Management of residents' health records;
First, the service object:
Permanent residents within the jurisdiction (referring to registered and non-registered residents who have lived for more than half a year), focusing on children aged 0-6, pregnant women, the elderly, patients with chronic diseases, patients with severe mental disorders and patients with tuberculosis.
Second, the service content:
Contents of residents' health records:
Residents' health records include personal basic information, health 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, severe mental disorders and tuberculosis 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.
Establish residents' health records;
1. When residents in the jurisdiction receive services in township hospitals, village clinics and community health service centers (stations), medical personnel are responsible for establishing residents' health records for them, filling in corresponding records according to their main health problems and service provision, and filling out and issuing residents' health record information cards for the clients. In areas where electronic health records are established, residents' health cards will be gradually made and distributed to clients, replacing residents' health record information cards as credentials for identity identification and updating electronic health records.
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 in the above ways. And upload the regional population health information platform according to the standard specification to realize the standardized reporting of electronic health record data.