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建立居民健康档案(HER)是卫生服务的前提和重要方面,规范建立和规范使用一直是卫生行政人员和业务人员关注的课题。本研究系统地梳理了北京市、上海市、江苏省和贵州省的居民健康档案的发展模式。研究了HER利用存在的主要问题,主要是健康档案内容标准化未统一,不能及时更新,不能实现数据共享,居民HER利用率低,配套法律规范缺失,卫生信息化管理人才严重缺乏。提出不同个体和机构(包括社区医生、公共卫生人员、社区卫生服务中心、疾病预防控制中心、卫生行政部门等)对HER有效利用路径和作用。同时就发展提出建议:统一设计,标准建设;政府主导,多方参与;因地制宜,稳步推进;搭建共享平台,提高利用水平;深入挖掘,提高效用;加强网络建设,提高内涵建设;加强人才队伍建设,实现可持续性发展健康档案的信息化管理。
The establishment of a resident health record (HER) is a prerequisite and important aspect of health services. Establishing and regulating the use of norms has always been a topic of concern to health administrators and practitioners. This study systematically reviews the development patterns of residents’ health records in Beijing, Shanghai, Jiangsu and Guizhou Provinces. The main problems existing in the utilization of HER are: the standardization of health files has not been standardized; the information can not be updated in time; the data sharing can not be achieved; the utilization rate of residents is low; the lack of supporting laws and regulations; Proposed different individuals and institutions (including community doctors, public health workers, community health centers, centers for disease control, health administration, etc.) the effective use of HER path and role. At the same time, we should make suggestions on the development: unified design and standard construction; government-led and multi-participatory participation; proceed steadily according to local conditions; build a sharing platform to enhance the utilization level; dig deeper to improve utility; strengthen network construction and enhance connotation construction; Achieve the sustainable development of health records of information management.