County Health Bureau, county community health service management office:
In order to better carry out the establishment of 20 1 1 residents' health records and summarize the experience of filing, we conducted a self-examination on the establishment process and file quality of 20 10 residents' health records, reviewed the shortcomings in the establishment of health records in the previous year, and examined the quality problems and areas that need to be strengthened in the established health records. The results of self-inspection are reported as follows:
First, the establishment process of residents' health records
According to the Training Guide for Residents' Health Records Management Service in the Service Specification for Urban and Rural Residents' Health Records Management, we have formulated the Service Specification for Rural Residents' Health Records Management to provide centralized training for personnel involved in establishing health records. Assess the population situation of each village. We bought three weighing scale, sphygmomanometer, stethoscope, hand-held blood glucose meter, vision examination table and other necessary equipment. Dean personally visited the village, stationed in front of the headquarters, contacted the village and community leaders, and sought support. Authorized the person in charge, all the staff of the prevention and protection station to participate, the village doctor to assist in the work, the rural area dedicated to a car, rain or shine, actively and seriously carry out the establishment of health records.
Second, the number of documents.
According to the spirit of the document "Notice on Issuing the Annual Target of Urban and Rural Residents' Health Records Filing Rate" (word 20 109 1) issued by the County Health Bureau (standardize the establishment and management of health records to ensure the true, complete and effective use of information). The dean put the establishment and improvement of health records in the first place, personally led and supervised, and increased support in financial and material resources. All the people involved in the declaration worked hard. There are many migrant workers in our hometown, with great mobility. We have established and improved the 807 1 rural residents' health records, and basically achieved the 30% target set by our superiors.
Third, the quality of filing.
According to "National Basic Public Health Service Standard" and "Urban and Rural Residents' Health Records Management Service Standard", the county health bureau uniformly printed various forms and books, and standardized the forms and pages used for filing. According to the filing process, health records are filed through outpatient clinics and rural households. In the process of filing, we adhered to the Standard for Management and Service of Urban and Rural Residents' Health Records, and conducted a general physical examination and health filing for rural personnel by taking the patients with chronic diseases screened out of outpatient clinics to file files immediately and bringing inspection equipment to rural households to file files.
We audit and check the files in Baocun according to the division of responsibilities, calculate the physical quality, and then check it by special personnel, and code it with standard number 17. In the case of busy work, first enter fixed information and general information in the computer "resident health file management system", classify key groups, and implement classified management of fixed files and dynamic files, so that patients with chronic diseases, children aged 0-3 and pregnant women can obtain access rights on the specified date.
Fourth, there is insufficient work.
In practical work, due to the lack of understanding of the spirit of superior documents and the establishment of residents' health records, we can't sum up experience in time, take some detours, and some businesses are not clear enough. At the same time, I feel that the task is heavy, the time is tight, and the study is not enough, which leads to my unfamiliar business. Through self-examination, it is found that scribbling, missing words, incomplete information, carelessness, data distortion and other phenomena exist in the physical examination process, which will lead to the failure to meet the qualification rate of health records.
Verb (abbreviation of verb) future work plan
Through the self-examination of the establishment process and file quality of residents' health files in our hospital, we will strengthen the rectification of the shortcomings and problems found, strengthen the professional knowledge training of the personnel involved in filing, strengthen the sense of responsibility, and carefully review, improve and update the health files that failed to meet the standards last year. While improving the professional level and understanding of leaders and staff, our hospital plans to take the following measures to continue the establishment of health records:
1. The staff of our hospital are full-time responsible for and personally complete the filing work, and the village doctors are still involved in the coordination and assistance of the filing work in the village, and there is no need for the village doctors to carry out the actual filing operation.
2. In rural areas, we still adopt the combination of outpatient service filing and physical examination filing, but we don't engage in the mode of all staff going to the countryside to complete the task by surprise, but adopt the mode of special groups going to the countryside to visit households. Still carrying equipment for on-site physical examination and on-site filing records to ensure that every complete file that meets the standards is established and improved. On the premise of striving for quality standards, ensure that the number of files that meet the standards is completed.
3. If conditions permit, strive to complete the establishment and improvement of personnel health records and complete the establishment of some family health records.
4. The established health records shall be reviewed by personnel in sections, and the personnel or family number shall be made according to the village number after calculating the physical fitness. After the relevant personnel input the relevant information in the computer resident health record management system, the fixed files are stored in the filing cabinet, and the dynamic files classified according to the key population are handed over to the person in charge, which is convenient for timely treatment and record updating.
5. Be strict in practical work, strengthen leadership and supervision, find problems in time and solve them in time. Really do a good job in the establishment of residents' health records.
Please check and criticize the above self-examination by leaders at all levels.
Loujie hospitals
2011February 20th