Application significance of trace retention in the electronic medical record system

Application significance of trace retention in the electronic medical record system

Yuan Yongfu

 

Trace retention is an important feature in the text editing of electronic medical records. According to the electronic medical record application specification published by the Ministry of Health, the theoretical electronic medical record system must have the trace retention function. Through visits to some hospital users, I learned that this function is still complex in practical applications.

One of the purposes of hospital trace retention is to help doctors at higher levels guide lower-level doctors.

Higher-level doctors have a lot of practical experience and medical technology. By modifying the medical records of lower-level doctors, they can guide lower-level doctors. Lower-level doctors can learn by looking at the traces left by higher-level doctors to help them correct and improve, and accelerate the improvement of medical care. This will improve the efficiency of new and old doctors in hospitals and accelerate the training of new doctors.

In actual development, the software displays trace information in two ways. One is full text comparison. The new version and the old version are displayed in the left and right columns, and the content difference between the two files is marked. The other is that the trace is directly displayed in the document, and the interface is similar.Word. The full text comparison method is easy to implement, and can also meet the needs of hospitals. However, it is complicated to directly display traces in the document, which makes it easier to apply.[Yuan Yongfu Copyright]

Different groups of people in the hospital have different attitudes towards trace retention. First-line doctors do not like trace retention. They feel that this increases their responsibilities, limits their freedom, and is more or less resistant. Hospital Management wants trace retention, in this way, the performance appraisal of frontline doctors can be strengthened, and management and control can be strengthened.

The electronic signature technology in electronic medical records is not yet widely used. A large number of medical records are printed to allow doctors to manually sign and archive them. However, the general trend is to popularize the electronic signature technology to achieve paperless medical office work. At this time, whether the hospital's medical records with electronic signatures need to retain trace data is controversial.

For in-hospital applications, hospital management hopes to carry electronic signature medical records with trace data, which facilitates the historical review of the medical process and facilitates enhanced management.[Yuan Yongfu Copyright]

For applications outside the hospital, the hospital wants to make the electronic signature of the medical records documents do not contain trace data, this can reduce the scope of responsibility, and there is room for maneuver in the case of medical disputes.

At this time, the hospital has two sets of systems. The electronic signature-based medical records document has two versions: Internal and External. The internal version contains trace data, and the external version does not contain trace data. This method is not transparent and is a potential rule, just like many enterprises have two sets of financial systems, which are true for external fraud.

When the hospital has two versions of electronic medical records, the hospital will certainly provide no trace data by default if the hospital needs to call the medical records outside the hospital. However, it is a problem if the hospital does not provide electronic medical records that contain trace data, for example, when a lawyer from mingzhen sends a letter asking for such information. If not, it is easy to be the defendant; if it is provided, this potential rule is exposed, and such a system cannot be mixed up in the future.[Yuan Yongfu Copyright]

In a closer step, the hospital may need to sign a signed medical record document to modify traces and then sign the documents. This also brings some problems[Yuan Yongfu Copyright]First, modifying the legal electronic signature data is a violation of the law. In addition, modifying traces may lead to the transfer of medical liability, which may also lead to more disputes.

Therefore, whether the electronic signature medical records contain trace information may become a very tangled issue for hospitals and health authorities sooner or later. As a developer, we can only say that we provide two solutions for hospitals to choose from, including traces and no traces. We may even need to enable the application system to switch between the two modes at any time. The software cannot afford to hurt the lion!

[ yuan Yongfu, author of this article, focuses on the development of the electronic medical record text editor and has mature products, blog URL http://cnblogs.com/xdesigner . ]