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KMID : 0986720160240020049
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Korean Journal of Medicine and Law
2016 Volume.24 No. 2 p.49 ~ p.68
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A Study on Electronic Medical record
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Baek Kyung-Hee
Lee In-Jae
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Abstract
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Medical Services Act is to give medical practitioners with duties such as writing medical records and storage those for a certain period of time. There is a prohibition on medical practitioners’ writing medical records in the false or fix it. In addition Medical Services Act has the new regulations on electronic medical records, and it is possible to create and store an electronic medical record with electronic signature instead of paper medical records.
However, Medical Services Act dose not standardize the terminology between electronic medical records and paper medical records and there are no legal sanctions against generation requirements and storage requirements of the electronic medical records. As a result, even if there are some descriptions of addition, correction or deletion about the electronic medical records by medical practitioners, there is no way for patients to confirm its change.
Therefore, this study intends to define significance, change, and regulation of paper medical records and electronic medical records and analyzes their relationship, and then present the direction of the law maintenance.
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KEYWORD
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Medical Services Act, electronic medical records, Paper Medical Record, electronic signature, medical practitioners
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