The so‑called electronic medical record, as the name suggests, is a digital way of recording the contents of a patient’s medical history, used to replace the traditional paper‑based record.
Traditional paper records not only document the patient’s clinical course but also serve as legally binding documents. Therefore, after completing a paper record, medical staff must sign it personally to assume responsibility.
In the era of electronic medical records, the records are digitized and can no longer be signed or stamped in the traditional way. Instead, medical personnel must indicate the author of the electronic record with an electronic signature after completing it, and encrypt it to prevent tampering. Currently, the most commonly used signing tool in the country is the medical staff’s IC card; once the digital record is signed with the IC card, the document becomes an electronic medical record.
After the Electronic Signature Act was passed domestically, the Health Department began vigorously promoting the adoption of electronic medical records in hospitals. Our hospital reported to the Kaohsiung City Health Bureau in December 2009 and received approval to commence electronic medical records. Currently, our hospital is actively expanding the implementation of electronic records, hoping to achieve the goal of becoming a fully electronic medical record hospital as soon as possible.
