Summary of residents' health records in central hospital 1 1. Establish a leading group for residents' health records.
20xx65438+February, after receiving the implementation plan of establishing rural residents' health records from the county health bureau, our hospital set up a leading group for the management of residents' health records, headed by Dean Shao. All the staff and village doctors jointly formulated the Implementation Plan for Establishing Rural Residents' Health Records in Wuguanyi Central Hospital, defined their respective responsibilities and actively carried out various tasks.
Second, unify our thinking and attach great importance to it.
After receiving the notice from the superior about the filing work, our hospital held a mobilization meeting for the establishment of health records for urban and rural residents in time, which conveyed the important spirit of the meeting of residents' filing work of county health bureau, emphasized the great significance of residents' filing work, and asked all staff to be patient and meticulous in their work, do a good job in propaganda and mobilization, and let residents realize the benefits of establishing health records, actively file and enjoy medical services in their jurisdiction.
Third, improve the software and hardware facilities.
In order to better carry out the filing work, our hospital set up a public health department after its establishment, organized investigators to conduct professional training from time to time, formulated various work rules and regulations, and purchased office facilities such as desks, filing cabinets and computers, which laid a solid foundation for the smooth filing work and ensured the smooth investigation of residents' personal information.
Four, conscientiously carry out all the work, and fully complete the goal of filing residents.
Health record work is an extremely complex and extensive basic project. There are * * administrative villages 13 in our town, with a total population of 533 1 person, and 4835 files have been entered into the system, with a filing rate of 9 1%. For patients with chronic diseases such as hypertension, diabetes and mental illness who have established and mastered the archives of the elderly, according to the requirements of superiors and their own conditions, we should carry forward the principle of not being afraid of hardship and fatigue.
In a word, our hospital has been conscientiously implementing the Implementation Plan for the Establishment of Health Records for Urban and Rural Residents in accordance with the requirements of municipal and county health bureaus, and doing a good job in collecting, sorting out and analyzing relevant data of health records. It provides more convenient, fast and efficient public health and medical services, and it is convenient for people to see a doctor to the maximum extent. In the future work, we will sum up experience, overcome shortcomings, adhere to the people-oriented, actively carry out various work, strive for greater progress, and make the public health service work in the jurisdiction reach a new level.
Summary of residents' health records in central hospital 2 pages. Residents' health record is an important public health work in the national medical reform plan, which is related to the physical and mental health of each resident and improves the health level of the whole country. It is the unshirkable responsibility of our health workers to establish a good resident health record, and it is also a major support for public health projects in the national medical reform work, realizing all public health projects and benefiting the whole country. In order to further strengthen the management norms of residents' health records, our hospital has conscientiously implemented the requirements of national basic public health services and related documents at higher levels, and combined with the work plan at the beginning of the year, the work situation in the past year is summarized as follows:
First, leaders attach importance to it.
In order to promote the management of residents' health records in the jurisdiction, our hospital set up a leading group for the management of residents' health records, headed by President Liu Benqiang. All members of each department work together in an orderly manner and implement them one by one according to the requirements of relevant documents of higher authorities. At the same time, we will invest a lot of people, money and materials to overcome difficulties, correct our thinking, put the responsibility on people, and promote the management of people's health records in an orderly manner.
Second, the work content
(1) Publicity and training
In 20xx, we organized specialized personnel to carry out training on filing, systematically mastered the requirements and technologies for the establishment, management and use of residents' health records, established the necessary medical knowledge and skills for health records, and operated and applied the health record information system. Explain the filling requirements of health records, that is, all items must be filled in accurately except those that do not need to be filled in, and it is necessary to know the information with residents in detail in order to achieve the accuracy and completeness of the records.
Establish health records
1, filing contents: including personal basic information, health examination, health management records of key populations and other medical and health service records, etc.
2. Filing method: Doctors are responsible for providing services for establishing health records for residents within their jurisdiction. Responsible for health investigation and basic health examination such as weight, height and blood pressure, and establish health files. On this basis, health records are established for key populations through on-site service (investigation), disease screening and health examination.
(3) Management of health records
1. Establish health record personnel as managers.
2. The establishment of health records should follow the principle of combining voluntary and guidance, and attention should be paid to protecting the personal privacy of the clients during use.
3, do a good job of backup of health records.
4. Standardize the management of health records. Establish a management system for consulting, reading, recording and storing residents' health records to ensure convenient use, long-term preservation and standardized management.
(4) Work flow of health records
The resident population in 20xx is 1 1700, and 77 14 health records and 77 14 electronic records have been established. 72 1 elderly people with household registration, 3 165438 patients with hypertension and 168 patients with diabetes. This year, 7 files were added1person, including 47 elderly people, 3 chronic diseases, 4 severe mental patients, 0-6-year-old children1person and pregnant women1person.
In 20xx, our hospital has made some achievements in establishing residents' health records. However, some residents are not very familiar with the purpose and significance of establishing residents' health records, and the cooperation with doctors needs to be deepened. Migrant workers can't establish their own information in time, and there are still many shortcomings in their work. Our hospital needs to continue to study and practice in depth, overcome difficulties, have high standards and strict requirements, and strive to make the next step more perfect.
Summary of health records of residents in central hospital. Under the correct leadership of the Municipal Health Bureau, with the active cooperation of doctors in Baocun and rural areas, the implementation plan for the management of residents' health records in basic public health services was earnestly implemented, and the filing work was carried out smoothly. The work is summarized as follows:
Complete the main work:
First, actively carry out project training.
Hold regular meetings every month, public health meetings and training courses attended by hospital directors, personnel in charge of project work, doctors in Baocun village and rural doctors. It laid a foundation for completing the project work with good quality and quantity.
The second is the filing of "residents' health records"
By June 25th this year, 26,990 people had been put on file, with a filing rate of 84%. Electronic filing personnel are 2392 1 person, and the filing rate is 75%. Among them, there are 74 elderly people over 65 years old, hypertensive patients, diabetic patients and severe mental patients.
Main measures taken:
The first is to strengthen organizational leadership.
A project work leading group and a Baocun group were set up to take charge of filing. Establish and improve various work systems, clarify responsibilities and implement them to people.
Second, extensive publicity and mobilization.
Strengthen the publicity of the whole town, and use radio, publicity materials, slogans and other means to make the broad masses of the people realize the content and significance of basic public health services.
Third, strengthen supervision.
In 20xx years, our hospital's free medical team supervised the countryside for more than 20 times, and checked the registration telephone number irregularly. Effectively ensure the smooth development of filing work and the quality level of work.
Main problems:
1. Due to various reasons, some grass-roots rural doctors lack enthusiasm and sense of responsibility, and their working attitude is not positive or serious. The quality and quantity of filing are poor.
2, the file update rate can not meet the requirements.
In a word, the filing of residents' health records has made some achievements, but there are also some problems. Therefore, in the future work, we should constantly find out the problems that restrict the filing work, study and formulate solutions to the problems, and ensure the high efficiency, high quality and high level of health file work.
Summary of Residents' Health Records in Central Hospital 4 Management of Residents' Health Records. Under the leadership of County Health and Drug Administration, County Center for Disease Control and Prevention, and Sang Mu Town People's Government, and with the active guidance and cooperation of project staff at all levels and departments, our town has earnestly implemented the Measures for the Administration of Basic Public Health Services in Guizhou Province, and earnestly managed the health records of rural residents, patients with chronic diseases and elderly people over 65 years old in our town. Now, we will carry out the work carried out this year.
I. Work carried out this year
1, hold a project mobilization meeting.
In April of 20xx, the Dean presided over a training meeting for rural doctors and relevant departments of the hospital. The meeting raised the basic public health service in our town to a new height, and made the relevant medical staff and rural doctors in our hospital have a higher understanding of the importance and urgency of this work.
2. Actively carry out project training.
The monthly regular meeting of rural doctors trained the contents of national basic public health service projects, and actively rectified the existing problems, laying a good foundation for completing the project work with good quality and quantity.
3. Filing, physical examination, chronic disease incidence, management and standardized management of the elderly over 65 years old.
1) since the training meeting at the beginning of the year, our hospital has set up a special management group for the elderly over 65 and patients with chronic diseases, including 3 public health departments, 0/3 rural doctors and 0/6 people.
2) Based on household surveys, residents' health records were established, filed at home and followed up regularly, and 66 articles on health literacy, leaflets on healthy diet of diabetic patients and knowledge of prevention and treatment of chronic diseases were distributed at home, and more than 4,000 publicity materials were distributed. The contents of residents' health were established, including weight measurement, height, waist circumference, hip circumference, blood pressure, blood sugar and routine hematuria. And gave advice and guidance to residents on disease prevention and health care knowledge. Summarize and analyze the health data of each resident and write them into paper health records. For patients with chronic diseases, regular home follow-up or telephone follow-up is conducted four times a year to update files in time and improve old files to prevent dead files.
3) The system of blood pressure measurement and blood sugar measurement for newly diagnosed patients over 35 years old shall be implemented by outpatient doctors, and the outpatient department shall distribute publicity materials and health education prescriptions. Patients with abnormal blood pressure make an appointment to measure their blood pressure three times in a row, and those with abnormal blood pressure are reported to the public health department in time and included in the health management of patients with hypertension. In the past year, the number of outpatients who checked their blood pressure for the first time reached 58 15, and 3 patients with hypertension were detected, including 20-35 years old 1 person, which improved the screening rate of hypertension among young people. The abnormal blood sugar was measured for the first time and reported directly to the health and family planning department.
4) Make use of 10.8, 10. 16.5438+04 and other related publicity days to publicize relevant health knowledge at the crossroads of our town, and distribute more than 6,000 related publicity materials, which promoted the health awareness of most residents in our town to a new level.
5) By the end of165438+1October 30th, the total population of our town was 24,824, and the resident population was 14683. Residents' health records have been established for residents in the area 18870, with a filing rate of128. Standardize electronic files 18870, and the filing rate of electronic files 100%. Among them, the elderly over 65 years old 1683 people, the elderly filing rate 1 14.62%. There were 744 patients with hypertension, the management rate of patients with hypertension was 100%, and there were 727 patients with standardized management, with a standardized management rate of 97.72%. There are 248 registered diabetic patients, the management rate of diabetic patients is 100%, the standardized management rate is 1 12, and the standardized management rate of diabetic patients is 45. 16%. Patients with severe mental illness were 5 1 person, special system managers were 5 1 person, and standard managers were 48. Management rate 100%, standardized management rate 94. 12%.
Second, the equalization of services has achieved initial results.
After several years of hard work, at present, the health file work in our town has achieved initial results. By the end of this year, 165438+ 10 * *, a paper file 18870 was established, and 18870 was entered, with an entry rate of 100%. Elderly people over 65 1683, 744 patients with hypertension, 248 patients with diabetes, and 5 patients with severe mental illness1person. Through filing and on-site follow-up, let residents know that the nature of our town is to serve the health of residents in the jurisdiction, improve the awareness rate of health service centers in the jurisdiction, and make the doctor-patient relationship more harmonious.
Third, the main problems
1, wrong information.
According to the health records, I visited patients regularly, but found that residents filled in the phone number space or owed money.
2. It is difficult to update residents' health records.
At present, residents' health records are mainly paper files. Due to the frequent replacement of electronic information system, the electronic information system can not be used normally, residents go to different medical units for treatment, and the file information can not be updated in time.
3. Regular follow-up is difficult.
I made an appointment for follow-up in advance. Those who moved out or often went out didn't inform us, and those who moved here didn't want to register here. The difficulty of follow-up work is one of the reasons why residents' health records become dead files, which makes it difficult for us to know the dynamic information of residents' health in time.
Fourth, the next step of rectification measures
1, strengthen publicity.
2. Strengthen the work.
3. Strengthen the supervision of rural doctors.
4. Complete all tasks assigned by superiors on time.
Health archives work has been carried out in 20xx, and the new year will push the quality and level of archives management in the jurisdiction to a new level, so that residents in the jurisdiction can enjoy more comprehensive, safer and more convenient services, improve the image of health service institutions in the jurisdiction and make residents more satisfied.