Resident health records
Health archives are normative records in the process of providing medical and health services for urban and rural residents by medical and health institutions. They are systematic documents and records that focus on residents' personal health, run through the whole life process, and cover various health-related factors. They are important information resources to meet residents' own needs and health management.
Residents' health records include: personal health records, family health records, and community health records.
Only by establishing complete and authentic health records can community health service workers understand the needs of residents for community health services, so as to provide comprehensive and continuous community health services, improve the health level of community residents and improve the community health status.
For individual residents, health records are indispensable medical data for self-care. They record the occurrence, development, treatment and prognosis of each of our diseases. By comparing the information and data examined over a period of time, community residents can find the changes in their health status, the trend of disease development, the treatment effect and other conditions, which is conducive to residents taking targeted health care measures. At the same time, residents who have established health records can also receive convenient, timely and free public health services in the community health service institutions in their respective jurisdictions. In addition, the establishment of electronic health records and the visit to the hospital also bring great convenience to doctors in diagnosis and treatment of diseases. When doctors see that some examinations have been done recently, they can avoid repeated examinations.
For community health service institutions, they can understand and master the health status and disease composition of community residents, find out the main health problems and health problems of community residents, and lay a foundation for screening high-risk groups, carrying out disease management and taking targeted preventive measures by establishing personal, family and community health files; It is also convenient for the responsible doctors in the community to regularly provide emergency prevention and health guidance for the elderly, women, children, patients with hypertension, diabetes and chronic diseases and other key groups.
The role of electronic health records in the management of patients with hypertension and diabetes
Hypertension and diabetes are chronic high incidence diseases affected by many factors. Only by starting from many aspects, comprehensive treatment can effectively reduce blood pressure, control blood sugar, and keep blood pressure and blood sugar stable. Only by establishing electronic health records for patients with hypertension and diabetes, can community doctors do a better job in primary prevention and reduce the medical expenses of ordinary people.
With the development of medical care and the change of disease spectrum, the diseases of community population in China have gradually changed from infectious diseases to chronic non infectious diseases, such as coronary heart disease, hypertension, diabetes, chronic bronchitis, etc. And chronic diseases are the main diseases that lead to physical and mental weakness, disability, death and large medical expenses of urban residents in China. The national strategy for chronic diseases has also moved forward from the back-end treatment to the systematic management of integrated prevention and treatment.
The establishment of residents' health records and the prevention and treatment of chronic diseases are important contents of community health management. Hypertension and diabetes are important risk factors for cardiovascular and cerebrovascular diseases. Blood pressure and blood sugar are the basic factors that determine the complications of hypertension and diabetes. The benefits of hypertension treatment mainly come from lowering blood pressure, while the benefits of diabetes treatment mainly come from effectively controlling blood sugar. Therefore, improving the control rate of blood pressure and blood sugar is the key measure to reduce the burden of cardiovascular and cerebrovascular diseases. Electronic health records can make primary prevention effective and standardized.
Community doctors can carry out regular home visits, measure blood pressure and blood sugar for patients, ask and record the condition in detail, and adjust the individualized treatment plan for patients in time. Its advantages are continuity, systematicness, timeliness and initiative. Doctors can comprehensively observe the changes in patients' symptoms, signs, risk factors, lifestyle and other aspects, and timely adjust the treatment plan. Patients and doctors have good interaction and high treatment compliance.
Some residents with hypertension and diabetes in the community do not understand, cooperate and file, which ultimately affects their own health and is irresponsible for themselves.