First, the concept of personal health records.
Personal health records can be simply defined as: systematic documents that record residents' personal health information, including medical records, health examination records, health care cards and personal and family records. Its complete personal health records play an extremely important role in community health services.
Second, the main contents of personal health records.
Personal health records include problem-centered personal health records and prevention-oriented regular health records. Personal health problems in community health services can be recorded through problem-oriented medical records (POMR). POMR consists of basic data, problem list, problem description, disease flow chart, etc.
3. What are the subjective data of personal health records?
Personal health monitoring files should include the following contents:-general information such as the name, gender, age, native place, marriage, education level and working years of the workers; -Workers' occupational history, past history of occupational hazards and exposure history; —Monitoring results of occupational hazard factors in corresponding workplaces; —Occupational health examination results and treatment;
-Workers' health information such as diagnosis and treatment of occupational diseases.
Extended data
Residents' health background information reflects residents' psychological and social problems, which is continuous and logical, and can be applied to medical education, which is conducive to cultivating medical students' clinical thinking ability and ability to treat patients. Use of residents' health records: (1) Residents must take the health record information card (or medical care card) to the township hospitals and village clinics for follow-up, and the attending doctor will update and supplement the corresponding records according to the follow-up situation. (2) Institutions that have established electronic health record information systems should update electronic health records synchronously. (3) Customers who need referral and consultation shall be filled in by the attending doctor. (4) All service records shall be collected by responsible medical personnel or file management personnel and filed in time.