Whatever you are doing, you should do it in a planned way. The following is the work plan about health file management that I collected for you. Welcome to read!
Work Plan for Health Records Management 1 I. Work Objectives
1. Establish a unified, scientific and standardized residents' health records, and realize the informationization of residents' health records management.
2. Take health records as the carrier to provide basic medical and health services for urban and rural areas that are connected, comprehensive, appropriate and economical.
Second, the main task
(A) the establishment of health records for urban and rural residents
1. Contents of health records. Including personal basic information, health examination records,
Health service records such as health management of key populations.
2. Filing methods. By providing basic public health services, daily outpatient services, health examination services, household surveys of medical personnel and other information collection methods, and following the principle of combining voluntariness with guidance, health records are established for residents in the area.
3. Determine the filing object. Have a pregnant woman, 0? Focus on patients with chronic diseases such as 6-year-old children, the elderly, hypertension, diabetes and severe mental illness, and gradually establish health records for all urban and rural 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, fill out and issue the information card of residents' health records, and explain the purpose and preservation requirements in detail according to the requirements of the National Basic Public Health Service Specification (20xx Edition). File for the first time, fill in personal basic information, health check-up form and information card. 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. Children's health care department medical staff set 0? Special files on health management and vaccination services for 6-year-old children; Medical staff in obstetrics and gynecology or women's health care department set up special files for maternal health care services after the diagnosis of early pregnancy; Medical technicians fill in the basic personal information of newly-built health records, conduct health examination and fill in the physical examination form.
5. Form record filing. Relevant record forms of health records are put into residents' health file bags, which can be stored in community health service centers and township hospitals in rural areas. Village clinics and community health service stations responsible for establishing health files regularly submit the established health files to township hospitals and community health service centers for archiving. According to the implementation steps and requirements of informatization of residents' health records in the autonomous region, 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. Community health service centers (stations) and township health centers (village clinics) shall retrieve and consult health files when residents pay a return visit and medical personnel provide on-site services, and doctors or on-site service personnel shall update and supplement the corresponding contents of health files in a timely manner according to the health status of residents. Other medical institutions are responsible for filling in service records such as consultation, referral and consultation when residents see a doctor, and communicate information regularly through regular meetings and other forms to maintain the continuity of information. For residents who need referral and consultation, the attending physician should fill in the records of referral and consultation, and be responsible for two-way feedback to the community referral medical and health institutions. All service records shall be uniformly summarized by the responsible medical personnel or file management personnel and filed in time. Residents who have filed a file must hold a health file information card when they go to a community health service center (station) or a township health center (village clinic) for treatment.
2. Timely analysis of residents' health problems. Community health service centers and township health centers shall sort out and analyze the information related to the health records of urban and rural residents within their jurisdiction at least once every six months, and list the health status, main health problems and lifestyle of all kinds of people as key management objects. At the beginning of the project, the main health problems of residents in the area were sorted out and analyzed, and a written report was made to the Banner Health Bureau and the Center for Disease Control and Prevention. Banner Center for Disease Control and Prevention collates and summarizes the main health problems of residents at least once every six months, puts forward pre-baking suggestions and reports them to the Health Bureau. Banner Health Bureau and Banner Disease Prevention and Control Center report to the higher authorities step by step every six months.
3. Formulate the health management work plan for residents in the jurisdiction. Community health service centers and township hospitals should promptly formulate health management work plans for residents in their respective jurisdictions, and clarify the main health management objects, major health problems and intervention measures.
4. Implement the intervention and effect evaluation of residents' health problems in the jurisdiction. Health bureaus, professional public health institutions, community health service centers and township health centers should adopt corresponding technologies and measures in a planned and focused manner, organize and implement interventions on health problems in their jurisdictions, carry out various forms of health education, consultation, prevention, health care, medical treatment and rehabilitation, and timely implement intervention measures and effect evaluation.
5. The establishment of rural residents' health records can be combined with the new rural cooperative medical system. Using the incidence information of new rural cooperative medical system residents to carry out the analysis of residents' health problems and health management of intervention; Using the residents' health records management project, the occurrence of major diseases among residents was sorted out and analyzed, and the ability of disease intervention and the level of medical security were gradually improved.
(3) standardize the management of residents' health records.
1. Equipped with health records management personnel. Health records management personnel in community health service centers and 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 take up their posts only after passing the examination.
2. Unified coding of residents' health records. Using 16 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. Health records managers, service personnel and inspectors have the right to use health records in their use, management and evaluation. 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 with the approval of the management institution and the consent of the residents themselves or their guardians. The use of health records should strictly protect the personal privacy of the parties.
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. Unless required by law or for the purpose of protecting residents' health, residents' health records shall not be transferred, sold to other personnel or institutions or used for commercial purposes. When the primary medical and health institutions in urban and rural areas change for some reason, they shall hand over the established residents' health records to the Banner Health Bureau or undertake the management of the institutions that continue their functions. If the files are lost or damaged due to refusal to implement, the responsibilities shall be investigated according to law.
The second work plan of health records management 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
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Through the implementation of the urban and rural residents' health records management service project, we will gradually establish a unified and standardized health record for urban and rural residents, standardize and scientifically record the health status of urban and rural residents, speed up the information construction, and implement dynamic management. By the end of 2xxx, 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? 80%;
(2) The qualified rate of health records? 80%;
(3) Utilization rate of health records? 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, as well as 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 aged 0-3, pregnant women, the elderly, patients with chronic diseases and severe mental illness 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. Community centers and community service stations organize medical staff to establish health records for residents through on-site service (investigation), disease screening and health examination, and fill in corresponding records according to their main health problems and health service needs.
3. Fill in the relevant record forms of health files in the process of medical and health services, and put them into the residents' health portfolio for 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.
Health records management work plan 3 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 the health file. The physical examination personnel on the first, second and third pages of the health file (except gynecology) must fill in it, and those marked with * are optional (such as auxiliary examination, which must be filled in if the patient has test results). (2) Under the leadership of each village committee, cooperate with each village committee.
The jurisdiction collects basic personal information of residents and obtains 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%.
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