How to print electronic medical records? Can electronic medical records be used as evidence?
Electronic medical record is also called computerized medical record system or computer-based medical record. It is a digital patient medical record saved, managed, transmitted and copied by electronic equipment (computers, health cards, etc.). ) instead of handwritten paper medical records. Its content includes all the information of paper medical records.
According to the basic framework and data standard of electronic medical record issued by the Ministry of Health, electronic medical record is defined as: electronic medical record is a digital medical service record of clinical diagnosis, treatment, guidance and intervention for outpatients and inpatients (or health care objects) by medical institutions.
Electronic medical record is a digital patient medical record that is saved, managed, transmitted and copied by electronic devices (computers, health cards, etc.). ), rather than handwritten paper medical records. Electronic medical record has the characteristics of initiative, completeness and correctness, knowledge relevance and timeliness. It is a digital medical service record for medical institutions to guide and intervene outpatient and inpatient patients (or health care objects).
Electronic medical records can be printed, and doctors need to print them when printing. The general medical record belongs to the patient's privacy and needs the patient's consent.
At present, some hospitals in Nanhai, Shenzhen and other places implement computerized patient prescription processing, which belongs to the national electronic medical record pilot area. Electronic medical records and paper medical records have the same legal effect in medical litigation, but the recording methods are different.
At present, when the court is in session, the required trial evidence must be in writing. Therefore, if the electronic medical record is to be accepted as evidence in court, the patient should immediately request to print the medical record, and at the same time, don't forget to find the doctor's signature and the seal of the hospital, so that the electronic medical record has the function of handwritten medical record. When patients are involved in medical litigation, they can be presented as evidence to the court or the medical accident appraisal department.