The reasons for the termination of residents' health records include death, migration, lost visit, etc. , and the date must be recorded. For those who move out of the jurisdiction, it is also necessary to record the basic situation of the place of immigration and the record of file handover.
Paper health records should be gradually transferred to electronic health records. Paper and electronic health records should be kept by the health record management unit (that is, the unit that managed their health records before residents died or lost their visits) with reference to the existing medical record retention period and methods.
The use of residents' health records
1. When filing residents to follow up in township hospitals, village clinics and community health service centers (stations), after obtaining their health files, the attending doctor will update and supplement the corresponding records in time according to the follow-up situation.
2. When carrying out home medical and health services, you should consult the health records of the clients in advance and carry the corresponding forms, and record and supplement the corresponding contents in the service process. The institution that has established the electronic health record information system shall update the electronic health record at the same time.
3. For clients who need referral and consultation, the attending doctor should fill in the referral and consultation records.
4. All service records should be collected and filed in time by the responsible medical personnel or file management personnel.