Health records are normative records in the process of medical and health institutions providing medical and health services to urban and rural residents. They are systematic document records that focus on residents' personal health, run through the whole life process and cover various health-related factors. Residents' health records are an important embodiment of the equalization of public health services for residents, an effective tool for medical and health institutions to provide high-quality medical and health services for residents, and a reference for governments at all levels and health administrative departments to formulate health policies. According to the Opinions of Central the State Council on Deepening the Reform of Medical and Health System (Zhong Fa [2009] No.6) and the Notice of the State Council on Printing and Distributing the Recent Key Implementation Plan of Medical and Health System Reform (2009-201year) (Guo Fa [2009] 12).
(1) guiding ideology. Under the guidance of Scientific Outlook on Development, according to the general requirements of deepening the reform of medical and health system, the establishment, use and management of residents' health records are regarded as an important measure to establish and improve the basic medical and health system, and the service mode of primary medical and health institutions is innovated, and the service function is improved, so as to gradually realize the goal of everyone enjoying basic medical and health services.
(2) Work objectives. By the end of 2009, according to the requirements of establishing residents' health records in a unified way throughout the country, the filing rate of rural residents' health records in pilot areas will reach 5%, and that of urban residents' health records will reach 30%; By 20 1 1, 30% in rural areas and 50% in cities. By 2020, a unified, scientific and standardized health record establishment, use and management system covering urban and rural residents will be initially established, which is in line with the reality at the grassroots level. Taking health records as the carrier, we will better provide sustained, comprehensive, appropriate and economical public health services and basic medical services for urban and rural residents.
(3) Basic principles.
-Policy guidance and voluntary participation of residents. Strengthen policy propaganda and actively guide urban and rural residents to voluntarily participate in the establishment of health records.
-Focus on key points and proceed step by step. Give priority to the establishment of health records for the elderly, patients with chronic diseases, pregnant women and children aged 0-3, and gradually expand them to the whole population.
-Standardize filing and effective utilization. Standardize the establishment, use and management of health records to ensure the continuity, integrity and effective utilization of information.
-Resource integration and information sharing. On the basis of primary medical and health institutions, make full use of relevant resources in the jurisdiction, * * * build * * to enjoy residents' health file information, and gradually realize electronic informatization.
(1) Establish health records step by step. The establishment of urban and rural residents' health records shall be under the unified leadership of the county (city, district) health administrative department, and shall be the responsibility of urban and rural grassroots medical and health institutions such as community health service centers, community health service stations, township hospitals and village clinics. Establish health records for residents by carrying out national basic public health services, daily outpatient service, physical examination, and on-site service of medical personnel, and make corresponding records according to the service provision. Health record information should be complete, true and accurate. Other medical and health institutions shall cooperate to supplement and improve health records. The contents of residents' health records are mainly composed of personal basic information, health examination records, health management of key populations and other health service records. The specific contents and methods should meet the relevant requirements of the National Basic Public Health Service Standard (2009 Edition).
(2) Effective use of health records. Health records should be uniformly stored in urban and rural primary medical and health institutions. According to the provisions of relevant laws and regulations, when providing medical and health services, urban and rural grassroots medical and health institutions should search and consult residents' health records, record, supplement and improve health records in a timely manner. It is necessary to do a good job in the collection, collation and analysis of health file data and related materials, understand and master the dynamic changes of residents' health in the area under their jurisdiction, and take appropriate technologies and measures to carry out health education, prevention, health care, medical care and rehabilitation services in view of the health problems found. Based on the residents' health records, we will promote grassroots medical and health institutions to change their service models and realize the health management of urban and rural residents.
(3) Standardize the management of health records. When establishing and using health records for residents, urban and rural grassroots medical and health personnel shall abide by the Law on Medical Practitioners, the Regulations on the Administration of Rural Doctors and other relevant laws and regulations. Grassroots medical and health institutions shall establish a system for obtaining, consulting, recording and keeping residents' health records, clarify the relevant responsible persons for the management of residents' health records, and ensure the convenient use and storage of residents' health records. The health administrative department at the county level shall implement the safeguard measures such as institutions, personnel, funds and facilities for establishing health records, and strengthen the supervision and management of establishing health records.
Once the residents' health records are established, they should be kept for life. It is necessary to abide by the file confidentiality system, not to damage or lose the health files, and not to disclose the personal information of residents and private information related to residents' health in the health files without authorization. Unless prescribed by law or for the purpose of protecting residents' health, residents' health records shall not be transferred or sold to other personnel or institutions, and shall not be used for commercial purposes.
When the primary medical and health institutions in urban and rural areas change for some reason, they shall transfer the established residents' health records to the county-level health administrative department or undertake the management of the institutions that continue their functions.
(four) gradually establish an electronic health record information system. All localities should actively create conditions to gradually promote the establishment of standardized electronic health records in accordance with the Basic Framework and Data Standard of Health Records (for Trial Implementation) (No.46 [2009] of Weifa), Guidelines for the Construction of Regional Health Information Platform Based on Health Records (for Trial Implementation) and related service specifications. Encourage provincial or prefecture-level cities to research and develop relevant information systems. The electronic health record information system should be gradually interconnected with the new rural cooperative medical system, the basic medical insurance information system for urban workers and residents, and the information systems for infectious disease reporting, immunization, maternal and child health care, and hospital electronic cases, so as to realize the sharing of information resources and establish a regional health information platform based on residents' health records.