Research On The Legal Problems Of Electronic Medical Record As Evidence

Medical records, the patient is in the hospital, diagnosis, treatment, most originalrecords the entire process, which includes a home page, progress notes, orders, surgicalrecords. Electronic medical records (EMR), is simply a fully computerized paper records,which contains the basic paper records for full functionality. In China, a considerable partof people believe that electronic medical records is a doctor will simply input paper recordsto an electronic medical records system that medical staff medical records using acomputer on the realization of electronic medical records, electronic medical records, butin fact is not entirely paper-based medical records electronic, our electronic medicalrecords compared to the United States, Japan and other developed countries, plus extensiveuse of electronic medical records, we can say development has been relatively slow.Evidence of the existence of a significant litigation. The judiciary and litigants indetermining the facts of the case, you need evidence and the law of evidence is to providea legal basis for the evidence. That is the law of evidence to prove active litigation legalnorms. Judicial prove judicial activities as an essential aspect of the trial of the case,judgments are essential, and evidence of judicial proof is an important part, the same asthe legislative, judicial, law enforcement and other areas of major decisions reference.The emergence of electronic medical records, medical system has accelerated theprocess of information, and its specific advantages: one, to protect the medical records inthe writing process more standards and unity. Although we previously used traditionalpaper-based medical records have a fixed format, dedicated medical records, etc., but it isafter all the different sections of different doctors writing together, so it is impossible to dothe same format, the same handwriting. The electronic medical record is different,electronic management makes it easy to achieve harmonization and standardization.2, themedical staff ’s work efficiency a great help. In the information society, we all understand,handwriting and typing input speed is very different, so that the use of keyboards andother electronic means entry medical records, medical records than full handwriting made much more rapidly. Additional features include improved quality of care in medicalinstitutions, and reduce the use of paper, reducing hospital management costs, therebyreducing the pressure on the patient’s medical expenses and so on.But more and more widely used in the electronic medical records today, in law,security, operations, there are still many problems finest. For example, a new entry wayeasily lead to mistakes in writing. EHR entry way, unlike traditional medical picked up apen to write on paper, the use of electronic medical records, it is not the way to usehandwriting, so I led the medical staff at entry, prone to typo errors or inaccurate content,For example," shadows" written "Silver shadow." There are various recording quality isnot high, the font size is inappropriate, typesetting not standardized, incomplete filling outthe auxiliary projects and so on.2, convenient, fast but easy to ignore the patient’sindividual characteristics. Doctors conducted on an objective description of the patient’scondition, due to electronic medical records generated speed characteristics, documentswith similar content can be copied using. However, some medical personnel medicalrecords after repeated use, without analyze specific issues, supplemented or modified,has led to significant loophole in the medical records, so that the records can not beguaranteed authenticity.3, writing medical records are not uniform format. Varioushospital departments have various sections of the characteristics of different sectionsdiagnose illness as different electronic medical records in writing, it will come with theirown departments characteristics, coupled with knowledge of every doctor, medicalconsultation in different ways, different people handle medical records have differentformats, so even in the hospital’s electronic medical record has a fixed format templateprovides that in practical applications, the format of records is very difficult to unify.4,some physicians in the medical record entry is complete, the signature can not be timely.This phenomenon after the application of electronic medical records, has beencommonplace, and this is the application of an electronic medical record deficiencies. AsChina’s medical institutions are profit institutions, higher physician practicing medicine inaddition to doing their own work to save people, we should also create economic benefitsbusy hospital, resulting in clinical work to subordinate senior physicians neglect the guidance of doctors and can not be signed.5, within the specified time, some medicalrecords can not be completed. Cause of this problem is that the doctor shortage inmanpower, work intensity in the case, the distribution of some unreasonable time causingthe corresponding medical records no longer required time to complete.The development of electronic medical records systems are technical standards, thefunctional scope of the problem encountered many obstacles. The main features ofelectronic medical records from its main function of departure, involving a wide range ofskill levels, and electronic medical records system structure is also very complex, and noone EHR forming technical specifications or industry technical standards. As in technologydevelopment, electronic medical records system function module development is no exactrange, so the development of such technologies will be extremely difficult and lengthyprocess.Since the development of electronic medical records is not mature, imperfect, so itsmore and more problems arising from the current introduction of electronic medicalrecords of the relevant laws are just some scattered regulations, standards, etc., in dealingwith legal matters related to electronic medical records especially electronic medicalrecords as evidence, it must be relevant in these laws and regulations, the points of thevarious strands of analysis to making it explicit terms, thus proving the legal status ofelectronic medical records. Especially when faced with medical disputes, electronicmedical records can serve as an effective judicial evidence to prove that, so far there is nota single argument, the paper on that issue, from the law of evidence and the application ofthe current situation of electronic medical records, the advantages of electronic medicalrecords and problems in the practical application of the analysis, combining electronicmedical records as legal evidence of the necessity and electronic medical records as legalevidence of the legality of electronic medical records as evidence in legal issues related toexploration, and electronic medical records to make future development prospects.