electronic case history is convenient, but after case history electronization, the hospital can not distort the case history arbitrarily, what if the medical dispute takes place in the future? A lot of patients will have such doubt.
As to this, issue newly>China's regulation, "establishment of the electronic case history data, it revise, not delete,etc. any operation it produce, if you can't keep, audit by daily record automatically ' at least including operating time, operator, operate by content,etc.) ,Offer according to audit the project, follow the trail of and look over his all operators, track that functions such as his all operation,etc. are looked over according to the operator " . "The patient can well understand, however, the ones that should told the patient are when producing such worry, the electronic case history can not be done false. " Xu Min introduces, in order to dispel this kind of worry of the patient's, they have taken the relevant measure in the pilot project for a long time. They make case history, seal compulsory measure up for safekeeping at first, the case history must finish in 24 hours after patient leave hospital, exceeding the 24-hour case history can't be filled in again. And stipulated the relevant rank doctor's modification authority, all modifications will be recorded. For the one that further raise the electronic case history " But trust " ,Qianfo Mount hospital is canvassing and trying third party's approval procedure. According to the introduction of Xu Min, if present electronic case history is used in the administration of justice, still need printing out, the doctor signs. "In order to improve the credibility of the electronic case history, we have already and had figure that the third party authorizes qualification to authorize the company and reach an agreement, they will authorize the electronic case history. This measure has estimated that can be implemented on the Spring Festival. " Concrete procedure, electronic case history, in the course of taking shape, each participate in the intersection of case history and medical personnel revised to write have one only figure authorize (namely U-K) ,His any operation to case history will be recorded, after finishing in case history, the case history will be passed to the third party and authorize the company, the hospital did not revise the authority hereafter.

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