On February 22, the National Health and Family Planning Commission issued the Notice on Printing and Distributing the Management Regulations for Electronic Medical Records (Trial).
In accordance with the "Opinions of the Central Committee of the Communist Party of China and the State Council on Deepening the Reform of the Medical and Health System" and the Notice of the General Office of the State Council on Printing and Distributing the Five Key Reforms of the Medical and Health System in 2009, the former Ministry of Health issued the "Basic Standards for Electronic Medical Records" in 2010. (Trial) (hereinafter referred to as the "Basic Specifications"). The formulation and implementation of the "Basic Norms" played an active role in strengthening the management of electronic medical records of medical institutions in China at that time, regulating the clinical use of electronic medical records, and promoting the informationization of medical institutions. With the continuous advancement of the application of electronic medical records, some provisions of the "Basic Specifications" have not adapted to the management requirements of electronic medical records under the new situation. To this end, the National Health and Safety Commission and the State Administration of Traditional Chinese Medicine organized experts to revise the "Basic Norms" and solicit opinions from all provinces (autonomous regions and municipalities), further revise and improve the "Electronic Medical Record Application Management Regulations (Trial)" .
The main revisions include: First, the concept of electronic medical record system and electronic medical record is defined, specific requirements are put forward for electronic medical record information system technical management and electronic medical record quality management; second, the terminology, coding, template and data used in electronic medical records should be consistent. Relevant industry standards and norms are required to promote the effective sharing of electronic medical record information; third, the relevant requirements of electronic medical records are linked with electronic signature laws; and fourth, the specific technical conditions and requirements for the storage of electronic medical record copies are clearly defined.
The full text is as follows:
Notice on Printing and Distributing the Management Regulations for Electronic Medical Records (Trial)
National Health Service Medical Journal [2017] No. 8
Health and Family Planning Commission of each province, autonomous region, municipality directly under the Central Government, Chinese Medicine Administration, Xinjiang Production and Construction Corps Health Bureau:
In order to implement the spirit of the National Health and Wellness Conference and deepen the requirements related to the reform of the medical and health system, standardize the clinical use and management of electronic medical records, promote the effective sharing of electronic medical records, and promote the informationization of medical institutions, the National Health and Family Planning Commission and the State Administration of Traditional Chinese Medicine. The "Electronic Medical Record Application Management Specification (Trial)" was formulated. It is printed and distributed to you (can be downloaded from the “Medical and Medical Management†section of the official website of the National Health and Family Planning Commission), please follow the instructions.
National Health and Family Planning Commission Office
Office of the State Administration of Traditional Chinese Medicine
February 15, 2017
Electronic medical record application management specification (trial)
Chapter I General
The first one is to standardize the application management of medical institutions' electronic medical records (including Chinese medical electronic medical records, the same below), meet the needs of clinical work, guarantee medical quality and medical safety, and ensure the legitimate rights and interests of both doctors and patients. According to the Law of the People's Republic of China on Practicing Physicians, This Code is formulated in laws and regulations such as the Electronic Signature Law of the People's Republic of China and the Regulations on the Administration of Medical Institutions.
Article 2 Medical institutions that implement electronic medical records shall apply this specification to the establishment, recording, modification, use, preservation and management of electronic medical records.
Article 3 Electronic medical records refer to the digitized information of words, symbols, charts, figures, figures, images, etc. generated by medical personnel during the medical activities, and which can realize medical records stored, managed, transmitted and reproduced. It is a form of record of medical records, including medical records of hospitals (emergency) and hospitalized medical records.
Article 4 The electronic medical record system refers to computer information that supports the collection, storage, access and online help of electronic medical record information within the medical institution, and provides information processing and intelligent service functions around improving medical quality, ensuring medical safety, and improving medical efficiency. system.
Article 5 The National Health and Family Planning Commission and the State Administration of Traditional Chinese Medicine are responsible for guiding the management of the application of electronic medical records throughout the country. Local health and family planning administrative departments (including Chinese medicine management departments) are responsible for the supervision and management of electronic medical records in their respective administrative regions.
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