Legal basis: national basic public health service standards. service content
(1) Contents of residents' health records 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 and gender, as well as basic health information such as past medical history and family history. 2. Physical examination includes general health examination, lifestyle, health status, medication for diseases and health evaluation. 3. The health management files of key populations include the health management files of children aged 0-6, pregnant women, the elderly, patients with chronic diseases and severe mental illness required by the national basic public health service project. 4. Other medical and health service records include other admission, referral and consultation records except the above records. (2) Establish the residents' health records 1. When residents in the area receive services in township hospitals, village clinics and community health service centers (stations), medical personnel are responsible for establishing residents' health records and filling in corresponding records according to their main health problems and service provision. At the same time, fill in and issue resident health record information cards for the clients. 2. Township hospitals, village clinics and community health service centers (stations) organize medical personnel to establish health records for residents through on-site service (investigation), disease screening and health examination, and fill in corresponding records according to their main health problems and service provision. 3. In areas where residents' electronic health record information system has been established, township hospitals, village clinics and community health service centers (stations) shall establish residents' electronic health records for individuals through the above-mentioned methods, and issue national unified standard medical care cards. 4. Fill in the relevant record forms of health files in the process of medical and health services, and put them into the residents' health archives for unified custody. In rural areas, it can be stored centrally in families. The data of residents' electronic health records are stored in the electronic health records data center.