公共卫生健康管理系统助力居民健康档案健康管理的高效完成

　　居民健康档案管理一、服务对象辖区内常住居民（指居住半年以上的户籍及非户籍居民），以0～6岁儿童、孕产妇、老年人、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、服务内容（一）居民健康档案的内容居民健康档案内容包括个人基本信息、健康体检、重点人群健康管理记录和其他医疗卫生服务记录。1.个人基本情况包括姓名、性别等基础信息和既往史、家族史等基本健康信息。2.健康体检包括一般健康检查、生活方式、健康状况及其疾病用药情况、健康评价等。3.重点人群健康管理记录包括国家基本公共卫生服务项目要求的0～6岁儿童、孕产妇、老年人、慢性病、严重精神障碍和肺结核患者等各类重点人群的健康管理记录。4.其他医疗卫生服务记录包括上述记录之外的其他接诊、转诊、会诊记录等。

　　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.

　　（二）居民健康档案的建立1.辖区居民到乡镇卫生院、村卫生室、社区卫生服务中心（站）接受服务时，由医务人员负责为其建立居民健康档案，并根据其主要健康问题和服务提供情况填写相应记录，同时为服务对象填写并发放居民健康档案信息卡。建立电子健康档案的地区，逐步为服务对象制作发放居民健康卡，替代居民健康档案信息卡，作为电子健康档案进行身份识别和调阅更新的凭证。2.通过入户服务（调查）、疾病筛查、健康体检等多种方式，由乡镇卫生院、村卫生室、社区卫生服中心（站）组织医务人员为居民建立健康档案，并根据其主要健康问题和服务提供情况填写相应记录。3.已建立居民电子健康档案信息系统的地区应由乡镇卫生院、村卫生室、社区卫生服务中心（站）通过上述方式为个人建立居民电子健康档案。并按照标准规范上传区域人口健康卫生信息平台，实现电子健康档案数据的规范上报。4.将医疗卫生服务过程中填写的健康档案相关记录表单，装入居民健康档案袋统一存放。居民电子健康档案的数据存放在电子健康档案数据中心。

　　（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.

　　（三）居民健康档案的使用1.已建档居民到乡镇卫生院、村卫生室、社区卫生服务中心（站）复诊时，在调取其健康档案后，由接诊医生根据复诊情况，及时更新、补充相应记录内容。2.入户开展医疗卫生服务时，应事先查阅服务对象的健康档案并携带相应表单，在服务过程中记录、补充相应内容。已建立电子健康档案信息系统的机构应同时更新电子健康档案。3.对于需要转诊、会诊的服务对象，由接诊医生填写转诊、会诊记录。4.所有的服务记录由责任医务人员或档案管理人员统一汇总、及时归档。

　　（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.

　　（四）居民健康档案的终止和保存1.居民健康档案的终止缘由包括死亡、迁出、失访等，均需记录日期。对于迁出辖区的还要记录迁往地点的基本情况、档案交接记录等。2.纸质健康档案应逐步过渡到电子健康档案，纸质和电子健康档案，由健康档案管理单位（即居民死亡或失访前管理其健康档案的单位）参照现有规定中的病历的保存年限、方式负责保存。

　　（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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