医院管理论坛|2024年1月第41卷第1期|93信息管理口腔专科门急诊电子知情同意书系统设计与应用DesignandApplicationofElectronicInformedConsentSysteminStomatologicalOutpatientandEmergencyDepartments□陈怡帆CHENYi-fan曹战强CAOZhan-qiang摘要Abstract目的开展无纸化病案归档建设，对传统门急诊纸质知情同意书进行电子化设计与应用。方法分析口腔专科特色的知情同意书应用需求，遵循移动性、一致性、可靠性原则，升级改造电子病历系统，引入第三方电子认证服务对电子知情同意书进行数字认证。结果实现了口腔专科门急诊电子知情同意书的移动、可信签署，试运行期间系统整体运行稳定。结论电子知情同意书的应用进一步保障了病案数据的完整可靠，业务流程和管理模式的转变需不断地磨合和优化，以进一步推动病案管理的信息化发展。ObjectiveTocarryouttheconstructionofpaperlessmedicalrecordsfiling,andtodesignandapplytheelectronicalinformedconsentforminoutpatientandemergencydepartments.MethodsTherequirementsofinformedconsentwithdentalspecialtycharacteristicswereanalyzed.Theelectronicmedicalrecordsystemwasupgradedaccordingtotheprinciplesofmobility,consistencyandreliability,andathird-partye-certificationservicewasintroducedfordigitalauthenticationofe-informedconsent.ResultsThemobileandtrustedsigningofelectronicinformedconsentforoutpatientandemergencydepartmentofstomatologywasrealized,andtheoveralloperationofthesystemwasstableduringtrialoperation.ConclusionTheapplicationofelectronicinformedconsentfurtherensurestheintegrityandreliabilityofmedicalrecorddata.Thetransformationofbusinessprocessesandmanagementmodelsneedstobecontinuouslyadjustedandoptimizedtofurtherpromotetheinformatizationofmedicalrecordmanagement.关键词Keywords：口腔医学Stomatology；知情同意书Informedconsent；数字签名Digitalsignature；病案Medicalrecords作者单位：北京大学口腔医院PekingUniversitySchoolandHospitalofStomatologyEmail:chenyifan@pkuss.bjmu.edu.cn通讯作者：曹战强中图分类号：R197.5；文献标识码：ADOI:10.3969/j.issn.1671-9069.2024.01.024我国民法典规定：医务人员在诊疗活动中应当向患者说明病情和医疗措施。需要实施手术、特殊检查、特殊治疗的，医务人员应当及时向患者说...
