The implementation of electronic signature in EMR of hospital / 中国医学装备

ABSTRACT

Objective: To gradually implement electronic signature in medical records included outpatient prescription, examination report, test report, hospitalization record and others so as to realize paperless archiving for electronic medical record(EMR) of hospital. Methods: The national law of electronic signature was used as the legal basis and the electronic signature technique was used as the technological foundation to establish electronic signature mechanism about signature, encryption and authentication. The dean who was responsible for informatization of hospital was appointed group leader, and section chief of each relevantly functional department, director of clinical department and head nurse were members of the group. Through perfect the leading group for informatization to ensure electronic signature was effectively implemented. Results: Through adhered to some principles included top-level design, gradual implementation and from easiness to difficulty, the electronic signatures about out-patient prescription, examination reports, test reports, documents of medical record and the paperless archiving for hospitalization record were realized after technique development of many years. Conclusion: The implementation of electronic signature can ensure the legality and authenticity of EMR, and the traceability of modified behavior. And it has realized paperless management for medical archives and has strengthened internal sharing of medical information in hospital.