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 takes residents' personal health as the core, runs through the whole life process, covers various 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. At present, it has become the basic method to establish residents' health records in many countries and regions in the world.
Residents refer to citizens who have lived in the administrative area of People's Republic of China (PRC) for a long time and hold certain legal identity certificates; Individuals who can obtain and accept their services through local medical and health service institutions.
Health records are normative records in the process of medical and health institutions providing medical and health services to urban and rural residents. They are systematic document records that focus on residents' personal health, run through the whole life process and cover various health-related factors.
The contents of residents' health records are mainly composed of personal basic information, health examination records, health management of key populations and other health service records. Contents of residents' health records:
1. General medical health records are divided into three parts in content, namely, personal health records, family health records and community health records. Personal health records are frequently used in general practice and have the highest use value.
2. Establish family health records and adopt different forms according to the actual situation.
3. Community health records have not been given more uniform requirements in general medical services, and are mainly used to evaluate doctors' understanding of the health status of residents in their communities and community resources, and to investigate the group views of general practitioners in patient care.