Article 1 In order to standardize the management of electronic medical records in medical institutions, to clarify the functions that the electronic medical record system of medical institutions should have, to better play the supporting role of electronic medical records in medical work, and to promote the construction of hospital informatization with electronic medical records as the core, according to the "People's Republic of China*** and the State of China's Practicing Physicians Law", "Regulations for the Administration of Medical Institutions", "Basic Norms for the Writing of Medical Records", "Basic Norms for Medical Records (for Trial Implementation)", "Electronic Basic Specification for Medical Records (Trial)" and "Electronic Medical Records Basic Architecture and Data Standards (Trial)" and other laws, regulations and normative documents, the formulation of this specification.
Second Article This specification applies to the establishment, use, data preservation, **** enjoyment and management of electronic medical record system in medical institutions.
The third electronic medical record system refers to the medical institutions to support the collection of electronic medical record information within the collection, storage, access and online help, and around the improvement of medical quality, safeguard medical safety, improve medical efficiency and provide information processing and intelligent service functions of the computer information system, including both the application of outpatient (emergency) clinics, wards, clinical information systems, but also includes the examination of tests, pathology, imaging, Cardiology, ultrasound and other medical technology departments of the information system.
Article 4 This specification is a medical institution to establish and improve the electronic medical record system function evaluation standards, focusing on improving the quality of medical care, safeguard medical safety, improve medical efficiency related to the important functions, does not involve the realization of the various functions of the technology and the way.
Article 5 of the electronic medical record system functions are divided into essential, recommended and optional three levels. Necessary function refers to the electronic medical record system must have the function; recommended function refers to the electronic medical record system can not have, but in the next step in the development should focus on expanding the function; optional function refers to further improve the electronic medical record system, medical institutions according to the actual situation choose to realize the function.