1, the authenticity of the data
Health records are composed of all kinds of original data, which should truly reflect the health status of residents at that time. When recording, for some unclear situations, we must obtain real results through investigation, and never take it for granted to describe them. The recorded information must not be changed at will for some needs.
2. The scientific nature of the data
Residents' health records shall be recorded in accordance with general medical norms. The written explanation and use of measurement units shall comply with the relevant provisions, be accurate and meet the standards. The names of health problems often used in practical work should conform to the classification standards of diseases, and the descriptions of health problems should conform to medical norms.
3. Data integrity and continuity
Although the records of residents' health records are relatively simple, the contents of the records must be complete, all kinds of materials must be complete, and the contents of the records must be complete.
All documents should be filled in with pen, not pencil or red pen. Write clearly and neatly.
Instructions for filling in health records
First of all, the cover
The family file number is 8 digits, the first 2 digits are township codes, 3-4 digits are village codes, and 5-8 digits are household names.
Family information: name, home address, contact number, etc. It should be consistent with the contents of the corresponding personal general information form.
For families who have lived locally for a long time and whose household registration is not local, fill in the household registration address.
Filing information: the filing unit shall fill in the full name, such as * * * Town * * Village Health Center; The filing person can be the responsible doctor himself or other medical personnel.
Second, the basic situation of the family
In the record table, for items with alternative answers, the number corresponding to the corresponding answer option number should be filled in the "□" in the item column. If the "Other" option is selected in the alternative answer, the corresponding content should be filled in the blank left by this option, and the number corresponding to the "Other" option number should be filled in the "□" in the item column. If there is no alternative answer, please fill in the appropriate text or data in the corresponding lines or boxes.
If there are children aged 0-3 years in the family, fill in the relevant basic information in the family member table, but for children under 3 years old, do not enter the personal basic information table and health checklist, but add the health management file of children under 3 years old, and then enter the personal basic information table and health checklist after the children reach 3 years old. If there are pregnant women in the family, they should join the "Maternal Health Management Archives".
Fill in the main health problems in the health status column of the family member information form: generally, it refers to diseases or life events that have affected personal health in the past, are affecting personal health now or will affect personal health in the future, and can fill in the clearly diagnosed chronic diseases, disabilities, operations, genetic problems, drug allergies, certain symptoms, abnormal signs and persistent abnormal test results.
Three. Personal basic information table
Number: the first 8 digits are consistent with the number of the cover health file, and the last 2 digits are the numbers of indoor family members.
For items with alternative answers in the table, the number corresponding to the option number of the corresponding answer should be filled in □ in the item column. If the "Other" option is selected in the alternative answer, the corresponding content should be filled in words in the blank left by this option, and the number corresponding to the "Other" option number should be filled in the □ in the item column. If there is no alternative answer, please fill in the appropriate text or data in the corresponding lines or boxes.
Contact name: refers to the emergency contact. It is required to fill in the names of relatives and friends who are closely related to the filing object. The contact person should be the person who can really get in touch and give help when it is impossible to communicate directly with the record object under special circumstances or emergencies and needs the help of relatives and friends of the record object urgently.
Blood type: fill in ABO blood type, if it is "RH negative" blood type, please indicate it specially.
Education level: the contents to be filled in include "illiterate/semi-illiterate/primary school/junior high school/senior high school/technical secondary school/junior college and"