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公共卫生康健治理系统助力住民康健档案康健治理的高效完成
- 2025-08-23
- / 原创
- 130
住民康健档案治理一、效劳工具辖区内常住住民（指栖身半年以上的户籍及非户籍住民），，以0～6岁儿童、孕产妇、晚年人、慢性病患者、严重精神障碍患者和肺结核患者等人群为重点 。。。。。。
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、效劳内容（一）住民康健档案的内容住民康健档案内容包括小我私家基本信息、康健体检、重点人群康健治理纪录和其他医疗卫生效劳纪录 。。。。。。1.小我私家基本情形包括姓名、性别等基础信息和既往史、家族史等基本康健信息 。。。。。。2.康健体检包括一样平常康健检查、生涯方法、康健状态及其疾病用药情形、康健评价等 。。。。。。3.重点人群康健治理纪录包括国家基本公共卫生效劳项目要求的0～6岁儿童、孕产妇、晚年人、慢性病、严重精神障碍和肺结核患者等种种重点人群的康健治理纪录 。。。。。。4.其他医疗卫生效劳纪录包括上述纪录之外的其他接诊、转诊、会诊纪录等 。。。。。。
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.
� 。。。。。。ǘ┳∶窨到〉蛋傅慕ㄉ�1.辖区住民到州里卫生院、村卫生室、社区卫生效劳中心（站）接受效劳时，，由医务职员认真为其建设住民康健档案，，并凭证其主要康健问题和效劳提供情形填写响应纪录，，同时为效劳工具填写并发放住民康健档案信息卡 。。。。。。建设电子康健档案的地区，，逐步为效劳工具制作发放住民康健卡，，替换住民康健档案信息卡，，作为电子康健档案举行身份识别和调阅更新的凭证 。。。。。。2.通过入户效劳（视察）、疾病筛查、康健体检等多种方法，，由州里卫生院、村卫生室、社区卫生服中心（站）组织医务职员为住民建设康健档案，，并凭证其主要康健问题和效劳提供情形填写响应纪录 。。。。。。3.已建设住民电子康健档案信息系统的地区应由州里卫生院、村卫生室、社区卫生效劳中心（站）通过上述方法为小我私家建设住民电子康健档案 。。。。。。并凭证标准规范上传区域生齿康健卫生信息平台，，实现电子康健档案数据的规范上报 。。。。。。4.将医疗卫生效劳历程中填写的康健档案相关纪录表单，，装入住民康健档案袋统一存放 。。。。。。住民电子康健档案的数据存放在电子康健档案数据中心 。。。。。。
� 。。。。。。�2） 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┳∶窨到〉蛋傅氖褂�1.已建档住民到州里卫生院、村卫生室、社区卫生效劳中心（站）复诊时，，在调取其康健档案后，，由接诊医生凭证复诊情形，，实时更新、增补响应纪录内容 。。。。。。2.入户开展医疗卫生效劳时，，应事先查阅效劳工具的康健档案并携带响应表单，，在效劳历程中纪录、增补响应内容 。。。。。。已建设电子康健档案信息系统的机构应同时更新电子康健档案 。。。。。。3.关于需要转诊、会诊的效劳工具，，由接诊医生填写转诊、会诊纪录 。。。。。。4.所有的效劳纪录由责任医务职员或档案治理职员统一汇总、实时归档 。。。。。。
� 。。。。。。�3） 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┳∶窨到〉蛋傅闹罩购蜕�1.住民康健档案的终止缘由包括殒命、迁出、失访等，，均需纪录日期 。。。。。。关于迁出辖区的还要纪录迁往所在的基本情形、档案交接纪录等 。。。。。。2.纸质康健档案应逐步过渡到电子康健档案，，纸质和电子康健档案，，由康健档案治理单位（即住民殒命或失访前治理其康健档案的单位）参照现有划定中的病历的生涯年限、方法认真生涯 。。。。。。
� 。。。。。。�4） 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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