1, personal basic information, including basic information such as name and gender, and basic health information such as past medical history and family history;
2. Physical examination, health status and drug use for diseases;
3. Health management records of key populations, including health management records of children aged 0-6, pregnant women, the elderly, patients with chronic diseases, severe mental disorders and tuberculosis required by the national basic public health service project;
4, other medical and health service records, other admissions, referrals, consultation records, etc.
Residents' health records include personal health records, family health records and community health records.
1 Personal health records are frequently used in general practice and have the highest use value.
2. Establish family health records and adopt different forms according to the actual situation.
3. Community health records have not been given more uniform requirements in general medical services, and are mainly used to evaluate doctors' understanding of the health status of residents in their communities and community resources, and to investigate the group views of general practitioners in patient care.
Why should we establish a national health record for residents?
1. In the process of filing, we can find many chronic diseases that are not easy to be found by patients, such as hypertension and diabetes, and carry out health management on the diseases. At the same time, it can popularize health knowledge, change people's bad living habits and improve their health level and quality;
2. Establishing a complete and true health file can make medical staff fully understand your health status, thus providing high-quality, comprehensive and continuous public health services;
3 residents' health records provide basic materials for medical treatment, two-way referral and medical insurance reimbursement. Community health service institutions, township hospitals and village clinics within the jurisdiction can establish health records at any time.
To sum up, residents' health records include personal basic information, health examination, health management records of key populations and other medical and health service records.
Legal basis:
Article 8 of the Regulations on the Administration of Rural Doctors
The state encourages persons who have obtained the qualifications of practicing doctors or assistant practicing doctors to set up village medical and health institutions or provide prevention, health care and medical services for villagers in village medical and health institutions.