Work plan for residents' health records management

Time flies, and people are caught off guard. Our work will be enriched in busyness and harvested in joy. It's time to start writing a plan. What is a good plan? The following is my work plan for the management of residents' health records, for reference only. Let's have a look.

Work plan for residents' 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 management of key populations and other health service records.

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. 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 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. When visiting newborns, medical staff in the Child Health Department set up special files for health management and vaccination services for children aged 0-6; 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 regularly communicate information 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 code of residents' health records was 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.

Work plan for the management of residents' health records II. Annual work target 1. Establish a unified, scientific and standardized resident health record, and realize the 100% information management of resident health record. To provide continuous, comprehensive, appropriate and economical basic medical and health services for all residents with health records as the carrier.

Second, villages give priority to the elderly, patients with chronic diseases, pregnant women and children aged 0-6. The filing rate of health records of key population residents is more than 95%, and that of other general population residents is more than 90%.

Third, the standardized filing rate of elderly people over 65 years old and people with chronic diseases such as hypertension and diabetes reached 100% during the year. 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

First, 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.

Second, improve the documentation of undocumented persons: collect the information of undocumented persons through daily outpatient service, disease screening, health check-up service, grid-based door-to-door service of medical personnel, follow the principle of combining voluntariness with 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.

Third, improve the utilization of files: when residents seek medical treatment and medical staff provide grid home service, the center or village clinic should search and consult health files, and doctors or home service staff 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.

Fourth, improve the distribution of residents' health cards: in accordance with the requirements of the provincial and municipal health authorities on the distribution of residents' health cards, actively do a good job in the preliminary work of distribution, and verify the authenticity and integrity 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 put together in a unified way in the family unit and stored in the village clinic in the natural village unit. 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 health intervention and effect evaluation: The center or village clinic should adopt appropriate technologies and measures in a planned and focused manner, organize and implement health intervention within its jurisdiction, carry out various forms of health education, consultation, prevention, health care, medical rehabilitation and other health management services, and timely implement intervention effect evaluation.

Seven, improve the residents' health records and the work of the new rural cooperative medical system: use the disease reimbursement information of the 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.

Eight, improve the management of 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 the management of residents' health records 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 65 years old, patients with chronic diseases, the disabled and the mentally ill, 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 XX0%. The utilization rate of health records reached more than 60%.

Second, the specific measures:

1. Organization and leadership:

Establish a leading group for health records, and 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 training for relevant personnel of each station, including the scientific establishment, effective use and standardized management of residents' health records. At the same time, various ways are adopted to carry out relevant publicity in various communities and 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 and the first page of the health file.

(2) With the cooperation of the village clinic staff, collect the basic personal information of residents in the jurisdiction and obtain the first-hand information for establishing health files. 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 clinic staff, we can collect information at home with the village clinic staff.

(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 XX0%.

Qindu District Ma Quan Community Health Service Center

20XX 65438+ 10 XX day

Work plan of residents' health records management 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. 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.

Longhua town hospitals

20xx65438+February 15

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