公共衛(wèi)生健康管理系統(tǒng)助力居民健康檔案健康管理的高效完成

　　居民健康檔案管理一、服務(wù)對象轄區(qū)內(nèi)常住居民（指居住半年以上的戶籍及非戶籍居民），以0～6歲兒童、孕產(chǎn)婦、老年人、慢性病患者、嚴重精神障礙患者和肺結(jié)核患者等人群為重點。

　　Residents' health records management 1. The permanent residents (registered residence registration and non registered residence registration residents who live for more than half a year) in the service object area focus on children aged 0 to 6, pregnant women, the elderly, patients with chronic diseases, patients with serious mental disorders and patients with pulmonary tuberculosis.

　　二、服務(wù)內(nèi)容（一）居民健康檔案的內(nèi)容居民健康檔案內(nèi)容包括個人基本信息、健康體檢、重點人群健康管理記錄和其他醫(yī)療衛(wèi)生服務(wù)記錄。1.個人基本情況包括姓名、性別等基礎(chǔ)信息和既往史、家族史等基本健康信息。2.健康體檢包括一般健康檢查、生活方式、健康狀況及其疾病用藥情況、健康評價等。3.重點人群健康管理記錄包括國家基本公共衛(wèi)生服務(wù)項目要求的0～6歲兒童、孕產(chǎn)婦、老年人、慢性病、嚴重精神障礙和肺結(jié)核患者等各類重點人群的健康管理記錄。4.其他醫(yī)療衛(wèi)生服務(wù)記錄包括上述記錄之外的其他接診、轉(zhuǎn)診、會診記錄等。

　　2、 Service Content (1) Content of Resident Health Records Resident health records include personal basic information, health check ups, health management records for 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 medical history and family history. 2. Health check ups include general health examinations, lifestyle, health status and medication for diseases, health evaluations, etc. 3. Key population health management records include health management records for various key populations such as 0-6-year-old children, pregnant and postpartum women, elderly people, chronic diseases, severe mental disorders, and tuberculosis patients required by the national basic public health service project. 4. Other medical and health service records include other reception, referral, consultation records, etc. beyond the above-mentioned records.

　　（二）居民健康檔案的建立1.轄區(qū)居民到鄉(xiāng)鎮(zhèn)衛(wèi)生院、村衛(wèi)生室、社區(qū)衛(wèi)生服務(wù)中心（站）接受服務(wù)時，由醫(yī)務(wù)人員負責(zé)為其建立居民健康檔案，并根據(jù)其主要健康問題和服務(wù)提供情況填寫相應(yīng)記錄，同時為服務(wù)對象填寫并發(fā)放居民健康檔案信息卡。建立電子健康檔案的地區(qū)，逐步為服務(wù)對象制作發(fā)放居民健康卡，替代居民健康檔案信息卡，作為電子健康檔案進行身份識別和調(diào)閱更新的憑證。2.通過入戶服務(wù)（調(diào)查）、疾病篩查、健康體檢等多種方式，由鄉(xiāng)鎮(zhèn)衛(wèi)生院、村衛(wèi)生室、社區(qū)衛(wèi)生服中心（站）組織醫(yī)務(wù)人員為居民建立健康檔案，并根據(jù)其主要健康問題和服務(wù)提供情況填寫相應(yīng)記錄。3.已建立居民電子健康檔案信息系統(tǒng)的地區(qū)應(yīng)由鄉(xiāng)鎮(zhèn)衛(wèi)生院、村衛(wèi)生室、社區(qū)衛(wèi)生服務(wù)中心（站）通過上述方式為個人建立居民電子健康檔案。并按照標(biāo)準(zhǔn)規(guī)范上傳區(qū)域人口健康衛(wèi)生信息平臺，實現(xiàn)電子健康檔案數(shù)據(jù)的規(guī)范上報。4.將醫(yī)療衛(wèi)生服務(wù)過程中填寫的健康檔案相關(guān)記錄表單，裝入居民健康檔案袋統(tǒng)一存放。居民電子健康檔案的數(shù)據(jù)存放在電子健康檔案數(shù)據(jù)中心。

　?。?） Establishment of Resident Health Records 1. When residents in the jurisdiction receive services at township health centers, village clinics, and community health service centers (stations), medical personnel are responsible for establishing resident health records for them, filling in corresponding records based on their main health problems and service provision, and filling out and issuing resident health record information cards to service recipients. In areas where electronic health records are established, gradually produce and distribute resident health cards to service recipients, replacing resident health record information cards as proof of identity recognition and access updates for electronic health records. 2. Through various methods such as home service (investigation), disease screening, and health check ups, medical personnel organized by township health centers, village clinics, and community health service centers (stations) establish health records for residents, and fill in corresponding records based on their main health problems and service provision. 3. In areas where a resident electronic health record information system has been established, township health centers, village clinics, and community health service centers (stations) should establish resident electronic health records for individuals through the above-mentioned methods. And upload the regional population health and hygiene information platform according to standard specifications to achieve standardized reporting of electronic health record data. 4. Put the health record forms filled out during the medical and health service process into the resident health record bag for unified storage. The data of residents' electronic health records is stored in the electronic health record data center.

　?。ㄈ┚用窠】禉n案的使用1.已建檔居民到鄉(xiāng)鎮(zhèn)衛(wèi)生院、村衛(wèi)生室、社區(qū)衛(wèi)生服務(wù)中心（站）復(fù)診時，在調(diào)取其健康檔案后，由接診醫(yī)生根據(jù)復(fù)診情況，及時更新、補充相應(yīng)記錄內(nèi)容。2.入戶開展醫(yī)療衛(wèi)生服務(wù)時，應(yīng)事先查閱服務(wù)對象的健康檔案并攜帶相應(yīng)表單，在服務(wù)過程中記錄、補充相應(yīng)內(nèi)容。已建立電子健康檔案信息系統(tǒng)的機構(gòu)應(yīng)同時更新電子健康檔案。3.對于需要轉(zhuǎn)診、會診的服務(wù)對象，由接診醫(yī)生填寫轉(zhuǎn)診、會診記錄。4.所有的服務(wù)記錄由責(zé)任醫(yī)務(wù)人員或檔案管理人員統(tǒng)一匯總、及時歸檔。

　?。?） The use of resident health records: 1. When registered residents visit township health centers, village clinics, and community health service centers (stations) for follow-up visits, after retrieving their health records, the attending doctors will update and supplement the corresponding record content in a timely manner based on the follow-up situation. When providing medical and health services at home, the health records of the service recipients should be consulted in advance and corresponding forms should be carried. During the service process, corresponding content should be recorded and supplemented. Institutions that have established electronic health record information systems should update their electronic health records simultaneously. 3. For service recipients who require referral or consultation, the receiving doctor shall fill out the referral or consultation records. 4. All service records shall be compiled and promptly archived by responsible medical personnel or archive management personnel.

　?。ㄋ模┚用窠】禉n案的終止和保存1.居民健康檔案的終止緣由包括死亡、遷出、失訪等，均需記錄日期。對于遷出轄區(qū)的還要記錄遷往地點的基本情況、檔案交接記錄等。2.紙質(zhì)健康檔案應(yīng)逐步過渡到電子健康檔案，紙質(zhì)和電子健康檔案，由健康檔案管理單位（即居民死亡或失訪前管理其健康檔案的單位）參照現(xiàn)有規(guī)定中的病歷的保存年限、方式負責(zé)保存。

　?。?） Termination and Preservation of Resident Health Records 1. The reasons for termination of resident health records include death, relocation, loss to follow-up, etc., and the date must be recorded. For those who move out of the jurisdiction, basic information about the relocation location and records of file handover should also be recorded. 2. Paper health records should gradually transition to electronic health records. Both paper and electronic health records should be managed by the health record management unit (i.e. the unit that manages the health records of residents before their death or loss to follow-up) in accordance with the existing regulations on the retention period and method of medical records. ?

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