Implementation plan of community residents' health records 1
I. Project objectives
(A) the overall goal
According to the requirements of the county, the center has basically established a unified, scientific and standardized management system for residents' health records, and gradually realized the informationization of residents' health records management. Take health records as the carrier, provide residents with sustained, comprehensive, appropriate and economical basic medical and health services, and establish residents' electronic health records.
(2) Annual target
In 20 13 years, paper files and electronic files reached 100% respectively.
Second, the scope and content of the project
(1) Scope: communities and administrative villages under its jurisdiction.
(2) Contents:
1, formulate the management standard of residents' health records.
Strictly implement the management norms of residents' health records formulated by the Ministry of Health, combined with relevant documents of our county. Standardize the service objects, contents of residents' health records, filing methods, service processes, file storage and utilization, etc. The newly established residents' health records must conform to the Regulations on the Management of Residents' Health Records formulated by the Ministry of Health and the regulations promulgated by the provincial health department. It should be updated gradually within 1 year to meet the new requirements and regulations.
2, health records management appropriate technical training
(1) Training objects: health technicians in community health service centers, doctors in community service stations and rural doctors. In order to improve the technical level and provide quality services for the establishment of health records for urban and rural residents.
(2) Training content: norms, requirements and technologies for the management and use of residents' health records, necessary medical knowledge and skills for establishing health records, information technology for file management, etc. The main teaching materials are: Archives Law of People's Republic of China (PRC), Regulations of the Ministry of Health on the Management of Residents' Health Records and Regulations on the Management of Medical Records, various regulations issued by national and provincial, municipal and county health administrative departments, and basic computer knowledge.
3. Establish residents' health records.
(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) Key population management records include 0? Follow-up and management records of key groups such as 3-year-old children's health care, maternal health care, elderly health care, and chronic disease patient management.
④ Other medical and health service records include other admission records, hospitalization records, referral records and consultation records.
(2) How to establish residents' health records: Community health service centers (stations), village clinics and other primary medical institutions are responsible for providing residents in their jurisdiction with services to establish health records.
① When residents in the jurisdiction receive services in primary medical and health institutions, the first-time doctor is responsible for establishing residents' health records for them, and filling in corresponding records according to their main health problems and health service needs.
(2) through on-site service (investigation), disease screening, health examination, etc., primary medical and health institutions are responsible for medical personnel to establish residents' health records for key groups in their homes or workplaces in stages, and according to their main
Fill in the corresponding health problems and health service records; 0? A special file on health management and vaccination services for 3-year-old children was established by child health care medical staff during newborn visits; After the diagnosis of early pregnancy is confirmed, the obstetrics and gynecology department or women's health care workers will establish a special file for maternal health care services.
(3) The related 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.
(3) Utilization of residents' health records
(1) When residents who have filed files go to primary health care institutions for follow-up, after obtaining their health files, the attending physician will fill in, update and supplement the corresponding records in time according to the follow-up situation.
② When carrying out medical and health services at home, you should consult the health records of the clients in advance and bring the corresponding forms, and record and supplement the corresponding contents in the service process.
(3) The clients who need referral and consultation shall be filled in by the attending physician.
(4) All service records shall be collected by the responsible doctor and filed in time.
(4) Health records management
Residents' health records are managed according to the Measures for the Administration of Medical Records, and the key requirements are as follows:
① The center has set up full-time (part-time) management personnel for residents' health record service, who have passed the training organized by this project and passed the examination. The management system of residents' health records in this unit should be formulated and strictly implemented.
(2) Health archives management should have necessary archives warehouse, equipped with archives fittings, which meet the requirements of theft prevention, light prevention, high temperature prevention, fire prevention, moisture prevention, dust prevention, rat prevention and insect prevention. , and appoint full-time (part-time) staff to be responsible for the management of health records to ensure the integrity and safety of health records.
③ Collect information through multiple channels and establish residents' health records. Health records should be updated in time to maintain the continuity of data.
④ The establishment of health records should follow the principle of combining voluntary and guidance, and attention should be paid to protecting the personal privacy of the parties during the use.
⑤ Unified coding of residents' health records, adopting l6-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.
⑥ Record relevant contents according to the requirements of relevant national special technical specifications. The recorded contents should be complete, true and accurate, with standardized writing and no omission of basic contents.
All landowners health records management and service personnel have the right to use health records in the use, management and evaluation. When other institutions or individuals need to use health records, they must submit a written application to the center, and they can only use them after being examined and approved by themselves or their guardians.
Residents' health records are public information resources, which should be preserved for a long time and must not be lost or damaged. Offenders shall be investigated for responsibility according to law.
4, gradually realize the information management of residents' health records management.
(1) main task: to implement the network management of health file information and improve the level and quality of residents' health file information management.
(2) Basic planning: use existing resources to input the newly established paper residents' health records into the computer network platform in time, and update the files in time.
Third, the project organization and management
1, the center is responsible for the leadership and management of the project implementation, and is responsible for formulating the implementation plan.
2. The person in charge is responsible for the project implementation, including the formulation of implementation plan, personnel training, technical guidance, performance appraisal, information management, etc.
3. Centers, service stations and village clinics are responsible for establishing residents' health records for the people they directly serve, and the centers are responsible for the guidance and management of filing work of community health service stations and village clinics within their respective jurisdictions.
Four. Supervision and evaluation of project implementation
(a) the center is responsible for the health education of community health service stations and village clinics under its jurisdiction for regular supervision and inspection and effect evaluation. The supervision, inspection and effect evaluation of county-level maternal and child health centers are not less than 2 times a year. The evaluation results are linked to evaluation and funding arrangements.
(2) The main contents of supervision and evaluation: project implementation plan formulation, organization and management, personnel training, availability and use of funds, quantity and quality of filing, file updating and management, service effect, residents' satisfaction, etc.
(III) Main evaluation indicators
1, health record filing rate = number of filing persons/resident population in the jurisdiction? 1O0%
2. The qualified rate of health files = the number of qualified files filled in/the total number of random files? 1O0%
3. Utilization rate of health records = number of files with dynamic records in spot check/total number of files in spot check? 100% (dynamically recorded files refer to health files of relevant medical and health service records that meet the requirements of various service specifications within one year)
4. The truthfulness rate of health records = the number of files with real contents in the random check files/the total number of random check files x 100% (truth can be found by telephone inquiry or logical judgment, etc. ).
Implementation plan of community residents' health records II
Residents' health records are standardized records in the process of medical and health institutions providing services to residents. It is a systematic record document that centers on residents' health and runs through the whole life process, covering all kinds of health-related factors and residents' enjoyment of basic medical and health services. In order to do a good job in the establishment of residents' health records, this implementation plan is formulated.
I. Objectives
(A) the overall goal
Gradually establish a unified, scientific health file management information network and standardized file management system to provide residents with continuous, comprehensive, appropriate and economical basic medical and health services.
(2) Annual target
The filing rate of residents' health records has reached more than 85%, and electronic file management has been gradually implemented; The qualified rate of health records is over 90%; The utilization rate of health records is over 95%; The truth rate of health records is over 98%.
Two. Scope and content
Implemented in the whole jurisdiction, the main contents are as follows:
(a) according to the 20 1 1 version of the residents' health records management service standards.
In strict accordance with the requirements of the Guiding Opinions of the Ministry of Health on Standardizing the Management of Urban and Rural Residents' Health Records, the National Standard for Basic Health Services, and the Implementation Plan for Establishing Urban and Rural Residents' Health Records at the Provincial, City and County Levels, the service objects, contents, filing methods, service processes, file storage and use of urban and rural residents' health records are unified and standardized.
(2) Appropriate technical training of archives management.
1. Training objective: The training rates of village clinic staff and public health professionals reach 70% and 90% respectively, so as to improve the technical level.
2. Training content: norms, requirements and technologies for the management and use of residents' health records, necessary medical knowledge and skills for the establishment of records, information technology for file management, basic computer knowledge, etc.
3. Contents of residents' health records
The contents include personal basic information, health examination, key population management records 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 children's health care for 0-3 years old, maternal health care, elderly health care, and management of patients with chronic diseases.
(4) Other medical and health service records include other admission records, hospitalization records, referral records, consultation records, etc.
4. File creation method
(1) When residents in the jurisdiction receive services, 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.
(2) By means of on-site service (investigation), disease screening, health examination, etc., the responsible medical staff will establish residents' health records for key people in their homes or workplaces in stages, and fill in corresponding records according to their main health problems and health service needs; The special file of health management and vaccination service for children aged 0-3 years old was established by the medical staff of the Children's Health Department during the neonatal visit; The special files of maternal health care services are established by medical staff in obstetrics and gynecology or women's health care department after the diagnosis of early pregnancy.
5. Utilization of residents' health records
(1) Residents who file in our hospital will fill in, update and supplement the corresponding records in time according to the follow-up situation after obtaining their files.
(2) When entering the family medical and health service, you should consult the health files of the clients in advance and bring the corresponding forms, record and supplement the corresponding contents in the service process, and enter the files in the rural hospitals in time.
(3) Customers who need referral and consultation shall be filled in by the attending doctor.
(4) All service records are collected by the responsible doctor.
6, residents' health records filing requirements
(1) Authenticity: Health records are composed of all kinds of original data, which should truly reflect residents' health status and truthfully record detailed information such as residents' illness changes, treatment process and rehabilitation status.
(2) Scientificality: As medical information, residents' health records should be recorded in accordance with general medical norms, and the production of various charts, text descriptions and the use of measurement units should comply with relevant regulations and be accurate.
(3) Integrity: The contents of residents' health records must be complete, including individuals, families and communities.
(4) Continuity: The complete and scientific health records of residents reflect the health services and health status of hospitals, families and individuals, and it is necessary to constantly update and enrich the information on health and diseases in order to maintain the continuity of health records.
(5) Accessibility: Basic public health services are medical and health services based on outpatient service, and health records are frequently used. Health records should be used and referenced in public health services, follow-up, referral and other medical and health services.
7, health records management
(1) Formulate the management system of residents' health records and strictly implement it.
(2) Ensure the integrity and safety of health records.
(3) Health records should be updated in time to maintain the continuity of data.
(4) The establishment of archives should follow the principle of combining voluntariness with guidance, and attention should be paid to protecting the personal privacy of clients in the process of utilization.
(5) Record relevant contents according to the requirements of relevant national special technical specifications. The recorded contents should be complete, true and accurate, with standardized writing and no omission of basic contents.
(6) Residents' health records are public information resources and should be preserved for a long time. Those who refuse to implement it, resulting in the loss or damage of files, shall be investigated for responsibility according to law.
Three, formulate the annual assessment content and plan.
1. The main contents of supervision and evaluation: quantity and quality of filing, updating and management of files, service effect, residents' satisfaction, etc.
2. Main evaluation indicators
1) filing rate = number of filing cases/number of permanent residents in the jurisdiction? 100%
2) File qualification rate = number of qualified files/total number of random files? 100%
3) File utilization ratio = number of files with dynamic records in spot check/total number of files in spot check? 100% (dynamically recorded files refer to health files of relevant medical and health service records that meet the requirements of various service specifications within one year)
4) File authenticity rate = number of files with real content in the file/total number of files? 100% (the truth can be inquired by phone, judged logically, etc. )
5) File management.
5. Management of health records.
Chapter III Implementation Plan of Community Residents' Health Records
I. Background
According to the provincial government's new rural five practical contents, farmers' health project? As an important fact of it. The goal of this project is to establish a new rural health service system to meet the needs of rural economic and social development and rural residents' health by 20 10, and to establish a government investment guarantee mechanism for rural public health to ensure that rural residents enjoy basic public health services. In 2009, the Opinions of the Central Committee of the Communist Party of China, the Central Committee and the State Council on Deepening the Reform of the Medical and Health System (Zhong Fa [2009] No.6) was promulgated, which clearly put forward the goal of popularizing basic medical and health services and promoted the equalization of basic public health services for urban and rural residents. According to the national, provincial and municipal documents and plans, guided by Scientific Outlook on Development, and combined with local conditions, our district has formulated the Detailed Rules for the Implementation of Rural Basic Public Health Service Projects in Chuzhou District. The implementation plan of residents' health records management guides the development of residents' health records management in our district.
Second, the target indicators
1. unify the format of residents' health records. The main information of health records includes: basic information of residents, major health problems and health service records. Establish health records for key groups, and the elderly over 60 years old are 20 10? 85%, rural? 55%, 20 1 1 year city? 90%, rural? 60%。 20 1 1 What is the filing rate of others? 40%。
2, the county (city, district) as a unit, the computer dynamic management rate of health records? 80%; The contents of health records of residents over 35 years old, disabled people and patients with chronic diseases are updated at least 1 time every year, and at least 4 times every year for those over 60 years old.
Third, countermeasures
1. Create an organization
The management of residents' health records in our district is led by the district government, organized by the district health bureau and implemented by the district CDC. Establish a hierarchical organization and improve the management network of residents' health records.
Each township shall, in accordance with the requirements of the district work plan, establish an organizational management system, formulate a work plan and form a work summary.
2. Make full use of physical examination and clinical data, combined with active door-to-door service, gradually establish dynamic health records for community residents and carry out targeted health intervention.
(1) Each township is responsible for establishing family health records, residents' health records and health records for the elderly over 60 years old for residents in its own area. The specific filing and follow-up work is undertaken by the community health service stations (village clinics), and the township prevention and protection offices dynamically grasp the specific statistics and follow-up situation of each village, and at the same time control the quality of file management.
(2) Filing objects and requirements: establish health records for the elderly over 60 years old, with a filing rate of 90%, and follow-up and update 4 times a year; Establish a health management card for women and children. Specific management requirements refer to the requirements of the District Maternal and Child Health Hospital, and township doctors responsible for maternal and child health care should do a good job in management and statistics; For patients with chronic diseases, establish health records according to the requirements of specific diseases, with a filing rate of 90% and a standardized management rate of 90%; Residents outside the above groups should also actively establish residents' health records, and families where residents live should also establish family health records to realize standardized management of one household and one file, update information at least once a year, and conduct physical examination for them every two years; The overall filing rate of all the above groups reached 50% of the total population.
(3) File management: The files of the elderly over 60 years old and the files of women and children can be stored separately, or they can be integrated with the health files of ordinary residents together with the family health files to realize the management of one file per household, and the files are stored in the order of village groups. Files of death and lost visits are stored separately. Gradually realize the computer dynamic management of health records, and the management rate reaches 80%.
(4) Follow-up contents: In addition to the contents of regular physical examination and medical records, the follow-up should highlight the education of health knowledge, the guidance of diet, exercise and lifestyle of the management object, and promote the establishment of a good lifestyle. Follow-up records are true, standardized and complete, and various health services and inspection documents are filed in time.
(5) Doctors in villages and towns for the prevention and treatment of chronic diseases shall, in accordance with the format requirements of Quarterly Report of Community Health Archives and Quarterly Report of Chronic Disease Management, summarize the filing and follow-up updates of villages, and report the summary results to the District CDC before 5th of the first month of next quarter.
3, the establishment of poor disabled people, low-income families, five guarantees and other registration, specific personnel, households according to the residents' health records, family health records at the same time. Files are kept separately. Visit the house for follow-up inspection more than 2 times a year.
Fourth, the timetable.
1 and 1-2 two months, start the management of residents' health records in an all-round way, make work plans, hold village doctors' meetings, and arrange all the work.
2. Carry out daily health management for residents, establish health records for those who have not been filed, classify the dead or lost residents and resettle them separately. And do a good job in dynamic management, data update, and complete quarterly reports.
3. In July, I finished the work summary for half a year.
65438+February and April, complete the work summary for the whole year.
Verb (abbreviation of verb) evaluation
The District Health Bureau shall evaluate the implementation of the project once every quarter, and evaluate the indicators of the project. Assessment in strict accordance with the "Chuzhou District rural basic public health service project work assessment rules". The assessment results are directly linked to the funds.
Intransitive verb cash fund
Refer to the Implementation Plan for Performance Appraisal of Basic Public Health Services in Chuzhou District, and cash the working funds.