摘要
目的 开展无纸化病案归档建设,对传统门急诊纸质知情同意书进行电子化设计与应用。方法 分析口腔专科特色的知情同意书应用需求,遵循移动性、一致性、可靠性原则,升级改造电子病历系统,引入第三方电子认证服务对电子知情同意书进行数字认证。结果 实现了口腔专科门急诊电子知情同意书的移动、可信签署,试运行期间系统整体运行稳定。结论 电子知情同意书的应用进一步保障了病案数据的完整可靠,业务流程和管理模式的转变需不断地磨合和优化,以进一步推动病案管理的信息化发展。
Objective To carry out the construction of paperless medical records filing, and to design and apply the electronical informed consent form in outpatient and emergency departments. Methods The requirements of informed consent with dental specialty characteristics were analyzed. The electronic medical record system was upgraded according to the principles of mobility, consistency and reliability, and a third-party e-certification service was introduced for digital authentication of e-informed consent. Results The mobile and trusted signing of electronic informed consent for outpatient and emergency department of stomatology was realized, and the overall operation of the system was stable during trial operation. Conclusion The application of electronic informed consent further ensures the integrity and reliability of medical record data. The transformation of business processes and management models needs to be continuously adjusted and optimized to further promote the informatization of medical record management.
作者
陈怡帆
曹战强
CHEN Yi-fan;CAO Zhan-qiang(Peking University School and Hospital of Stomatology)
出处
《医院管理论坛》
2024年第1期93-96,40,共5页
Hospital Management Forum
关键词
口腔医学
知情同意书
数字签名
病案
Stomatology
Informed consent
Digital signature
Medical records
