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电子病历的使用涉及到医疗、法律和网络等方面的知识,与纸质病案相比要求更高,所以国家在规范纸质病历书写的基础上,针对电子病历书写出又台了专门的法规,其目的是规范医疗机构电子病历管理,保护医患双方的合法权益。然而部分医务人员在电子病历书写过程中,对相关法律规范认识不足或法律知识缺乏,不免出现违法情况,侵犯了医患双方的合法权益。本文对电子病历临床使用中常见法律问题进行探讨并提出应对策略,为提高电子病历书写质量,减少或避免电子病历书写过程中出现的法律纠纷提供一定帮助。
The use of electronic medical records involves medical, legal and network knowledge, which is more demanding than paper medical records. Therefore, on the basis of regulating the writing of paper medical records, the state has written and implemented special regulations on electronic medical records, Its purpose is to standardize the medical records management of electronic medical records to protect the legitimate rights and interests of both doctors and patients. However, some medical staff in the electronic medical record writing process, lack of understanding of the relevant legal norms or lack of legal knowledge, can not help but appear illegal, violating the legitimate rights and interests of both doctors and patients. This article discusses the common legal issues in the clinical use of electronic medical records and puts forward countermeasures to help improve the quality of electronic medical records writing and reduce or avoid the legal disputes arising from the writing of electronic medical records.