1, residents' health records

The contents of residents' health records include personal basic information, physical examination, records of key population management and other medical and health service records. (1) Personal basic information includes basic information such as name and gender, and basic health information such as family history and past history. (2) Physical examination includes general health examination, lifestyle, health status, medication for diseases and health evaluation.

(3) The management records of key populations include the follow-up and management records of various key populations such as 0-3 years old children's health care, maternal health care, elderly health care, and chronic disease patient management required by the national basic public health service project. (4) Other medical and health service records include other admission records, hospitalization records, referral records, consultation records, etc.

2. Establish residents' health records.

All departments of the center and community health service stations provide services for establishing health records for residents within their jurisdiction.

(1) When residents in the jurisdiction receive services, the first-time doctors are responsible for establishing residents' health records and filling in corresponding records according to their main health problems and health service needs.

(2) Through on-site service (investigation), disease screening, health examination, health education, etc., the responsible medical staff will establish residents' health records for key people in their homes or workplaces in stages, and fill in corresponding records according to their main health problems and health service needs; Children's health service management files; The special file of vaccination service is established by the children's health department of the center; After the diagnosis of early pregnancy is confirmed, the central Ministry of Women's Health Protection will establish the management files of maternal health care services. The above work files shall be carefully filled in according to the service items.

(3) The related record forms of health records established in the process of providing medical and health services are put into the residents' health records for unified storage, so that they can be entered into computers in the future and electronic health records can be established.

3. Utilization of residents' health records

(1) When residents who file files go to primary medical and health institutions for follow-up, after obtaining their health files, the attending doctor will fill in, update and supplement the corresponding records in time according to the follow-up situation.

(2) When medical and health services enter the household, the health records of the clients should be consulted in advance and the corresponding forms should be carried, and the corresponding contents should be recorded and supplemented during the service. (3) Customers who need referral and consultation shall be filled in by the attending doctor. (4) All service records shall be collected by the responsible doctor and filed in time.

4, health records management

Residents' health records are managed according to the Measures for the Administration of Medical Records, and the key requirements are as follows:

(1) The establishment of residents' health records is a complex systematic project with strong policy, coordination and technology. It is necessary to strengthen the professional training of relevant personnel, so that they can understand the requirements of filing, master the necessary methods and skills, and pay special attention to the training of communication skills and data collection skills, so as to ensure the smooth progress of filing and lay a mass foundation for future public health activities. It is necessary to do a good job in the preparatory work for filing, and carry out various forms of publicity and mobilization activities such as posting notices, hanging banners, and distributing free clinic leaflets. , so that residents are willing to accept and actively cooperate with the record. Institutions providing services for the establishment of residents' health records must be equipped with full-time (part-time) management personnel, have received training organized by this project, and have passed the examination. The management system of residents' health records in this unit should be formulated and strictly implemented.

(2) The management of health files should have necessary file storeroom, equipped with file fittings, and properly keep health files according to the requirements of theft prevention, light protection, high temperature prevention, fire prevention, moisture prevention, dust prevention, rat prevention and insect prevention, and designate full-time (part-time) personnel to be responsible for the management of health files to ensure the integrity and safety of health files.

(3) Establish residents' health records through information collection methods such as daily diagnosis and treatment, free clinic, chronic disease follow-up and health education. Health records should be updated in time to maintain the continuity of data.

(4) The establishment of health records should follow the principle of combining voluntary and guidance, and attention should be paid to protecting the personal privacy of the parties during use.

(5) Unified coding of residents' health records, adopting the 16-bit coding system, based on the unified national administrative division coding, taking towns (streets) as the scope and village (neighborhood) committees as the unit, and compiling the unique coding of residents' health records. At the same time, the resident's ID number will be used as a unified identity code.

(6) Record relevant contents according to the requirements of relevant national special technical specifications, and the recorded contents shall be complete, true and accurate, with standardized writing and no omission of basic contents.

(7) Health records management and service personnel have the right to use health records in use, management and assessment. When other institutions or individuals need to use health records, they must submit a written application to the health records management institution, and they can only use them after being approved by the management institution and agreed by themselves or their guardians.

(8) Residents' health records are public information resources and should be preserved for a long time. If a medical and health institution is revoked or merged, it must be handed over to the county (district) health administrative department or the medical and health institution designated by the county (district) health administrative department, and refuses to implement it, resulting in the loss or damage of the file, the responsibility shall be investigated according to law.

(four) gradually realize the informatization of residents' health records management.

In 2009, user training was carried out by using the computer network platform of provincial residents' health records; In 20 10, the construction of computer network platform for municipal residents' health records was completed, and the research on the integration of residents' medical information in primary medical and health institutions and hospitals above the second level was initiated, so that the management of residents' health records in the city was basically informationized.

Third, the project organization and management

1, attaches great importance to it, and regards it as the premise, foundation and key work of community health service standardization construction. First, we should do a good job in appropriate technical training of health file management, clarify the division of labor, have a director in charge and a person in charge, and actively create favorable conditions to ensure practical results. Led by the Central Community Office, with the residents' health records management team as the core, the chronic disease management team, service stations, neighborhood committees or residential properties as the help targets, and quantitative standards as the hard standard. Surprise filing and centralized filing? What is the main strategy of archiving? One-time in place, standardized filing? Record quality standards.

2. Improve the filing service process and adopt two filing methods: daily outpatient filing and centralized household filing. In order to ensure the quality and quantity of filing and improve work efficiency, it is planned to divide the filing personnel into several groups and concentrate on a certain community or residential area for filing, so as to strive to enter a community. Qing? A community has reached the filing rate. It is necessary to sort out and count the daily workload and progress of each group in time, and summarize and exchange experience in filing, so as to improve the next day.

3. Pay attention to the integrity, accuracy and authenticity of data collection, because the data we collect can not only be used to establish residents' health records, but also provide first-hand information for community diagnosis, chronic disease management, health education, academic research and government decision-making.

4. In order to give full play to the role of health files, the health files of residents, especially key groups, should be turned into living files and valuable files, which should not only be filed and updated as required, but also be organically combined with residents' health survey, health education, community free clinic, free physical examination and daily outpatient service. For example, when we carry out the residents' health survey of community diagnosis, as long as we add more ID numbers to the residents' health survey, it can be used as files and updated materials. In addition, in the daily management of residents with chronic diseases, by the way, knowing the health status of their family members can be used to update files.

Four. The project will be implemented from September 30th to June 30th, 200910.

Verb (abbreviation of verb) Project implementation supervision and assessment (1) Incorporate the implementation of the project of establishing residents' health records for basic public health services into one of the key tasks of the center, strengthen the regular supervision and inspection of this work, rectify the problems found in time, and take the implementation of the project of establishing residents' health records as the main content of performance appraisal of relevant personnel.

(2) The main contents of supervision and evaluation: project implementation plan formulation, organization and management, personnel training, availability and use of funds, quantity and quality of filing, file updating and management, service effect, residents' satisfaction, etc.

(III) Main evaluation indicators

1, health record filing rate = number of filing persons/resident population in the jurisdiction? 100%

2. The qualified rate of health files = the number of qualified files filled in/the total number of random files? 100%

3. Utilization rate of health records = number of files with dynamic records in spot check/total number of files in spot check? 100% (dynamically recorded files refer to health files of relevant medical and health service records that meet the requirements of various service specifications within one year)

4. The truth rate of health records = the number of files with true contents in the files/the total number of files? 100% (the truth can be inquired by phone, judged logically, etc. )

Chapter III Implementation Plan of Community Residents' Health Records

First, the overall goal

By standardizing the establishment of residents' health records and implementing dynamic management, we can fully grasp the health status of residents in Chengguan office, create conditions for the implementation of health management and medical care services, further enhance residents' health awareness and improve the health level of the whole people.

Second, the specific work indicators

1. service object;

The resident population within the jurisdiction, including the registered and non-registered population who have lived for more than half a year, 0? 6-year-old children, pregnant women, the elderly, patients with chronic diseases and severe mental patients are the focus.

2. Service content

The contents of residents' health records include personal basic information, physical examination, health management records of key populations and other medical and health service records.

(1) Personal basic information includes basic information such as name, gender and past.

Basic health information such as medical history and family history.

(2) Physical examination includes general physical examination, lifestyle and health status.

And its disease medication and health evaluation.

(3) The health management files of key populations include national basic public health services.

0 required for the project? Health management records of 6-year-old children, pregnant women, the elderly, patients with chronic diseases and patients with severe mental illness.

(4) Other medical and health service records include other records besides the above records.

Consultation and referral records.

3. What is the qualified filing rate of residents in the jurisdiction? 70% and updated in time.

Third, the specific working methods

Person in charge of health records of the center: Chen Jing.

1. The person in charge of health records at each station and center shall be responsible for the establishment of health records.

The collection station and village doctors establish their own health records, and fill in corresponding records according to their main problems and service provision. Chengguan community includes Jesse, North Street and Xiguan. The people in each village are Hu Shuhua, Hou Ming and Wei Xiaohong. They are responsible for collecting information and establishing health records. Access to health records: Chen Jing, Wang Yaping.

2. The person in charge of each village has passed the door-to-door service, disease screening and health examination.

Methods Health records were established for residents. The health file administrators of Dongguan Station, Yaotu Station and Xiguan Station are Tang Ruiying, Hu, respectively. Each person in charge collects the health information reported by the village doctors in this area and the health files established in time, and then the designated personnel of each station enter the electronic files.

3. On 30th of each month, the village leaders collect information and report it to each station.

Establish the health file number, and each station will report it to the center every June 1, and establish the paper and electronic input number of the health file; The center shall report the number of paper and electronic health records to the community management center and the CDC on the 2nd of each month, and shall not fail to report, make a false report or make a false report.

Fourth, the task

1. The person in charge of each village establishes health records for residents through household surveys and disease screening, and delivers the established health records to the person in charge of each station on the specified date.

2. Each station shall timely file and enter the health records reported by the village head.

3. When will the person in charge of the center file the health records reported by the person in charge of the village? And make statistical report at the specified time.

Verb (abbreviation for verb) working system

Establish a strict confidentiality system and borrowing system: the person in charge of health records in each station and village and the person who enters the health records should strictly keep the information secret of the archivists, and cannot arbitrarily change or delete the entered health records.

Six, the assessment in strict accordance with the "Chengguan community health service center performance appraisal scheme" standard implementation.

1. The standard workload is: information collection 1 person-time =0.5, complete entry into the provincial health department network = 0. 1.0 screening =0.5 health record filing rate = filing number/resident population in the jurisdiction? 100%。 Qualified rate of electronic records = number of patients with electronic health/number of permanent residents in the jurisdiction? 100%。 Utilization rate of health records = number of files dynamically recorded by friends in files? 100% (files with dynamic records refer to health files with relevant records meeting the requirements of various service specifications within 1 year).

2. Statistical procedures;

Before the 2nd day of each month, each station counts the monthly workload of this station and the villages under its jurisdiction and reports it to the central project leader, who will review it by the central assessment leading group, and cash performance pay and village doctor remuneration according to the audit results.

Seven, cash funds

1. Calculate 0,5 for each collection and screening, and complete more every month 1.5 yuan.

2. Every time the information collector collects a piece of information, the other ID numbers will be deducted by 0.2, the address will be deducted by 0. 1, and the information will be deducted by 0.05. Duplicate health records will not be counted.

3. The input electronic documents must be completely consistent with the paper information. If the ID number is wrong, 0.2 will be deducted for the wrong address, 0.01for the wrong information, and 0.05 will be deducted.

4. Failing to report the deduction 1 workload on time.