202 1 work plan for residents' health records (1)
With everyone enjoying basic medical and health services as the goal and people's health as the center, we will improve the accessibility of public health services for urban and rural residents, improve their health status, narrow the gap between urban and rural areas and promote social harmony. According to the national basic public health service projects and the actual situation of the center, the following work plan is formulated:
I. Work objectives
Through the implementation of urban and rural residents' health records management service project, we will gradually establish a unified and standardized health record for urban and rural residents, scientifically record the health status of urban and rural residents with health records, speed up information construction, and implement dynamic management. By the end of 20 12, a health management system focusing on disease prevention, health protection and health promotion will be basically established among urban and rural residents.
(1) The filing rate of health records is ≥ 80%;
(2) The qualified rate of health records is ≥ 80%;
(3) The utilization rate of health records is ≥80%.
Second, the service object
Permanent residents within the jurisdiction, including registered and non-registered residents who have lived for more than half a year. Focus on children aged 0 ~ 3, pregnant women, the elderly, patients with chronic diseases and other people.
Third, the service content.
(a) the contents of the residents' health records
Residents' health records include personal basic information, health examination, health management records of key populations and other medical and health service records.
1. Personal basic information includes basic information such as name and gender, as well as basic health information such as past medical history and family history.
2. Physical examination includes general health examination, lifestyle, drug use of health and its diseases, health evaluation, etc.
3. The health management files of key populations include the health management files of children aged 0-3, pregnant women, the elderly, patients with chronic diseases and severe mental illness required by the national basic public health service project.
4. Other medical and health service records include other medical records and consultation records except the above records.
(B) the establishment of residents' health records
1. When residents in the area receive services in community centers and community service stations, medical personnel are responsible for establishing residents' health records and filling in corresponding records according to their main health problems and service provision. At the same time, fill in and issue resident health record information cards for the clients.
2. Community centers and community service stations organize medical staff to establish health records for residents through on-site service (investigation), disease screening and health examination, and fill in corresponding records according to their main health problems and health service needs.
3. Fill in the relevant record forms of health files in the process of medical and health services, and put them into the residents' health portfolio for unified custody. In rural areas, centralized storage and custody are carried out on a family basis. And input it into the computer to create an electronic health record.
Fourth, strengthen leadership and implement responsibilities.
(a) to strengthen organizational leadership, clear responsibilities and tasks.
In order to ensure the smooth implementation of the project, the working group of urban and rural residents' health records management service project was established to be responsible for the leadership, organization, coordination and supervision of the project. Do a good job in project publicity, research, information collection, basic information entry, file management and update.
(2) Strictly standardize management.
In accordance with the "national basic public health service project", do the following work:
1, raise awareness. All community health service stations should put this work into the important agenda, strengthen leadership, implement responsibilities, define tasks and indicators, arrange the progress reasonably, and seriously organize the implementation.
2. Improve service capabilities. Combined with the actual situation of the jurisdiction, improve the management system and workflow, strictly operate and standardize services to ensure the authenticity and accuracy of information collection and ensure the quality of input.
3. Strengthen project publicity. Centers and community service stations should do a good job in publicity activities, publicize and mobilize at all levels, let residents know the contents and benefits of establishing health records, and mobilize the masses to actively participate.
4, establish and improve the performance appraisal system, improve the evaluation system and methods, to ensure the implementation of the task and benefit the masses. At the same time, strengthen the supervision and management of project implementation, severely investigate and deal with fraud, so that residents can get more benefits.
202 1 Work Plan for Residents' Health Records (II)
Residents' health records are standardized records in the process of providing services to residents by primary medical and health institutions. It is a systematic record that centers on residents' health and runs through the whole life process, covering all kinds of health-related factors, and it is the embodiment of residents enjoying basic medical and health services. The state and province list the establishment of residents' health records as a basic public health service project. In order to do this work well, this scheme is specially formulated.
I. Project objectives
(A) the overall goal
Through the implementation of the project of establishing residents' health records, the city 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 to provide residents with sustained, comprehensive, appropriate and economical basic medical and health services.
(2) Annual target
In 20021year, the filing rate of health records of urban and rural residents reached 60%(40%) and 20% respectively. 202 1 year reached 70%(50%) and 30% respectively. Give priority to the establishment of health records for key groups such as the elderly, pregnant women, children, the disabled and chronic diseases.
Second, the scope and content of the project
202 1 Project is implemented in all counties (districts) of the city. The main contents are as follows:
(a) to formulate the management norms of residents' health records.
Strictly implement the management norms of residents' health records formulated by the Ministry of Health, and standardize the service objects, contents, filing methods, service processes, file storage and use of residents' health records. Residents' health records newly established from 20211must conform to the system of the Ministry of Health.
Formulate the requirements of the National Basic Public Health Service Standard (version 20 16) and the Management Service Standard of Urban and Rural Residents' Health Records and the relevant regulations promulgated by the Provincial Health Department. Residents' health records established before 200211should be gradually improved before the end of 20 16 to meet the above requirements and regulations.
(2) Training of residents' health records management
1. Training targets: community health service institutions, health technicians in township hospitals, rural doctors, disease prevention and control and maternal and child health care institutions, and relevant personnel of health administrative departments.
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, and information technology for file management. The main teaching materials are: Archives Law of People's Republic of China (PRC), National Basic Public Health Service Standard (Version 20 15), Urban and Rural Residents' Health Archives Management Service Standard, Medical Records Management Standard, Computer Basic Knowledge, etc.
3. Training plan: 50% of the training tasks will be completed on 20 16 and 202 1 respectively.
(C) the establishment of health records of residents
1. Contents of residents' health records
Residents' health records include personal basic information, health examination, health management records of key populations and other medical and health service records.
(1) Personal basic information includes basic information such as name and gender, as well as basic health information such as past medical history and family history.
(2) Physical examination includes general physical examination, lifestyle, health status, medication for diseases and health evaluation.
(3) The health management files of key populations include children aged 0-36 months, pregnant women, the elderly, chronic diseases and severe mental illness required by the national basic public health service project.
Health management records of patients and other key groups.
(4) Other medical and health service records include other medical records and consultation records except the above records.
(5) On the basis of residents' personal health records, rural areas can increase the basic information and changes of family members, as well as the main health problems of family members, social and economic conditions, the use of kitchens and toilets in rural areas, the setting of livestock pens and other information.
2. Establish residents' health records
(1) When residents in the jurisdiction receive services in township hospitals, village clinics and community health service centers (stations), medical personnel are responsible for establishing residents' health records and filling in corresponding records according to their main health problems and service provision. At the same time, fill in and issue resident health record information cards for the clients.
(2) Township hospitals, village clinics and community health service centers (stations) should organize medical personnel to establish health records for residents through on-site service (investigation), disease screening and health examination, and fill in corresponding records according to their main health problems and health service needs.
(3) Fill in the relevant record forms of health files in the process of medical and health services, and put them into the residents' health archives for unified custody. In rural areas, it can be stored centrally in families. Conditional area input computer, the establishment of electronic health records.
3. The use of residents' health records
(1) When residents who have filed files go to township hospitals, village clinics and community health service centers (stations) for follow-up, they should hold the residents' health file information card, and after the attending doctor obtains their health files, they should 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 during the service.
(3) For clients who need referral and consultation, the attending doctor shall fill in the referral and consultation records.
(4) All service records shall be collected by responsible medical personnel or file management personnel and filed in time.
(5) The establishment of rural residents' health records can be combined with the new rural cooperative medical system.
4. Management of residents' health records
When establishing and using health records for residents, urban and rural grassroots medical and health personnel shall abide by the Law on Medical Practitioners, the Regulations on the Administration of Rural Doctors and other relevant laws and regulations. Residents' health records are managed according to the Measures for the Administration of Medical Records, and the key requirements are as follows:
(1) The institution providing the service of establishing residents' health records must designate the personnel responsible for the management of residents' health records, be equipped with full-time (part-time) management personnel, have received the training organized by this project, and pass the examination. Management systems for the collection, consultation, recording and storage of residents' health records in this unit should be formulated and strictly implemented.
(2) The management of health files should have necessary file storeroom, equipped with file fittings, and 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 the management of health files to ensure the integrity and safety of health files.
(3) Primary medical and health institutions should use multi-channel information collection to establish residents' health records. Record relevant contents according to the requirements of relevant national special technical specifications, and the recorded contents shall be complete, true, accurate, standardized in words, and the basic contents shall be free from defects. 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 the file confidentiality system should be observed in the process of use, so that health records are not damaged or lost, and personal information of residents and private information related to residents' health should not be disclosed without authorization.
(five) unified coding of residents' health records, using a 20-bit coding system, based on the unified national 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) Health records management and service personnel have the right to use health records in use, management and assessment. 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.
(7) Once the residents' health records are established, they should be kept for life. If a medical and health institution is revoked or merged, it must submit the saved health files to the health administrative department of the county (district) under its jurisdiction, or the medical and health institution designated by the health administrative department of the county (district). If the file is lost or damaged due to its refusal to implement, it shall be investigated for responsibility according to law.
(four) gradually realize the informatization of residents' health records management.
Using the computer network platform of provincial residents' health records, the health records management information network covering the whole city was established. Internet users include all medical and health institutions and will be open to the public when conditions are ripe. Unified use of provincial residents' health file information management software, improve the level of residents' health file information management, gradually realize the informationization of residents' health file management in the province, and provide services for medical research and scientific decision-making.
Third, the project organization and management
Health administrative departments at all levels are responsible for the leadership and management of project implementation, and are responsible for formulating implementation plans, fund management, supervision and inspection, and work assessment plans. County (District) Health Bureau is responsible for the printing of health records. Community health service management institutions at all levels, disease prevention and control institutions, maternal and child health care institutions and public hospitals are responsible for providing technical guidance.
Community health service centers, township hospitals and village clinics are responsible for establishing residents' health files for the people they directly serve. Community health service centers and township hospitals are respectively responsible for the guidance and management of filing work of community health service stations and village clinics within their respective jurisdictions.
Fourth, the project implementation time
202 1 March1to 2021June 5438+001October 30th.
Verb (abbreviation of verb) supervision and evaluation of project implementation
(a) health administrative departments at all levels should, under the leadership of the local government, incorporate the implementation of the basic public health service residents' health records establishment project into the annual target assessment of key health work, and into the work tasks and performance assessment of community health service management institutions at all levels and primary medical and health institutions. County (District) level community health service management institutions are responsible for the supervision and inspection and effect evaluation of community health service centers and township hospitals, not less than 2 times a year. Municipal community health service management institutions shall supervise and inspect the implementation of the project of establishing residents' health records at least 1 time every 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 _ 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 inspection files/total number of files with dynamic records _ 100% (files with dynamic records refer to health records with relevant service records meeting the requirements of various service specifications within 1 year).
_ _ Health Center Ministry of Public Health
202 1 Work Plan for Residents' Health Records (III)
20021Annual Work Plan of Residents' Health Records In order to further improve the work of establishing residents' health records free of charge, according to the arrangement and deployment of basic public health services in jurong city and the requirements of the implementation plan of basic public health services in Chishan Lake Management Committee in 20 16, the work plan of residents' health records in 20 16 is formulated as follows:
First, the annual work goal 1, to establish a unified, scientific and standardized residents' health records and realize the information management of residents' health records 100%. To provide continuous, comprehensive, appropriate and economical basic medical and health services for all residents with health records as the carrier.
2 villages give priority to the elderly, patients with chronic diseases, pregnant women and children aged 0-6. The establishment rate of health records of key population residents is more than 95%, and the establishment rate of health records of other general population residents is more than 90%.
3. During the year, the standardized filing rate of the elderly over 65 and people with chronic diseases such as hypertension and diabetes reached 100%. 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
1. 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.
2. Improve the documentation of undocumented persons: collect the information of undocumented persons through daily outpatient service, disease screening, health check-up service and grid-based door-to-door service of medical personnel, follow the principle of combining voluntary and 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.
3. Improve the utilization of files: when residents make diagnosis and treatment and medical staff provide grid-based door-to-door service, the center or village clinic should retrieve and consult health files, and doctors or door-to-door service personnel 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.
4. Improve the issuance of residents' health cards: according to the requirements of the provincial and municipal health authorities on the issuance of residents' health cards, actively do a good job in the preliminary work of issuance, and verify the authenticity and completeness 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 collected in a unified way by family and stored in village clinics in a unified way by natural villages. 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 the intervention and effect evaluation of health problems: the center or village clinic should adopt appropriate technologies and measures in a planned and focused manner, organize and implement the intervention of health problems in the jurisdiction, carry out various forms of health management services such as health education and consultation, prevention, health care, medical treatment and rehabilitation, and timely implement the evaluation of intervention effect.
7. Combine the improvement of residents' health records with the new rural cooperative medical system: use the disease reimbursement information of 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.
8, improve the 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.