electronic signatures and electronic records related to legal issues
Abstract: With the development of science and technology, electronic medical records should be in the medical activities as the main source of information replacing paper medical records, medical records and to provide services beyond the paper, but due to technical, legal constraints and other factors, the reality the use of electronic medical records electronic medical records is only just. Promulgated and implemented the new electronic signature, as medical research and development of electronic medical records have been undertaken to create a favorable legal environment.
Keywords: electronic medical records; electronic signature; data message; legal status; evidence
electronic medical records are electronically managed health status of the individual life and health care behavior, is the medical use of computer and database system set up, including clinical data, laboratory data, medical imaging and other digital information, including [1]. The application of electronic medical records the hospital medical activities not only improve the quality and efficiency and sharing of information resources for the realization of creating medical conditions. Electronic medical records should be in the medical activities as the main source of information replacing paper medical records, medical records and to provide services beyond the paper to meet all medical, legal and regulatory requirements [2]. However, due to technological advances, a few years because of many documents or data storage media format is not compatible and can not read. Coupled with the integrity of electronic documents, evidence and so can not be guaranteed, resulting in many medical institutions for hospital information system electronic medical record are first printed and then hand-signed by the medical staff saved. This is not true of electronic medical records electronic medical records, electronic medical record is only just. But the good news is that April 1, 2005 from the implementation of the
First, medical records and electronic medical records
1. The definition of medical records and the carrier: 1 September 2002 from the implementation of the
and the (urgent) patient records and medical records, Under this definition, the connotation of medical records is widespread and abundant, and is not in the form and carrier limitations. The records listed in the definition of the content, that is, words, symbols, graphics, images, slices,
lisseur ghd prix, etc., are likely to electronic information as a carrier. In fact, with the development of medicine and the application of new medical equipment, some medical records have been achieved within the digital.
2. Electronic medical records and computerized clinical documentation: electronic medical records are hospital clinical information system after the development of a more perfect result, is patient-centric information integration and related services. Prescription written by all doctors, laboratory orders, test results and so is scanned, only the computerized medical records. May be established only after the number of electronic medical records system, it may be shared, computing, statistics, through the levy, research, and assist the medical and other functions. Electronic medical records should have covered the whole person's health record and online transmission to the two basic properties,
cheap louis vuitton belts, should have information-sharing systems, medical alert systems and medical information improperly database support. Some experts believe that electronic health records (EHR).
Second, the legal status of medical records
1. Mainly due to the legal significance of medical evidence of its role: medical records is to determine the relationship between civil law to determine people's capacity to prove the victim victimization, and involves the importance of forensic medical evidence based on the role of medical records related to the number of civil rights and obligations of the parties. The role of medical evidence, not its form, material and carrier are different. Medical records, whether paper or electronic medical records, their significance and role of the law, are mainly due to the evidence of property [4].
2. Medical records in medical malpractice lawsuits in the special legal status of the medical evidence of medical disputes in the role of meaning and evidence, and other litigation cases is significantly different. Complete medical records of the subject is a party to the dispute (health), and medical records and descriptions of the object is the other party (the patient), most of the medical content of the two sides do not have the Therefore, in medical litigation, patients or their families are often challenged the authenticity of the records, evidence of the effectiveness of medical records. Physician medical records also reflect the clinical
bed speculative process, in the event of medical malpractice, misdiagnosis often is considered the fault of [5].
3. Records amended, modified, and make note of legitimacy: records are records of medical staff, medical personnel have the right to make their own work record be amended, modified, and make note. original writing. , failed to write medical records, the medical personnel should be within 6 hours after the rescue and truly make up mind, be noted.
4. . Medical malpractice litigation for the special requirements of proof: April 1, 2002, medical institutions can not provide evidence that medical practice as long as no fault, medical behavior and no causal relationship between the injurious consequences, the presumption of fault established a heavy burden of proof in medical institutions. However, the medical institutions that can give evidence of major medical records, medical records can imagine the importance of [5].
Third, electronic signature
1. Definition: electronic signature means data in electronic messages in the form in, affixed to identify the signer identity,
moncler branson down jacket grey, and that the undersigned endorses the contents of the data. Electronic signature is through a complex encryption technology (public key or asymmetric) and generated, it requires electronic certification service providers the identity of electronic signatures to authenticate electronic signatures to ensure content validity of the certificate are complete and accurate to ensure that electronic signatures dependence can only confirm or learn more about issues in order to provide credit guarantee to the counterparty.
2. Features: Electronic signatures and handwritten signature or seal as the identity of the signer can be identified, confirmed the authenticity of documents that were approved and authorized signatories of the document and document content, and made a legal commitment. In addition, the electronic signature has the following characteristics: ① Non-repudiation: that is linked to the individual and the signature, the signature against the signer is the owner or deny a signed electronic documents, electronic signature applied over [6]. ② security: that the person has a private key to protect the security of keys, to prevent others from using the key. ③ uniqueness: the signature must be the only signatory to others will not have the same key signature. ④ integrity: that is the signature of the signed documents and the integrity of the original document and the signature has not been confirmed changes [6]. ⑤ signed document verification and contact: the signature with the public key to decrypt the hash, and comparison with the document hash to verify the signature with the signature relevant to the content.
3. Application: Currently, many hospital information systems have been used in electronic signatures, electronic signatures, but only a physician's signature will be scanned to images stored in the computer mode, use the This
Fourth,
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to regulate the behavior of electronic signatures to establish the legal effect of electronic signatures, the state has developed The law clearly provides for electronic medical records of the The promulgation and implementation of the Act the development of electronic medical records and create a favorable legal environment for the construction of hospital information system to create a broad space for development.
1. : ① involving marriage, adoption, inheritance and other personal relationships. ② involving land, housing and other real property interest transferred. ③ involved to stop water supply, heating, gas, electricity and other utility services. ④ laws and administrative regulations do not apply under the circumstances of other electronic instruments [7]. Electronic medical records are not within the prohibition, in line with the electronic, optical, magnetic or similar means, generated, sent, received or stored information defined and That electronic medical records for
2. form Which to some extent, to solve the long haunt the construction and development of electronic medical records system, the In the future, electronic medical records of the
3. be rejected as evidence The provision of evidence confirms the value of electronic medical records, electronic medical records as evidence in court can be used to lay a hint. To ensure the authenticity of evidence, detailed in section 8 of the Bill in the review of electronic medical records several factors to be considered: ① generated, stored or communicated data messages reliability of the method. ② reliability of the method to maintain the integrity of the content. ③ reliability of the method used to identify the sender. ④ other relevant factors. These factors have no problem in the case of electronic medical records meet the evidence requirements.
4. electronic signature creation data are controlled only by; the signing of any changes to the electronic signature can be found; data message after signing the content and form of any changes to be found, in line with the above conditions, that is, in law as a reliable electronic signature. Article 14 defines the legal status of secure electronic signatures, that
5. and seriousness of [8].
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