居民健康檔案管理服務規范

 一、服務對象

轄區內常住居民(指居住半年以上的戶籍及非戶籍居民),以0~6歲兒童、孕產婦、老年人、慢性病患者、嚴重精神障礙患者和肺結核患者等人群為重點。

二、服務內容

(一)居民健康檔案的內容

居民健康檔案內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療衛生服務記錄。

1.個人基本情況包括姓名、性別等基礎信息和既往史、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生服務項目要求的0~6歲兒童、孕產婦、老年人、慢性病、嚴重精神障礙和肺結核患者等各類重點人群的健康管理記錄。

4.其他醫療衛生服務記錄包括上述記錄之外的其他接診、轉診、會診記錄等。

(二)居民健康檔案的建立

1.轄區居民到鄉鎮衛生院、村衛生室、社區衛生服務中心(站)接受服務時,由醫務人員負責為其建立居民健康檔案,并根據其主要健康問題和服務提供情況填寫相應記錄,同時為服務對象填寫并發放居民健康檔案信息卡。建立電子健康檔案的地區,逐步為服務對象制作發放居民健康卡,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閱更新的憑證。

2.通過入戶服務(調查)、疾病篩查、健康體檢等多種方式,由鄉鎮衛生院、村衛生室、社區衛生服務中心(站)組織醫務人員為居民建立健康檔案,并根據其主要健康問題和服務提供情況填寫相應記錄。

3.已建立居民電子健康檔案信息系統的地區應由鄉鎮衛生院、村衛生室、社區衛生服務中心(站)通過上述方式為個人建立居民電子健康檔案。并按照標準規范上傳區域人口健康衛生信息平臺,實現電子健康檔案數據的規范上報。

4.將醫療衛生服務過程中填寫的健康檔案相關記錄表單,裝入居民健康檔案袋統一存放。居民電子健康檔案的數據存放在電子健康檔案數據中心。

(三)居民健康檔案的使用

1.已建檔居民到鄉鎮衛生院、村衛生室、社區衛生服務中心(站)復診時,在調取其健康檔案后,由接診醫生根據復診情況,及時更新、補充相應記錄內容。

2.入戶開展醫療衛生服務時,應事先查閱服務對象的健康檔案并攜帶相應表單,在服務過程中記錄、補充相應內容。已建立電子健康檔案信息系統的機構應同時更新電子健康檔案。

3.對于需要轉診、會診的服務對象,由接診醫生填寫轉診、會診記錄。

4.所有的服務記錄由責任醫務人員或檔案管理人員統一匯總、及時歸檔。

(四)居民健康檔案的終止和保存

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。對于遷出轄區的還要記錄遷往地點的基本情況、檔案交接記錄等。

2.紙質健康檔案應逐步過渡到電子健康檔案,紙質和電子健康檔案,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)參照現有規定中的病歷的保存年限、方式負責保存。

三、服務流程

(一)確定建檔對象流程圖

(二)居民健康檔案管理流程圖

四、服務要求

(一)鄉鎮衛生院、村衛生室、社區衛生服務中心(站)負責首次建立居民健康檔案、更新信息、保存檔案;其他醫療衛生機構負責將相關醫療衛生服務信息及時匯總、更新至健康檔案;各級衛生計生行政部門負責健康檔案的監督與管理。

(二)健康檔案的建立要遵循自愿與引導相結合的原則,在使用過程中要注意保護服務對象的個人隱私,建立電子健康檔案的地區,要注意保護信息系統的數據安全。

(三)鄉鎮衛生院、村衛生室、社區衛生服務中心(站)應通過多種信息采集方式建立居民健康檔案,及時更新健康檔案信息。已建立電子健康檔案的地區應保證居民接受醫療衛生服務的信息能匯總到電子健康檔案中,保持資料的連續性。

(四)統一為居民健康檔案進行編碼,采用17位編碼制,以國家統一的行政區劃編碼為基礎,以村(居)委會為單位,編制居民健康檔案唯一編碼。同時將建檔居民的身份證號作為身份識別碼,為在信息平臺上實現資源共享奠定基礎。

(五)按照國家有關專項服務規范要求記錄相關內容,記錄內容應齊全完整、真實準確、書寫規范、基礎內容無缺失。各類檢查報告單據和轉、會診的相關記錄應粘貼留存歸檔,如果服務對象需要可提供副本。已建立電子版化驗和檢查報告單據的機構,化驗及檢查的報告單據交居民留存。

(六)健康檔案管理要具有必需的檔案保管設施設備,按照防盜、防曬、防高溫、防火、防潮、防塵、防鼠和防蟲等要求妥善保管健康檔案,指定專(兼)職人員負責健康檔案管理工作,保證健康檔案完整、安全。電子健康檔案應有專(兼)職人員維護。

(七)積極應用中醫藥方法為居民提供健康服務,記錄相關信息納入健康檔案管理。

(八)電子健康檔案在建立完善、信息系統開發、信息傳輸全過程中應遵循國家統一的相關數據標準與規范。電子健康檔案信息系統應與新農合、城鎮基本醫療保險等醫療保障系統相銜接,逐步實現健康管理數據與醫療信息以及各醫療衛生機構間數據互聯互通,實現居民跨機構、跨地域就醫行為的信息共享。

(九)對于同一個居民患有多種疾病的,其隨訪服務記錄表可以通過電子健康檔案實現信息整合,避免重復詢問和錄入。

五、工作指標

(一)健康檔案建檔率=建檔人數/轄區內常住居民數×100%。

注:建檔指完成健康檔案封面和個人基本信息表,其中0~6歲兒童不需要填寫個人基本信息表,其基本信息填寫在“新生兒家庭訪視記錄表”上。

(二)電子健康檔案建檔率=建立電子健康檔案人數/轄區內常住居民數×100%。

(三)健康檔案使用率=檔案中有動態記錄的檔案份數/檔案總份數×100%。

注:有動態記錄的檔案是指1年內與患者的醫療記錄相關聯和(或)有符合對應服務規范要求的相關服務記錄的健康檔案。

 

附件:
            附件1居民健康檔案表單目錄.docx
            附件2居民健康檔案封面.docx
            附件3個人基本信息表.docx
            附件4健康體檢表.docx
            附件5接診記錄表.docx
            附件6會診記錄表.docx
            附件7雙向轉診單.docx
            附件8居民健康檔案信息卡.docx
            附件9填表基本要求.docx
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