Health record

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 all kinds of health-related factors, and realizes multi-channel dynamic information collection to meet 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. Directory file establishment background resident health file-introduction of resident health file-establishment principle resident health file-basic content resident health file-features 1, and the content of health file is comprehensive and sufficient; 2. Residents' health records are more widely used; 3. It is more convenient to find and use; 4. File storage is simpler; 5. It is sudden and contagious. Multi-disease provides residents' health file information-files to be solved, background to be established, introduction to residents' health file, principles to be established, basic contents of residents' health file, features 1, comprehensive and sufficient contents of health file, 2, wider application scope of residents' health file, 3, more convenient retrieval and use, 4, simpler file storage, 5, sudden, infectious and residents' health file provides multi-disease information-editing of problems to be solved. Background of the establishment of this paragraph The recent key implementation plan of medical and health system reform (2009-20 1 1 year) published on April 7, 2009 proposes that the services of the recent key implementation plan of basic public health medical and health system reform will be gradually equalized, and residents' health records will be gradually established nationwide from 2009. By the end of 2009, according to the requirements of establishing residents' health records in a unified way throughout the country, the filing rate of rural residents' health records in pilot areas will reach 5%, and that of urban residents' health records will reach 30%; By 20 1 1, 30% in rural areas and 50% in cities. By 2020, a unified, scientific and standardized health record establishment, use and management system covering urban and rural residents will be initially established, which is in line with the reality at the grassroots level. Taking health records as the carrier, we will better provide sustained, comprehensive, appropriate and economical public health services and basic medical services for urban and rural residents. Residents' health record is a systematic file record consisting of personal basic information form, health physical examination form, admission record form, medical record form, two-way referral form and residents' health record information card. It is a systematic document for recording residents' health information and an important tool for collecting and recording community residents' health information in community health services. It is an important guarantee for the community to successfully carry out various health care work, meet the "six-in-one" health service needs of community residents such as prevention, medical treatment, health care, rehabilitation, health education and birth guidance, and provide economic, effective, comprehensive and sustainable primary health services. Through the establishment of personal, family and community health records, we can understand and master the health status and disease composition of community residents, understand the main health problems and epidemiological characteristics of community residents, and lay the foundation for screening high-risk groups, carrying out disease management and taking targeted preventive measures. Community health service centers need to establish perfect health records of community residents, manage them strictly and use them effectively, and carry out systematic community health services in a targeted manner. The residents' health records edited in this paragraph-brief introduction of residents refers to citizens who have lived in People's Republic of China (PRC) and an administrative region of China for a long time and have certain legal identity certificates; Individuals who can obtain and accept their services through local medical and health service institutions. The advantages of health records are: personal health problems are concise, focused and clear, which is convenient for computer data processing and management. Diagram of hospital informatization construction 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 increases the difficulty of data exchange with the outside of 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. So how to make the patient as the core, and the patient's information runs through the whole system business process or in what way? There is no doubt that the patient's electronic medical record must be established and run through the whole system. Medical record is a comprehensive record of medical work, which objectively reflects the whole process of disease condition, examination, diagnosis, treatment and its results, and is an organic combination of all words, data, charts, images and other materials formed by medical personnel in the process of medical activities. Electronic medical record is to collect the patient's medical records into the computer through computer technology, and collect, analyze and sort out the relevant information of the medical records through the computer to form standardized information, thus improving the medical quality and professional level and providing help for clinical teaching, scientific research and information management. Electronic medical records can generally be interpreted as computerized medical record systems or computer-based medical records. In 199 1, the American medical computerization Committee pointed out that computerized medical records refer to electronic medical records stored in a system, which can support users to obtain complete and accurate information; Prompt and warn medical staff; Give clinical decision-making services; Connection management, books and periodicals catalogue, basic clinical knowledge and other equipment. Because the electronic medical record involves all aspects of the hospital and is highly complex, it not only refers to the static medical record information, but also includes the related services provided. It is not simply to computerize paper medical records, and it has more advantages than paper medical records. However, electronic medical records have not found effective technical means in the description, integration, transmission and exchange of medical records information, which makes the development process of electronic medical records very complicated and technically difficult. However, the developed system has single function and poor universality, which makes the overall cost of electronic medical records high and difficult to be applied to medical systems on a large scale in a short time. From the legal point of view, the electronic medical record is only a copy of the patient's medical information, not a legal material, and it is difficult to become a legal basis when a medical dispute occurs. From the perspective of identity recognition, the promotion of electronic signature has little effect at present, and it is difficult to protect patients' data from being leaked. These unfavorable factors restrict the development of electronic medical records. Edit the residents' health records in this section-establishment principle ① step by step principle; ② Forward-looking principle of data collection; ③ Basic project dynamics principle; ④ Principle of objectivity and accuracy; ⑤ Principle of confidentiality. Edit this paragraph of residents' health records-basic contents General medical health records are divided into three parts, 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. The establishment of family health records, according to the actual situation in different forms. Community health records have not been given more uniform requirements in general medical service, and are mainly used to evaluate doctors' understanding of the health status and community resources of residents in their communities, and to investigate the group views of general practitioners in patient care. Edit this section of residents' health records-features 1, and the health records are comprehensive and sufficient. Health records not only simply input the contents recorded in paper medical records into computers, but also record the bits and pieces of health-related information in residents' daily lives. Collecting residents' health information anytime and anywhere can not only record the medical history, course of disease and diagnosis and treatment, but also complete the information integration centered on residents' health. Doctors can extract relevant information anytime and anywhere, and get a quick and comprehensive understanding of the situation. 2. The application of residents' health records is more extensive. With the rapid development of network technology, electronic commerce and electronic services have appeared in the health field. Residents' health records can realize information transmission and resource sharing in the WAN environment, and can provide basic information for any authorized person anytime and anywhere. No matter which hospital you go to for medical treatment or physical examination, you can extract past health records. The application of electronic health records and computer information system will greatly shorten the consultation time and improve the quality of doctors. Information exchange between higher and lower hospitals can improve the medical level of primary hospitals. 3. It is more convenient to find and use. Anyone who has been to the archives to inquire about materials knows that if you want to use paper materials, you must first find the relevant index and input it layer by layer before you can browse. When inquiring about health records in different regions, it is not only slow and labor-consuming, but also the information is not completely concentrated. The unique data format and centralized storage of health records in Ju Mang are conducive to the rapid input, quick retrieval, inquiry and processing of all kinds of medical information, providing a large number of integrated materials for clinical, teaching and scientific research, facilitating the sharing and exchange of information resources, and also being comprehensive and reliable data for statistical analysis and health management, which greatly improves the utilization efficiency of files. 4, file storage is easier to save paper medical records, there should be enough space, storage period, but also to solve the paper wear, aging, moisture-proof, fire, moth and other issues. It takes a lot of manpower and material resources. Effective storage system and backup scheme of health records can realize the unification of mass storage and real-time access, with small occupation space, large storage capacity and permanent preservation. 5. Provide information on sudden, infectious and multiple diseases. Residents' health records can directly, quickly and accurately provide information for sudden, infectious and multiple sexually transmitted diseases. For example, during the period of SARS, if the characteristics of atypical pneumonia can be extracted from health records, we can get hints from these symptoms and find a treatment plan to save patients' lives and an effective method to prevent the spread of the disease. Edit this section of residents' health records-problems to be solved 1. The storage system and backup scheme of health records should be improved. There is no doubt that health information needs long-term storage and accumulation, but the amount of data is so large that it is impossible to store all the information online for a long time. As a resident health record system, it should not only realize the long-term preservation of resident information. Moreover, when a fault occurs, the required information will not be lost and can be extracted if necessary. The data archiving method is very different from the traditional data backup method centered on various businesses. Therefore, it is necessary to establish a hierarchical storage structure, realize the unification of mass storage and real-time access, realize automatic archiving, and provide tools to restore online status; After the fault occurs, the data can be restored to the breakpoint state. Second, data exchange standards and methods, one of the advantages of health records is to facilitate the exchange of information between medical institutions. In order to achieve this goal, it is necessary to formulate a standard information exchange format; Provide conversion means to convert information into standard exchange format for transmission on the network or storage in removable media, and vice versa. Related to the above work is the need to formulate a series of standards and specifications, introduce HL7 standard, and conduct localization research. This work needs the active organization of the relevant state departments and the cooperation of information technology personnel, clinical workers and hospital managers. Thirdly, the security mechanism of health records, because it records a large number of basic and private information of residents, its security control is particularly important. Ju Mang Science and Technology adopts B/S architecture, including Cookie encryption, URL random code, preventing SQL code injection and other technologies to prevent information leakage. At present, the software and hardware technologies to realize the large-scale promotion of residents' health records have been basically available. In developed countries, such as the United States and Japan, many universities, research institutions and manufacturers are committed to research in this field. Although it may take a long time to complete. But now we should seize the opportunity to establish the framework of residents' health records in China, and lay the foundation for the further development of hospital information system to clinical application and three-level prevention and treatment measures.