Permanent residents within the jurisdiction.
Second, the service content
1. Contents of residents' health records
The contents of residents' health records include personal basic information, physical examination, records of key population management and other medical and health service records.
(1) Personal basic information includes basic information such as name and gender, and basic health information such as family history and past history.
(2) Physical examination includes general health examination, lifestyle, health status, medication for diseases and health evaluation.
(3) The management records of key populations include the follow-up and management records of various key populations such as 0-3 years old children's health care, maternal health care, elderly health care, and chronic disease patient management required by the national basic public health service project.
(4) Other medical and health service records include other admission records, hospitalization records, referral records, consultation records, etc.
2. Establish residents' health records
(1) When residents in the jurisdiction receive services in primary medical and health institutions, the first-time doctors are responsible for establishing residents' health records and filling in corresponding records according to their main health problems and health service needs. At the same time, fill in and issue resident health record information cards for the clients.
(2) Grassroots medical and health institutions are responsible for medical staff to establish residents' health records for key groups in their homes or workplaces by stages through on-site service (investigation), disease screening and physical examination, and fill in corresponding records according to their main health problems and health service needs; The special archives of health management and vaccination services for children aged 0-3 years old shall be established immediately by the medical staff of the Children's Health Department during the neonatal visit; The special file of maternal health care service is established by medical staff in obstetrics and gynecology or women's health care department immediately after the diagnosis of early pregnancy.
(3) The relevant record forms of health records established in the process of providing medical and health services shall be put into the residents' health records for unified custody. Conditional area input computer, the establishment of electronic health records.
3. The use of residents' health records
(1) Residents who have filed files should hold the residents' health record information card when they go to the primary medical and health institutions for follow-up. After obtaining their health records, the attending doctor will fill in and update/supplement the corresponding records in time according to the follow-up situation.
(2) When medical and health services enter the household, the health records of the clients should be consulted in advance and the corresponding forms should be carried, and the corresponding contents should be recorded and supplemented during the service.
(3) Customers who need referral and consultation shall be filled in by the attending doctor.
(4) All service records shall be collected by the responsible doctor and filed in time.
Third, the service process
National Basic Public Health Service Standard (Draft for Comment)
Fourth, the service requirements
1. Health file management should have necessary file warehouses and file fittings, properly keep health files according to the requirements of theft prevention, light protection, high temperature prevention, fire prevention, moisture prevention, dust prevention, rat prevention and insect prevention, and designate full-time (part-time) personnel to be responsible for health file management to ensure the integrity and safety of health files.
2 grassroots medical and health institutions should use multi-channel information collection to establish residents' health records. Health records should be updated in time to maintain the continuity of data.
3. The establishment of health records should follow the principle of combining voluntariness with guidance, and pay attention to protecting the personal privacy of the clients during the use.
4. Unified coding of residents' health records, using the 16-bit coding system, based on the national unified administrative division coding, taking towns and streets as the scope and village (neighborhood) committees as the unit, and compiling the unique coding of residents' health records. At the same time, the resident's ID number will be used as a unified identity code.
5. Record relevant contents according to the requirements of relevant national special technical specifications. The contents of the record shall be complete, true and accurate, with standard writing and no omission of basic contents.
6 health records management and service personnel have the right to use health records in the use, management, evaluation and other work. 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 after being approved by the management institution and agreed by themselves or their guardians.
Verb (abbreviation of verb) evaluation index
1. Health record filing rate = number of filing persons/resident population in the jurisdiction × 100%.
2. The qualified rate of health files = the number of qualified files filled in/the total number of random files × 100%.
3. Utilization rate of health records = number of files with dynamic records in random files/total number of random files × 100%.
Records with dynamic records refer to health records with relevant medical and health service records that meet the requirements of various service specifications within one year.