Health records refer to the standardized and scientific records of residents' physical and mental health (normal health status, sub-health disease prevention, health protection and promotion, unhealthy disease treatment, etc.). It is an information resource that runs through the whole life process, covers all kinds of health-related factors, realizes multi-channel dynamic information collection, and meets residents' own needs and health management. Pomr (Problem-Oriented Medical Record) was first proposed by Weed et al. in 1968 in the United States, requiring doctors to adopt individual health problem-oriented records in medical services. The advantages are: individual health problems are concise, focused and clear, which is convenient for computer data processing and management. It has become the basic method to establish residents' health records in many countries and regions in the world.
Whether in China or developed countries, hospital informatization construction is a long exploration process. There are no and impossible finished products in HIS, CIS and GMIS systems, which must be constantly improved, updated and enriched in the application process. Compared with the informatization construction of other industries, the informatization of medical industry has its distinctive characteristics. Hospital information management must be patient-centered, patient information flow runs through the whole system, and all clinical business should be patient-centered; There are many kinds of hospital business, complicated management and frequent data exchange between business items; There is no general norm, standard and legal basis for hospital informatization, which makes it more difficult to exchange data with outside the hospital, and some application projects are difficult to carry out because of the lack of legal basis. I have been engaged in hospital information management for many years and summed up some experience in my work. Now I will discuss my personal views with all the friends present here.