病案管理（Case management）.docVIP

病案管理（Case management） Basic specifications for electronic medical records (for Trial Implementation) Chapter I General Provisions Article 1 in order to standardize the management of electronic medical records in medical institutions, to ensure that the legitimate interests of both doctors and patients, according to the Peoples Republic of China medical practitioners, medical institutions management regulations and Regulations on handling medical accidents, nurse regulations and other relevant laws and regulations, the enactment of this specification. Second, this specification applies to the establishment, use, preservation and management of electronic medical records in medical institutions. Third electronic medical records is that medical personnel in the medical activities in the process of information generated by the information system of medical institutions text, symbols, graphics, charts, data, and other digital images, and can realize the storage, management, transmission and reproduction of medical records, medical records is a record form. The medical records edited and printed using word processing software do not belong to the electronic medical records as mentioned in this standard. The construction of the electronic medical record system of the fourth medical institutions should meet the needs of clinical work, follow the medical workflow, and ensure the quality of medical care and medical safety. The second chapter basic requirements of electronic medical records Fifth electronic medical records should be kept in accordance with objective, truthful, accurate, timely and complete principles. Sixth electronic medical records should be used in Chinese and medical terms, requiring accurate expression, clear sentences, punctuation correct. The common foreign language abbreviations and no official Chinese translations of symptoms, signs, disease names, etc. can be used in foreign languages. The date of record shall be in Arabia figures, and the time of rec