Time flies, I believe everyone is full of expectations for the upcoming work and life! You might as well sit down and write a work plan. What problems should be paid attention to when writing a work plan? The following is my carefully prepared work plan for residents' health records in 2020. Welcome to reading. I hope you will like it.
Residents' Health Records 1 Work Plan According to the arrangement of the County Health Bureau, according to the contents of the National Basic Public Health Service Project 20xx Edition and the spirit of the county health work conference, combined with the actual situation of the town, the following work plan is formulated:
I. Work objectives
1. By the end of 20xx, the whole town will basically establish a unified, scientific and standardized residents' health records, and realize the informationization of residents' health records management. Taking health records as the carrier, we will provide urban and rural residents with basic medical and health services that are connected, comprehensive, appropriate and economical.
By the end of 2.20xx, the standardized filing rate of the whole town residents reached over 70%. The standardized filing rate of elderly people over 60 years old and people with chronic diseases such as hypertension and diabetes is over 90%. The standardized filing rate of pregnant women and children aged 0-6 is over 90%. The filing rate of electronic files reaches 90% of the total filing population; The qualified rate of health records is over 90%.
Second, the main task
(A) the establishment of health records for urban and rural residents
1, health file. Including personal basic information, health examination records, health management of key populations and other health service records.
2. Archiving mode. By providing basic public health services, daily outpatient service, health examination service, household survey of medical staff and other information collection methods, and following the principle of combining voluntariness with guidance, health records are established for the whole town residents.
3. Determine the filing object. Focus on pregnant women, children aged 0-6, the elderly, patients with chronic diseases such as hypertension, diabetes and severe mental illness, and gradually establish health records for all residents.
4. Fill in the file form and issue information cards. Fill in the basic information of residents, record the main health problems and service provision, and explain the requirements for use and storage in detail according to the requirements for filling health records in the Service Specification for Urban and Rural Residents' Health Records Management. File for the first time, fill in personal basic information and health check-up form. It is required that the contents of the records are complete, true and accurate, the writing is standardized, and the basic contents are not omitted. When visiting newborns, the medical staff of maternal and child health care department set up special files for health management and vaccination services for children aged 0-6; Establish a special file for maternal health care services after early pregnancy diagnosis; Medical technicians fill in the basic personal information of newly-built health records, conduct health examination and fill in the physical examination form.
5. Filing of form records. Relevant record forms of health records are put into residents' health file bags and stored in township hospitals. According to the implementation steps and requirements of residents' health records informatization, relevant information will be entered into electronic health records in time.
(2) Use and health management of residents' health records
1. Supplementary update of health records. Township health centers (village clinics) should retrieve and consult health files when residents pay a return visit and medical staff visit, and relevant personnel should update and supplement the corresponding contents of health files in time according to the health status of residents. All service records shall be uniformly summarized by the responsible medical personnel or file management personnel and filed in time.
2, formulate the work plan of health management of residents in the area. Township health centers shall formulate the health management work plan for residents in their respective jurisdictions, and define the main health management objects, main health problems and intervention methods.
(3) standardize the management of residents' health records.
1, equipped with health records management personnel. Health records management personnel in township hospitals shall abide by the Law on Medical Practitioners, Regulations on the Administration of Rural Doctors and other relevant laws and regulations, receive training in this project, and pass the examination.
2. Unified coding of residents' health records. Using 17-bit coding system, based on the unified national administrative division code, taking towns (streets) as the scope and village (neighborhood) committees as the unit, the unique coding of residents' health records is compiled. At the same time, the resident ID number is used as the identification code, which lays the foundation for realizing resource sharing under the information platform.
3. Strictly manage the use of health records. Residents' health records are public information resources, and health records managers and service personnel have the right to use health records in the use, management and evaluation, and the use of health records should protect the personal privacy of the clients.
4, strict health records preservation and custody. To preserve health records for residents for life, we must abide by the file confidentiality system, and shall not damage or lose health records, and shall not disclose personal information of residents and private information related to residents' health without authorization. Residents' health records shall not be transferred or sold to other personnel or institutions, and shall not be used for commercial purposes.
5. Strengthen the infrastructure construction of archives management. The central health center is responsible for providing necessary conditions for the management of health files, equipped with archives and basic equipment, and keeping health files properly according to the requirements of anti-theft, avoiding light, preventing high temperature, preventing fire, moisture, dust, rats and insects, so as to ensure the integrity and safety of health files.
Work plan of residents' health records II. Work objectives
According to the work plan of residents' health records of Tuzuoqi Health Bureau, a unified, scientific and standardized management system of residents' health records will be established, and the informationization of residents' health records management will be gradually realized, and health records will be used as a carrier to provide residents with sustained, comprehensive, appropriate and economical basic medical and health services. By the end of 20xx, the filing rate of residents' health records reached over 80%.
Second, the scope and content of the project
(a) to formulate the management norms of residents' health records. Strictly implement the management norms of residents' health records formulated by the Ministry of Health, and standardize the service objects, contents, filing methods, service processes, file storage and use of residents' health records.
(2) Appropriate technical training for health record management.
1. Training target: community basic public health service personnel.
2. Training content: norms, requirements and technologies for the management and use of residents' health records, and medical knowledge and skills necessary for the establishment of health records.
3. Training plan: through systematic training, gradually improve the professional skills and service level of service personnel, and ensure the standardization of health file management.
(C) the establishment of health records of residents
1. Contents of residents' health records: The contents of residents' health records include personal basic information, health examination, records of key population management and other medical and health service records.
(1) Personal basic information includes basic information such as name and gender, and basic health information such as family history and past history.
(2) Physical examination includes general health examination, lifestyle, health status, medication for diseases and health evaluation.
(3) The management records of key populations include the follow-up and management records of various key populations such as 0-3 years old children's health care, maternal health care, elderly health care, and chronic disease patient management required by the national basic public health service project.
(4) Other medical and health service records include other admission records, hospitalization records, referral records, meeting records, etc.
2, the establishment of residents' health records:
(1) For the first time, rural doctors mainly set up health records for residents at home by stages through on-site service (investigation), and fill in corresponding records according to their main health problems and health service needs; Establish a special file for health management and vaccination services for children aged 0-3 when visiting newborns; The special files of maternal health care services are established by women and children after the diagnosis and confirmation of early pregnancy.
(2) The relevant record forms of health records established in the process of providing medical and health services shall be put into the residents' health records for unified custody.
3. Use of residents' health records: Use residents' health records flexibly to improve the living file rate of residents' health records.
(1) When residents who file files go to primary medical and health institutions for follow-up, after obtaining their health files, the attending doctor will fill in, update and supplement the corresponding records in time according to the follow-up situation.
(2) When medical and health services enter the household, the health records of the clients should be consulted in advance and the corresponding forms should be carried, and the corresponding contents should be recorded and supplemented during the service.
(3) Customers who need referral and consultation shall be filled in by the attending doctor.
(4) All service records shall be collected by the responsible doctor and filed in time.
4, health records management
(1) Health records should be kept in the filing cabinet of the village clinic.
(2) Establish a management system for the collection, consultation, recording and preservation of rural residents' health files, define the person in charge of health file management, and ensure the convenient use, storage and preservation of farmers' health files.
(3) All medical and health institutions should establish residents' health records by collecting information through multiple channels. Health records should be updated in time to maintain the continuity of data.
(4) 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 parties during use.
(5) Record relevant contents according to the requirements of relevant national special technical specifications. The recorded contents are complete, true and accurate, with standardized writing and no omission of basic contents.
(6) Health records management and service personnel have the right to use, manage and assess health records at work. When other institutions or individuals need to use health records, they must submit a written application to the health records management institution, and they can only use them after being approved by the management institution and agreed by themselves or their guardians.
Three. Organization and management
Community public health service personnel are responsible for establishing residents' health records for the people directly serving within their respective jurisdictions, and the community public health service leading group is responsible for the guidance and management of filing work within their respective jurisdictions.
Fourth, the timetable.
By the end of 20xx, the filing rate of community residents will reach 80%.
Verb (abbreviation of verb) supervision of work implementation
(1) Supervision methods. Under the leadership of the Health Bureau, the community service center is responsible for the regular supervision and inspection and effect evaluation of health records within its jurisdiction, at least twice a year.
(2) The main contents of supervision. Work implementation, filing quantity and quality, file update and management, service effect, residents' satisfaction, etc.
(3) Main evaluation indicators.
1, health record filing rate = number of filing persons/resident population in the jurisdiction × 100%.
2. The qualified rate of health files = the number of qualified files filled in/the total number of random files × 100%.
3. The utilization rate of health records = the number of files with dynamic records in the spot check files × 100% of the total number of files. (Records with dynamic records refer to health records with relevant medical and health service records that meet the requirements of various service specifications within one year. )
4. The truthfulness rate of health records = the number of files with true contents in the random files/the total number of random files × 100%. (through telephone inquiry, logical judgment, etc. )
5. Management of health records.
Scheme 3 of Residents' Health Records In order to further improve the work of establishing residents' health records free of charge, according to the arrangement and deployment of basic public health services in jurong city and the requirements of the implementation scheme of Chishan Lake Management Committee's 20XX basic public health service project, the scheme of 20XX residents' health records is formulated as follows:
I. Annual Work Objectives
1. Establish a unified, scientific and standardized resident health record, and realize 100% information management of the resident health record. To provide continuous, comprehensive, appropriate and economical basic medical and health services for all residents with health records as the carrier.
2 villages give priority to the elderly, patients with chronic diseases, pregnant women and children aged 0-6. The establishment rate of health records of key population residents is more than 95%, and the establishment rate of health records of other general population residents is more than 90%.
3. During the year, the standardized filing rate of the elderly over 65 and people with chronic diseases such as hypertension and diabetes reached 100%. The electronic file entry rate of all filers100%; The authenticity rate of health records reached100%; The qualified rate of electronic health records is over 99%, and the utilization rate of health records is 50%; Health records are updated and maintained in a timely manner to reach more than 80%.
Second, the main work content
1. Improve the contents of paper and electronic health records: the basic contents of health records should mainly include personal basic information and major health service records. Including personal basic information, health examination records, health management of key groups and other health service records, this year will focus on personal telephone and medical history.
2. Improve the documentation of undocumented persons: collect the information of undocumented persons through daily outpatient service, disease screening, health check-up service and grid-based door-to-door service of medical personnel, follow the principle of combining voluntary and guidance, and the medical staff in the center or village clinic will establish health files for their residents, fill in corresponding records according to their main health problems and health service needs, and enter them into the electronic file system to improve the filing rate.
3. Improve the utilization of files: when residents make diagnosis and treatment and medical staff provide grid-based door-to-door service, the center or village clinic should retrieve and consult health files, and doctors or door-to-door service personnel will update and supplement the corresponding contents of health files in time according to the health status of residents. Other staff keep records of services such as visits, referrals and consultations. And timely input the data into the system through irregular information communication to maintain the continuity of the data. All service records shall be uniformly summarized by the responsible medical personnel or file management personnel and filed in time.
4. Improve the issuance of residents' health cards: according to the requirements of the provincial and municipal health authorities on the issuance of residents' health cards, actively do a good job in the preliminary work of issuance, and verify the authenticity and completeness of the basic information of residents, major health problems, service provision and other contents in the health files. Prepare for the issuance of resident health cards and issue them as soon as conditions are ripe.
5. Improve the filing of health records: paper health records are collected in a unified way by family and stored in village clinics in a unified way by natural villages. The health records of people who die or go out should be filed and processed in time and reported to the center every month.
6. Improve the intervention and effect evaluation of health problems: the center or village clinic should adopt appropriate technologies and measures in a planned and focused manner, organize and implement the intervention of health problems in the jurisdiction, carry out various forms of health management services such as health education and consultation, prevention, health care, medical treatment and rehabilitation, and timely implement the evaluation of intervention effect.
7. Combine the improvement of residents' health records with the new rural cooperative medical system: use the disease reimbursement information of new rural cooperative medical system residents to carry out health management such as analysis and intervention of residents' health problems; Based on the analysis of residents' major diseases by residents' health records management project, we will guide the formulation of reimbursement scope and reimbursement ratio of cooperative medical care, and gradually improve the ability of disease intervention and the level of medical security.
8, improve the health records, personnel should abide by relevant laws and regulations, accept the training of this project, and have a certain professional foundation and sense of responsibility. Managers shall keep health records for residents for life, abide by the file confidentiality system, and shall not damage or lose health records, and shall not disclose personal information of residents and private information related to residents' health 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 village clinic changes for some reason, it shall hand over the established residents' health records to the center or undertake the institutional management of the clinic and continue to perform its functions. Refuse to implement, resulting in the loss or damage of files, shall be investigated for responsibility according to law.
Work plan for residents' health records 4 I. Work objectives:
1. Complete the establishment of health records and computer information entry of permanent residents in the jurisdiction. Focus on women, children, the elderly over 60 years old, patients with chronic diseases, disabled people and mental patients, and gradually expand to the general population. Establish a unified, scientific and standardized health file and input it into a computer for computerized management.
2. Make the filing rate of health records and electronic health records reach over 70%, and the qualified rate of health records reach over 100%. The utilization rate of health records reached more than 60%.
Second, the specific measures:
1. organization and leadership: set up a leading group for health records, which will be fully responsible for the organization, implementation and coordination of the establishment of residents' health records. If the required quantity is not reached, the regular inspection of the leading group will be included in the year-end performance appraisal.
2. Training and publicity: The leading group of residents' health records regularly organizes relevant personnel of each station to carry out training, including the scientific establishment, effective use and standardized management of residents' health records, and at the same time carries out relevant publicity in various ways in various communities to obtain the support and cooperation of the broad masses.
3. Filing method:
(1) Outpatient consultation: Patients come to see a doctor and fill in health records. Physical examiners on page 1 1, page 2 and page 3 (except gynecology) of the health record must fill in, and those marked with * are optional (such as auxiliary examination, if the patient has test results, it must be filled in).
(2) Under the leadership of each village committee, cooperate with each village committee to collect the basic personal information of residents in the jurisdiction and obtain the first-hand information for establishing health records. Including the basic personal information of residents.
(3) Household survey: the method of collecting data from villagers' homes in the countryside was adopted. In order to get the cooperation of residents in this area, more publicity should be carried out to deepen communication and understanding among residents in this area. At the same time, with the cooperation of the village Committee, you can go home with village cadres and village doctors to collect information.
(4) Health check-up: residents are simply checked and registered through rural household surveys, and collected through annual women's health check-up, children's follow-up, chronic patients' follow-up, and health check-up of the elderly.
4. Filing requirements:
(1) Establish health files and health files for the elderly, patients with hypertension, patients with type 2 diabetes and patients with severe mental illness;
(2) Adhere to gradual progress, starting from key groups and gradually expanding to the general population;
(3) The contents of health records should be complete, objective, true and accurate, with standard writing and neat handwriting, and the basic contents should be complete.
5. Information input: Before information input, all relevant personnel should be trained uniformly to master the basic operation methods and precautions of information input; The entry of health records should be carried out by the doctors in each health station within their respective jurisdictions. And ensure that the qualified rate of input files reaches 100%.
The fifth work plan of residents' health records aims at everyone's access to basic medical and health services, focusing on human health, improving the accessibility of urban and rural residents to public health services, improving the health status of urban and rural residents, narrowing the gap between urban and rural areas and promoting social harmony. According to the national basic public health service projects and the actual situation of the center, the following work plan is formulated:
I. Work objectives
Through the implementation of the service project of urban and rural residents' health records management, we will gradually establish a unified and standardized health record for urban and rural residents, scientifically record the health status of urban and rural residents by using the health record specification, speed up the information construction, and implement dynamic management. By the end of 20xx, a health management system focusing on disease prevention, health protection and health promotion will be basically established among urban and rural residents.
(1) The filing rate of health records is ≥ 80%;
(2) The qualified rate of health records is ≥ 80%;
(3) The utilization rate of health records is ≥80%.
Second, the service object
Permanent residents within the jurisdiction, including registered and non-registered residents who have lived for more than half a year. Focus on children aged 0 ~ 3, pregnant women, the elderly, patients with chronic diseases and other people.
Third, the service content.
(a) the contents of the 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, and basic health information such as past medical history and family history.
2. Physical examination includes general health examination, lifestyle, drug use of health and its diseases, health evaluation, etc.
3. The health management files of key populations include the health management files of children, pregnant women, the elderly, patients with chronic diseases and severe mental illness within 0-3 years as required by the national basic public health service project.
4. Other medical and health service records include other medical records and consultation records except the above records.
(B) the establishment of residents' health records
1. When residents in the area receive services in community centers and community service stations, medical personnel are responsible for establishing residents' health records and filling in corresponding records according to their main health problems and service provision. At the same time, fill in and issue resident health record information cards for the clients.
2. Through on-site service (investigation), disease screening, health examination, etc., community centers and community service stations organize medical personnel to establish health records for residents, and fill in corresponding records according to their main health problems and health service needs.
3, will fill in the process of medical and health service health records related forms, into the residents' health records centralized and unified custody. In rural areas, centralized storage and custody are carried out on a family basis. And input it into the computer to create an electronic health record.
Fourth, strengthen leadership and implement responsibilities.
(a) to strengthen organizational leadership, clear responsibilities and tasks.
In order to ensure the smooth implementation of the project, the working group of urban and rural residents' health records management service project was established to be responsible for the leadership, organization, coordination and supervision of the project. Do a good job in project publicity, research, information collection, basic information entry, file management and update.
(2) Strictly standardize management.
In accordance with the "national basic public health service project", do the following work:
1, raise awareness. All community health service stations should put this work into the important agenda, strengthen leadership, implement responsibilities, define tasks and indicators, arrange the progress reasonably, and seriously organize the implementation.
2. Improve service capabilities. Combined with the actual situation of the jurisdiction, improve the management system and workflow, strictly operate and standardize services to ensure the authenticity and accuracy of information collection and ensure the quality of input.
3. Strengthen project publicity. Centers and community service stations should do a good job in publicity activities, publicize and mobilize at all levels, let residents know the contents and benefits of establishing health records, and mobilize the masses to actively participate.
4, establish and improve the performance appraisal system, improve the evaluation system and methods, to ensure the implementation of the task and benefit the masses. At the same time, strengthen the supervision and management of project implementation, severely investigate and deal with fraud, so that residents can get more benefits.
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