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Maternal and child health information system basic function specification

2019-02-18 13:41 / 5M Technical Information / 2019-02-18 13:41 / 5M

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Maternal and Child Health Information System Basic Function Specification (Trial)
Ministry of Health Information Technology Leading Group Office February 2008 Maternal and Child Health Information System Basic Function Specification (Trial)
table of Contents
The first part of the Maternal and Child Health Information System basic function specifications ... .. 3
Chapter 2 Maternal and Child Health Care Information System Sub-System Functional Specifications ... 12
Chapter 1 Functional Specifications of the Basic Archives Management System for Women and Children ... 13
Chapter 2 Functional Specifications of Pre-Marital Health Care Management Sub-System ... 15
Chapter III Functional Specifications of the Family Planning Technical Service Management Sub-System ... 17
Chapter 4 Functional Specifications of Women's Disease Census Management Sub-System ...
Chapter V Functional Specifications for the Management System of Health Services during Maternity ... 21
Chapter 6 Functional Specifications of the Maternal High-risk Management Sub-System ... twenty four
Chapter VII Functional Specifications of the Birth Medical Certificate Management Sub-System ...
Chapter VIII Functional Specifications of Prenatal Screening and Diagnosis Management Sub-system ...
Chapter IX Functional Specifications of the Maternal Death Report Management Sub-System ...
Chapter 11 Functional Specifications of Child Health Examination Management Sub-System ...
Chapter 12 Functional Specifications of the Frail Child Management Sub-System ... ... 36
Chapter 13 Functional Specifications for the Birth Defect Monitoring Management Sub-System ...
Chapter 14 Functional Specifications of the Sub-System for the Management of Death Reports of Children Under Five
Chapter 15 Specifications of the Maternal and Child Health Statistical Reporting System ...
appendix................................................. ............. 44
Appendix 2: Flow chart of business functions of the MCH Information System Sub-System ...
2 Maternal and Child Health Information System (Trial)
The first part of the basic function specification of the MCH information system 3 The basic function specification of the MCH information system (trial implementation Chapter 1 General Provisions Article 1 According to the Ministry of Health "National Health Information Development Plan Outline 2003-2010" requirements, to strengthen the MCH institutions Standardized management of informatization work, promote and guide the construction of maternal and child health informatization in various places, improve the work efficiency and information management level of maternal and child health business, realize the exchange and sharing of maternal and child health information, and meet the national and all levels of government's scientific decision-making on maternal and child health care. If necessary, this specification is specially formulated.
Article 2 This specification is a basic requirement for MCH information systems, a guiding document for the establishment of MCH information systems by MCH institutions at all levels, and a basic standard for evaluating the construction and operation management of MCH information systems in various places.
Article 3 Definition of Maternal and Child Health Information System: refers to the work of maternal and child health services provided to maternal and child health institutions and related medical and health institutions by computer technology, network communication technology and other modern means in accordance with the requirements of relevant national laws, regulations and policies and standards. Collection, processing, storage, analysis, transmission and exchange of business, management and other data generated in each major stage, so as to provide a comprehensive, automated management and various services information system for health administrative departments, maternal and child health institutions and the public . The MCH information system is the basis for the long-term, continuous tracking and management of its clients and the development of quality services by the MCH institutions, and it is the indispensable infrastructure and supporting environment for the modernization of MCH institutions.
Article 4 The relevant laws, regulations, policies and standards of the country on which this Code is based are: (1) the Law of the People's Republic of China on Maternal and Child Health Care (2) the Measures for the Implementation of the Law of the People's Republic of China on Maternal and Child Health Care (3) " Outline for the Development of Chinese Women (2001-2010) (4) "Outline for the Development of Chinese Children (2001-2010)" (5) "The Law of the People's Republic of China on Infectious Diseases" (6) "Improving the Quality of the Birth Population and Reducing Birth Defects and Disabilities in China Action Plan (2002-2010) (7) "Population and Family Planning Law of the People's Republic of China" (8) "Law of the People's Republic of China on the Protection of Women's Rights and Interests" (9) "The Law of the People's Republic of China on Practitioners" (10) "The Chinese People" Law of the Republic on Keeping State Secrets (11) "Electronic Signature Law of the People's Republic of China" (12) "Statistical Law of the People's Republic of China" 4 Basic Functions of Maternal and Child Health Information System (Trial) (13) "Planning Family Planning Technical Services" Management Regulations (14) The Ministry of Health's "Implementation on Improving the Quality of Birth Population (15) "Maternal and Child Health Work Regulations" of the Ministry of Health (16) "Primary Health Care Management Procedures (Trial)" (17) Ministry of Health "National Urban Perinatal Health Management Measures (Trial)" (10) 8) "Administrative Measures for Rural Maternal System Health Care (Trial)" (19) Ministry of Health "National Quality Standards and Requirements for Urban and Rural Maternal Health Care" (20) "Ministry of Health Health Care Requirements for Urban and Rural Children" (20) 1) "Healthcare system for nurseries and kindergartens" of the Ministry of Health (22) "Healthcare Management System for Diaspora Children" of the Ministry of Health (23) "Specifications of Premarital Health Care Work" of the Ministry of Health (24) "Prenatal Diagnosis of the Ministry of Health" Technical Management Measures (25) Ministry of Health "Technical Specifications for Screening of Newborn Diseases" (26) Ministry of Health "Basic Standards of Special Technical Services for Maternal and Infant Health Care" (27) Ministry of Health "National Maternal and Child Health Surveillance Program (28) Ministry of Health and Ministry of Public Security, "Notice on Uniformly Regulating Medical Certificates of Birth" (29) Ministry of Health, Ministry of Public Security Issuing the Circular on Supplementary Provisions on the Management of Biomedical Certificates (30) "Outline of National Health Informatization Development Plan 2003-2010" (31) "National Health Statistical Survey System" (32) Ministry of Health "National Maternal and Child Health Investigation System" (33) "People's Republic of China Computer Information System Security Protection Regulations" (34) "China Computer Security Regulations and Standards" Article 5 This specification does not include the construction of a maternal and child health information system network operation platform Contents of technical specifications.
Article 6 The requirements for the construction of information systems related to clinical medical activities and hospital management in maternal and child health institutions shall refer to the "Basic Functions of Hospital Information Systems" of the Ministry of Health; the requirements for the construction of information systems related to infectious diseases of women and children shall refer to the Ministry of Health Relevant regulations on prevention and control information system construction. Article 7 Each locality may, based on its own conditions and needs, formulate implementation rules for the construction of a maternal and child health information system based on this specification, and make necessary extensions to the system's components and functions.
5 Specification of Basic Functions of Maternal and Child Health Information System (Trial) Chapter 2 Basic Contents of Maternal and Child Health Information System Article 8 This specification divides Maternal and Child Health Information System into Women and Children's Basic File Management System, Women's Health Information System, Children's Health Information System, Women and Children There are four basic components such as the health statistical reporting system. Article 9 The basic file management system for women and children is to establish the personal basic information files of women and children, and to provide a unified and shared basic information management and data interface for the women's health information system and the child's health information system. Article 10 The women's health information system is based on women's individual cases and takes women's health information as the core. It manages and processes the main business data generated in the process of women's health services, and realizes the modernization and scientificization of women's health management. Application information system.
The women's health information system includes eight sub-systems: (1) Pre-marital health service management sub-system: records and manages pre-marital health guidance, pre-marital health consultation, and pre-marital medical examinations. (2) Family planning technical service management sub-system: records and manages family planning technical service case information. (3) Women's Disease Census Management Sub-system: Records and manages case information of women's diseases census and tracking service management. (4) Sub-system of health care management during pregnancy and childbirth: Record and manage case information such as prenatal examination, delivery registration, newborn visit, and postpartum visit registration. (5) Maternal high-risk management sub-system: record and manage high-risk maternal high-risk scores and track case management information. (6) Birth medical certificate management sub-system: Record and manage the complete circulation file of "Birth Medical Certificate". (7) Prenatal screening and diagnosis management sub-system: record and manage case information of pregnant women's prenatal screening, diagnosis and tracking service management. (8) Maternal death report management sub-system: Record and manage case information such as maternal death registration and review records. 6 Maternal and child health information system basic function specification (trial) Article 11 Child health information system is based on the child case, with child health information as the core, computer management and processing of the main business data generated in the process of child health services , To achieve the modernization and scientific application of child health management and application information system. The child health information system includes five sub-systems: (1) Newborn Disease Screening Management Sub-System: Records and manages case information of newborn disease screening and tracking service management. (2) Child health physical examination management sub-system: Record and manage case information such as child physical examination, growth and development evaluation, feeding guidance, eye health, oral health, hearing health, and mental health. (3) Sub-system for the management of frail children: record and manage case information such as registration, treatment and tracking service management of frail children. (IV) Birth defect monitoring and management sub-system: Record and manage case information such as birth defect registration, birth defect population monitoring information, and tracking service management.
(5) Sub-system for the management of death reports of children under five years of age: record and manage case information such as death registration and review records of children under five years of age. Article 12 The statistical report system for maternal and child health is based on the national statistical report on maternal and child health, and it organizes, sorts, summarizes, analyzes, and analyzes the relevant business data collected and managed by women's health and child health information systems. , To achieve the modern and scientific application information system of maternal and child health information management. Maternal and child health statistics report system at this stage of the information content mainly includes: children under the age of 7 health work survey, maternal health survey, women's disease survey questionnaire, family planning technical services quantity and quality questionnaire, premarital health State-level maternal and child health statistical statements such as questionnaires, questionnaires on the health status of children and maternal health of the floating population. Chapter III Basic Functions of the Maternal and Child Health Information System Article 13 The basic functions of the Maternal and Child Health Information System shall mainly include: data collection, quality review, query statistics, data output, transmission and exchange, and authority control.
Article 14 The basic file management system for women and children, women's health information system and children's health information system shall have the following basic functions: 7 Basic functions and specifications of the MCH information system (trial) (1) Entry and modification functions: It is convenient to provide case data, Integrity entry function provides modifiable functionality for unarchived data. (2) Logical error checking function: It can set the logical review relationship between data items, and realize the automatic error checking function when data is entered. (3) Case query function: Provides single and multiple combination query functions for case data. (4) Privilege control function: It can flexibly set different operator use privileges to ensure system security. (5) Standard reference value: The standard reference value of commonly used detection indicators for maternal and child health care can be set and stored in advance. (6) Evaluation and prompt function: The system can compare the case data information with the standard reference value, and automatically give the result evaluation and prompt. (VII) Report generation and printing: It can automatically generate statistical reports and graphics in multiple formats, and can query, print and export report data. Support report format customization. (8) Transmission and exchange functions: Data transmission and exchange between upper and lower maternal and child health database systems can be performed in accordance with unified information standards, and related data information can be queried, exported, and printed within the scope of sharing authority.
Article 15 The statistical report system for maternal and child health shall have the following basic functions: (1) Data collection function: Provides two types of data collection functions, such as direct data entry and automatic transfer from women's health information system and child health information system. (2) Logical error detection function: It is possible to set the logical relationship among reports, between reports, and the data item itself, and it has the function of automatic error detection of data. (3) Summary analysis function: It can automatically generate and print summary analysis reports according to different statistical requirements, and can provide single and multiple combined query statistics functions. (IV) Dynamic monitoring function: It can perform data comparison and dynamic monitoring from the time, space and population distribution of indicators, realize the early warning function of abnormal conditions, and display it in the form of charts. (5) Can make corresponding system adjustments based on changes in administrative divisions. Article 16 The data management functions of the Maternal and Child Health Information System: (1) Data management follows the principle of territorialization and hierarchical management. Personal identification codes are compiled in accordance with unified coding rules, and district (county) -level maternal and child health institutions are used as basic data management units to establish and manage the original case database in the area under jurisdiction, and collect various information on service objects in the area under permanent jurisdiction or residence data.
8 Maternal and Child Health Information System Basic Function Specification (Trial) (2) Each medical and health care institution providing technical services for maternal and child health shall collect the data of the service object through network operation and exchange the data to the area where the service object is usually resident ( County) level maternal and child health institutions. (3) Maternal and child health institutions at all levels are responsible for summarizing and classifying statistics on report data in their respective jurisdictions, and implementing report-by-level reporting and sharing of related case data through network operations. Article 17 The Maternal and Child Health Information System referred to in this specification is an application information system that operates in a network environment. Inter-system functional modules and upper and lower-level systems must implement interconnection and data sharing. They must also be interrelated and mutually restrictive. Article 18 The MCH information system must have external interfaces to support data exchange and sharing. (1) It has vertical and horizontal interfaces with maternal and child health information systems and community health service information systems at all levels to realize hierarchical management, transmission, exchange and sharing of data. (2) It has the interface with the hospital information system, and the clinical medical data required by the system can be imported directly from the hospital information system, avoiding repeated entry of data and errors. (3) Supporting the interface with the disease prevention and control information system to achieve data exchange and sharing with the disease prevention and control information system including the child planning immunization information system and the death report system. (4) Support the interface with the information systems of social-related departments such as family planning, public security, and civil affairs. Chapter 4 Data Standardization Article 19 Data standardization mainly includes standard content such as data elements, basic data sets, and data dictionaries. Article 20 The data element referred to in this specification refers to the most basic unit of the basic data set of the Maternal and Child Health Information System, and its main content includes related social, economic, cultural, business work, and administrative data items. The content of the data elements shall follow the requirements of relevant international and domestic standards. Article 21 The basic data set of the Maternal and Child Health Information System contains the main data elements and metadata of women and children's basic files, women's health information, child health information, and maternal and child health statistical reports. Article 22 The data dictionary of the Maternal and Child Health Information System shall conform to relevant national standards, industry standards and local standards, and shall not be customized. When using a standard that allows users to expand, it should be extended in strict accordance with the coding principles of the standard, and use the standard coding immediately after the new standard is promulgated. If technical restrictions result in the use of the 9 Maternal and Child Health Information System basic function specifications (trial) The system cannot replace the data dictionary, a comparison table between a custom dictionary and a standard dictionary should be established, and corresponding retrieval and data conversion procedures should be developed. Chapter V System Construction and Implementation Article 23 The construction of a maternal and child health information system shall be based on the actual needs of maternal and child health care in various places, and a thorough analysis of the needs shall be made. The overall plan and technical design plan are planned, implemented, and implemented in stages. The function of the information system after completion should have good practicability and expandability. Article 24. The information system for maternal and child health care is a regional network information management system based on the organizational structure of the state, province, city, district (county). The scope of users involved in its construction and operation management includes the scope of administrative regions at all levels. All maternal and child health institutions and related health care institutions that provide maternal and child health technical services. Article 25 The technical documents that should be provided and archived for the construction of a maternal and child health information system mainly include: overall design report, requirements analysis specification, summary design specification, detailed design specification, data dictionary, data structure and process, test report, operation and use instruction , System maintenance manual, etc. Article 26 The security requirements for the operation of the Maternal and Child Health Information System: (1) Adopt a secure, stable, and reliable network platform design to support the data transmission encryption function. (2) Adopting a secure and strict user login management and authority control mechanism to support digital certificate identity authentication functions. (3) The design and use of the database shall ensure the accuracy, reliability, completeness, security and confidentiality of the data. The necessary security technology should be adopted to ensure the security of the database in the network operating environment. (4) It shall have the function of ensuring data security. Traceable modification functions should be provided for important data. (5) Equipped with system and database backup and recovery functions, and support automatic backup functions. There should be relevant protection measures for data storage media management. To prevent unforeseen accidents and disasters, remote backup management should be implemented. Article 27. Confidentiality requirements of the Maternal and Child Health Information System: The management of data shall comply with the state's regulations on confidentiality systems. The data input, processing, storage, transmission and maintenance should be provided with hierarchical review and 10 basic functions and specifications of MCH information system (trial) authorized management measures. The confidential data should be encrypted and stored, and the relevant data storage media should be strictly managed in accordance with relevant confidentiality requirements. Article 28 Management requirements for operation and maintenance of the MCH information system: Various information management systems and operating procedures shall be established, and a system emergency response plan shall be established. System maintenance includes system parameter modification, data dictionary maintenance, user account and password maintenance, permission control, data backup and recovery, virus monitoring, and troubleshooting. Article 29 When the legality of the relevant electronic documents of the MCH information system has not been guaranteed by national laws, the use of important information and data by management agencies shall also retain paper documents as the legal basis. Chapter VI Supplementary Provisions Article 30 The Office of the Leading Group of Information Work of the Ministry of Health is responsible for the interpretation of this code. Article 31 This Code shall be implemented as of the date of its official promulgation. 11 Maternal and Child Health Care Information System Basic Function Specification (Trial) Part 2 Maternal and Child Health Care Information System Sub-System Function Specification 12 Maternal and Child Health Care Information System Basic Function Specification (Trial) Chapter 1 Women and Children Basic Archives Management System Function Specification Article 1 Women and Children Foundation The file management system is a computer application system for establishing and managing the personal basic information files of women and children under seven years of age. The main task is to establish the basic files of women and children, to ensure the uniqueness of the basic information of women and children, and to link the data files of other sub-systems. Article 2 The relevant national laws, regulations, standards and standards on which this Code is formulated are: (1) the "Maternal and Child Health Care Law of the People's Republic of China" (2) "Maternal and Child Health Regulations" of the Ministry of Health (3) "Urban and Rural of the Ministry of Health" Requirements for Children's Health Work (4) National Health Quality Standards and Requirements for Urban and Rural Maternal Health in the Ministry of Health Article 3 Basic Functional Requirements: (1) Registration of Basic Files for Women and Children Establish basic files for women and children, including unique Personal identification number; In addition to establishing a personal identification code, it provides the function of modifying the basic file and saves the modification log; 2. 2. After referring to other subsystems, it is not allowed to delete the basic files; 3. Provide the function of associating child and mother identification codes; This function can be embedded and called in other sub-systems; 5. According to the identification variables, the basic information can be determined and the associated identification can be revised. (B) Inquiry 1. Query the basic files of women and children, modify the log, survival, health, death, and receiving health care services according to single or multiple conditions, and display them in a list. 2. Supports individual case inquiry and association inquiry of children and mother files. (3) Printing and data export 1. Support report printing and query result printing; 2. Can export all case data and report data, or export according to query results; 3. The exported data can be used for statistical analysis. Article 4 System operation requirements: (1) The sub-system should provide the "Pre-marital Health Care Service Management Sub-System", "Planning Family Technical Service Management 13 Basic Functions and Specifications of the Maternal and Child Health Care Information System (Trial) Sub-system", and "Women's Disease Census Management Sub-system" System "," Maternal health care management sub-system "," Maternal high-risk management sub-system "," Birth medical certificate management sub-system "," Prenatal screening and diagnosis management sub-system "," Maternal death report management Sub-System "," Child Health Check-up Management Sub-System "," Newborn Disease Screening Management Sub-System "," Frail Child Management Sub-System "," Birth Defect Surveillance Management Sub-System "," Management of Death Reports for Children Under Five The data interface of the Subsystem. (2) Support the interface with external related information systems. 14 Maternal and Child Health Care Information System Basic Function Specification (Trial) Chapter 2 Premarital Health Care Management Subsystem Function Specification Article 1 Premarital Health Care Management Subsystem is used to complete the data collection of premarital health care case information in the process of developing premarital health care services , Processing, storage, statistical analysis and exchange of computer application systems. The main task is to record and manage the basic information of pre-marital examinations for men and women, examination information (medical history, physical examination, auxiliary examinations), pre-marital health consultation, pre-marital health guidance, and result reporting. Article 2 The relevant national laws, regulations, norms and standards on which this Code is formulated are: (1) the Law of the People's Republic of China on Maternal and Child Health Care (2) the Measures for the Implementation of the Law of the People's Republic of China on Maternal and Child Health Care (3) Health Article 3 of the "Pre-marital Health Care Work Specification" Basic functional requirements: (1) Processing of examination information of service objects Complete the entry and processing of pre-marital medical examination data for men and women, including basic information, medical history (previous history, current medical history, family history, marriage and childbirth history) Etc.), physical examination (full-body examination, genital and secondary sexual characteristics examination), auxiliary examination, examination results, medical opinions and pre-marital health consultation and guidance. 1. With data review function, the data cannot be modified after the review; 2. 2. With referral registration function; 3. With appointment review function; With case information input function in stages. (2) Query Querying information about men and women's marriage check cases (basic information, test results, evaluation results, treatment status, etc.), appointment review, and referral registration according to single or multiple item combinations. It is displayed in a list and supports case inquiry. (3) Printing and data export 1. Pre-marital medical checklists and pre-marital medical examination reports for men and women can be printed; 2. Report printing and query result printing can be supported; 3. All case data and report data can be exported, or the query results can be exported 4. The exported data can be used for statistical analysis. (IV) Statistical reports 15 Basic functions and specifications of the MCH information system (trial) 1. Able to generate and print statistical reports such as “Pre-marital Medical Examination Questionnaire”; 2. Reports can be generated according to query conditions. Article 4 System operation requirements: (1) Basic information can be obtained from the "Basic Archives Management System for Women and Children". (2) Those who meet the requirements for the management of health services during pregnancy and maternity during the pre-marital health care process can be transferred to the "Management System for Health Services during Maternity". (3) Support the interface with external related information systems. 16 Maternal and Child Health Care Information System Basic Function Specification (Trial) Chapter III Functional Specification of Family Planning Technical Service Management Subsystem Article 1 Family Planning Technical Service Management Subsystem is used to complete family planning technical service objects in the process of developing family planning technical services Computer application system for data collection, processing, storage, statistical analysis and exchange of individual case information. The main task is to record and manage the client's basic information, past and present medical history, physical examination, receiving family planning technical services, female clients' maternity history, and gynecological examinations. Article 2 The relevant national laws, regulations, standards and standards on which this Code is formulated are: (1) "People's Republic of China Maternal and Child Health Law" (2) "Implementation Measures of the People's Republic of China Maternal and Child Health Law" (3) " Law of the People's Republic of China on Practitioners (4) Law of the People's Republic of China on Population and Family Planning Law (5) Regulations of the State Council on the Management of Family Planning Technical Services Article 3 Basic functional requirements: (1) Complete registration of medical records for family planning technical services Entry of medical records of family planning technical services. Medical records of male family planning technical services include: basic information, past history, current medical history, physical examination, male genital examination, and family planning surgery; medical records of female family planning technical services include: basic information, past history, current medical history, motherhood History, physical examination, gynecological examination, receiving family planning technical services, etc. Cases of undergoing family planning surgery included surgical complications for both men and women. 1. With data audit function, the data cannot be modified after the audit confirmation; 2. 2. Can import related data from "Hospital Information System"; Provide follow-up results recording function. (B) Inquiry 1. Able to query the complete case information of the family planning technical service object. 2. Query basic information, surgical records, and surgical complications of family planning technical service objects based on a single item or multiple conditions. Displayed as a list. (3) Printing and data exporting 1. With the function of printing family planning surgery certificate and family planning surgery record form; 17 Maternal and Child Health Care Information System Basic Function Specification (Trial) 2. Support report form printing and query result printing; 3. Exportable 3. All case data and report data can also be exported according to the query results; The exported data is available for statistical analysis. (4) Statistical reports can generate and print "statistical surveys on the number and quality of family planning operations" and other statistical reports. Reports can be generated based on query conditions. Article 4 System operation requirements: (1) Basic information can be obtained from the "Basic Archives Management System for Women and Children". (2) The sub-system should provide data interfaces with the "Maternal Health Service Management Sub-System", "Maternal Death Report Management Sub-System" and "Birth Defect Monitoring Management Sub-System". (3) Support the interface with external related information systems. 18 Maternal and Child Health Care Information System Basic Function Specification (Trial) Chapter 4 Function Specification of Women's Disease Census Management Sub-system Article 1 Women's Disease Census Management Sub-System is to collect, process, store, and analyze data generated by women's disease census work , Transmission and exchange of computer application systems. The main task is to record the basic situation and inspection of women, and to achieve follow-up management of women's disease patients. Article 2 The relevant national laws, regulations, standards and standards on which this Code is formulated are: (1) the Law of the People's Republic of China on the Protection of Women's Rights and Interests; (2) the Law of the People's Republic of China on Statistics; and (3) the Outline for the Development of Chinese Women (2001-2010) (4) The Basic Functions of Article 3 of the "Maternal and Child Health Work Regulations" of the Ministry of Health: (1) The registration of basic information and the entry of women's general information, their marriage and childbearing history, and past history. (2) Information management of women's disease examination According to the procedure of women's disease examination, women's physical conditions are examined (including laboratory examinations, equipment and equipment examinations) and diagnoses are given. (3) Early-warning and forecasting Early-warning of disease populations and regions where there are risk factors or greater harm to women's health, and forecasting of women and regions with high-risk diseases. (4) Inquiry 1. Able to query the complete case information of women's disease census subjects. 2. Query basic information and examination information of women's disease census objects according to single or multiple conditions. It is displayed in a list mode and supports case inquiry. (V) Printing and data exporting 1. Able to print women's disease examination reports; 2. Support report printing and query result printing; 3. Export all case data and report data, or export according to query results; 4. Export data can be exported For statistical analysis. (VI) Statistical reports 19 Basic functions and specifications of the MCH information system (trial) Can generate and print statistical reports such as the Survey Form for Women's Diseases. Article 4 System operation requirements: (1) Basic information can be obtained from the "Basic Archives Management System for Women and Children". (2) Support the interface with external related information systems. 20 Maternal and Child Health Care Information System Basic Function Specification (Trial) Chapter V Functional Specification of Maternity Health Service Management Sub-system Function Article 1 Maternity Health Service Management Sub-system is for business, management and other data generated during maternal health care work Computer application system for collection, processing, storage, analysis, transmission and exchange, including the registration of basic information of pregnant women, prenatal examination records, delivery records, postpartum visits and other parts. The main task is to record all information of pregnant women from pregnancy to 42 days postpartum, establish a complete maternal system management file, and achieve dynamic continuous tracking and management of pregnant women. Article 2 The relevant national laws, regulations, standards and standards on which this Code is formulated are: (1) "People's Republic of China Maternal and Child Health Law" (2) "Implementation Measures of the People's Republic of China Maternal and Child Health Law" (3) " Law of the People's Republic of China on Practising Physicians (4) "National Urban Perinatal Health Management Measures (Trial)" (5) Ministry of Health "Rural Maternal Health Management Measures (Trial)" (6) "National Urban and Rural Pregnancy Management" Quality standards and requirements for maternity health care Article 3 Basic functional requirements: (1) Basic information registration Completion of maternal perinatal health card (book) Basic information (including general information, menstrual history, history of pregnancy, past history, family history , Physical examination, gynecological examination, etc.), can import relevant data from the "Basic Archives Management System for Women and Children" and "Premarital Health Care Service Management System". 1. 1. Automatically calculate the expected date of delivery and gestational week based on the date of the last menstrual period; It has the function of inputting in stages according to prenatal, childbirth and postpartum. (2) Prenatal inspection management Complete the entry of prenatal inspection information (including general medical examination, obstetric examination, auxiliary examination, diagnosis, treatment, and guidance), and make appointment for follow-up consultation. 1. 1. Generate pregnancy chart based on prenatal examination data and provide printing function; 2. You can print the prenatal inspection record sheet and production inspection reservation form; Support for recording multiple births. (3) Early-warning and confirmed diagnosis of high-risk pregnant women According to the maternal "High-risk Pregnancy Score Sheet", the high-risk factors of perinatal health collection data are judged, and the basic functional specifications of the Maternal and Child Health Information System (trial) are shown. At the same time transferred to the "Maternal High-risk Management Sub-System" for management. (4) Management of childbirth records Records of childbirth delivery information (including maternal admission and admission registration, childbirth process, newborn status, postpartum diagnosis, postpartum observation, etc.) in health care institutions 1. With the function of printing birth records; 2. With the function of recording the information of multiple babies. (5) Post-natal visit management records Information on postpartum visits performed by the mother within 28 days after delivery. With the function of printing the post-natal visit list. (6) Registration of visits to newborns The registration of visits to newborns within 28 days of birth, including body temperature, weight, skin, jaundice, urination, umbilical cord, feeding status, guidance, and handling of abnormal conditions. (7) 42 days postpartum inspection registration and case management records the 42 days postpartum inspection information, and print the 42 days postpartum inspection report. (8) Case closure of maternal health management In the following cases, systemic management of maternal cases is closed and relevant statistical indicators are automatically generated. 1. After 42 days of postpartum inspection; Termination of pregnancy; Maternal deaths, and files are established in the "Maternal Death Report Management Sub-System". (9) Reminders can be combined with business routines to automatically prompt when there should be prenatal inspections, high-risk management, and postpartum visits. Automatic screening of scheduled dates should be checked and not checked beyond the scheduled date; scheduled dates should be managed at high risk, and beyond the scheduled date without high risk management; pregnant women who are scheduled for postpartum visits and not scheduled for postpartum visits beyond the scheduled date should be reminded and given a list Print function. (X) Inquiry 1. It can query the complete perinatal health records of pregnant women, and has the related query function with the corresponding files of other sub-systems. 2. According to single or multiple conditions, the basic information of pregnant women, prenatal examinations, delivery records, postpartum visits and inspection information are searched. It is displayed in a list mode and supports case inquiry. (11) Printing and data export 22 Basic functional specifications of MCH information system (trial) 1. Support report printing and query result printing; 2. Export all case data and report data, or export according to query results; 3. The exported data is available for statistical analysis. (12) Statistical reports can generate and print statistical reports such as "Maternal Health Work Survey Form" and support conditional inquiry. Article 4 System operation requirements: (1) Basic information can be obtained from the "Basic Archives Management System for Women and Children". (2) The sub-system for the management of health services during pregnancy and childbirth must follow the principle of territorial management to classify and classify the territorial management. 1. 1. Medical and health care institutions: responsible for the registration and management of information on receiving maternal health services in this institution; 2. Community health service stations and village clinics: responsible for the registration and management of information on maternal health services in the community and village; 3. Community health service center and township (town) hospital: grasp the management status of maternal health care in the area under their jurisdiction according to the management authority, and conduct summary and statistical analysis; District, county, city, province and other levels of maternal and child health institutions: Understand the management status of maternal health care in the area under their jurisdiction according to different management authority, and be responsible for the exchange, aggregation and statistical analysis of relevant information of health care institutions in the area. (3) According to different information options of this system, it can be transferred to other sub-systems. 1. 1. A birth medical certificate needs to be issued after delivery and transferred to the "Birth Medical Certificate Management Sub-System"; 2. Prenatal screening was carried out during prenatal inspection and transferred to the "Prenatal Screening and Diagnosis Management Sub-System"; 3. High-risk factors found in maternal health care are transferred to the "Maternal High-risk Management Sub-System";孕产期保健中发生孕产妇死亡,转出至《孕产妇死亡管理分系统》; 5.发现出生缺陷情况,转出至《出生缺陷监测管理分系统》; 6.产后42 天内发生儿童死亡,转出至《5 岁以下儿童死亡管理分系统》; 7.发现异常情况在孕中期引产者,转出至《计划生育技术服务管理分系统》。 (四)分系统应提供与《妇女儿童基础档案管理系统》、《婚前保健服务管理分系统》的数据接口。 (五)支持与外部相关信息系统的接口。 23 妇幼保健信息系统基本功能规范(试行) 第六章孕产妇高危管理分系统功能规范第一条孕产妇高危管理分系统是协助医疗保健机构开展孕产妇高危管理工作的计算机应用系统。主要任务是建立孕产妇高危专案管理,处理高危因素筛查、登记、追踪和高危结案信息,确保医疗保健机构对其服务对象进行连续追踪管理和开展优质服务。第二条制定本规范所依据的国家有关法律法规和规范、标准主要有: (一)《中华人民共和国母婴保健法》 (二)《中华人民共和国母婴保健法实施办法》 (三)卫生部《妇幼卫生工作条例》 (四)卫生部《全国城乡孕产期保健质量标准和要求》 (五)卫生部《全国城市围产保健管理办法(试行)》 (六)卫生部《农村孕产妇系统保健管理办法(试行)》 (七)卫生部《母婴保健专项技术服务基本标准》 第三条基本功能要求: (一)高危因素评判完成对高危孕产妇的高危因素动态评判。由系统根据孕产妇基本情况及产前检查情况进行动态评分,供医生审核确诊。 1.高危因素评判参照《高危妊娠评分表》; 2.具备标识高危妊娠分级分类功能。 (二)高危孕产妇追踪服务管理对高危孕产妇进行分级分类,制定不同的追踪服务管理方案,包括预约随诊、 指导意见、指定分娩机构等。对高危孕产妇的追踪服务管理情况进行登记。 1.能够打印高危孕产妇预约通知单; 2.发出预约通知单后,超过规定时间未来随诊者,系统自动给出提醒。 (三)高危孕产妇结案管理在下列情形下,系统对高危孕产妇进行结案,并能将孕产妇孕期、产时的基本情况进行记录与汇总。支持孕妇多次进出分系统管理的情况。 24 妇幼保健信息系统基本功能规范(试行) 1.高危孕产妇高危因素消失; 2.终止妊娠; 3.分娩结束并登记相应信息; 4.孕产妇死亡并在《孕产妇死亡报告管理分系统》中建立档案。 (四)预警预报对高危评分异常高且相对集中的高危孕产妇人群及地区进行预警,对危险度相对较高的高危因素的孕产妇人群和地区进行预报。 (五)转诊登记根据高危孕产妇的分级分类和孕期情况,按规定进行转诊登记。 (六)查询1.能够查询高危孕产妇完整的专项档案,具备与《孕产期保健服务管理分系统》的关联查询功能。 2.根据单个或多个条件组合查询高危孕产妇基本情况、追踪情况、预约情况、结案信息等,采用一览表方式显示。 (七)打印和数据导出1. 具备打印相关表的单功能; 2. 支持报表打印和查询结果的打印; 3. 可导出全部个案数据和报表数据,也可按查询结果导出; 4. 导出数据可供统计分析。 (八)统计报表能生成、打印《孕产妇保健工作情况调查表》等统计报表,并支持条件查询。第四条系统运行要求: (一)与《孕产期保健服务管理分系统》共享基本信息。 (二)设置操作员使用权限控制,指定具有一定资格人员操作。 (三)遵循《孕产期保健服务管理分系统》数据管理要求。 (四)支持与外部相关信息系统的接口。 25 妇幼保健信息系统基本功能规范(试行) 第七章出生医学证明管理分系统功能规范第一条出生医学证明管理分系统是各级卫生行政部门、依法许可的医疗保健机构对儿童出生信息进行管理的计算机应用系统。主要任务是记录和管理儿童《出生医学证明》的订购、发放、签发、补发、作废等信息,建立《出生医学证明》完整的流转管理档案。第二条制定本规范所依据的国家有关法律法规和规范、标准主要有: (一)《中华人民共和国母婴保健法》 (二)《中华人民共和国母婴保健法实施办法》 (三)卫生部、公安部(关于统一规范《出生医学证明》的通知) (四)卫生部、公安部(关于印发《出生医学证明》管理补充规定的通知) (五)卫生部《妇幼卫生工作条例》 第三条基本功能要求: (一)基本信息登记完成基本信息录入(包括父母信息、儿童信息)。 1.能从《妇女儿童基础档案管理分系统》、《孕产期保健服务管理分系统》 转入; 2.提供完整的基本信息录入功能; 3.提供审核和修订功能,审核确认后不允许修改基本信息,并作为签发《出生医学证明》的前提; 4.具备《出生医学证明》相关信息修改日志保存功能。 (二)《出生医学证明》签发与补发完成《出生医学证明》的签发和补发功能。签发时,登记《出生医学证明》 签发信息;补发时,登记《出生医学证明》补发信息(如签发日期、原签发单位相关材料等信息)。 1.提供《出生医学证明》套打功能; 2. 《出生医学证明》打印失败时,系统应对原《出生医学证明》作作废处理,才能重新打印《出生医学证明》。 (三)《出生医学证明》管理26 妇幼保健信息系统基本功能规范(试行) 完成对《出生医学证明》运转的管理(包括《出生医学证明》的订购、接收、 领用、作废) 1.必须提供对《出生医学证明》的流水帐管理; 2.具备《出生医学证明》作废原因记录功能。 (四)查询1.根据单个或多个条件组合查询《出生医学证明》信息、签发信息、补发信息、作废信息及修改日志,采用一览表方式显示,具备打印和数据导出功能。 2.能够按帐簿式查询《出生医学证明》的流转情况并提供打印功能。 (五)统计报表能自动生成打印《出生医学证明》库存统计表、《出生医学证明》使用情况统计表等,并支持数据导出。第四条系统运行要求: (一)能从《妇女儿童基础档案管理系统》获取基础信息。 (二)卫生行政主管部门、妇幼保健机构、各助产机构应具备数据传递交换功能,支持《出生医学证明》的流转。 (三)支持与外部相关信息系统的接口。 27 妇幼保健信息系统基本功能规范(试行) 第八章产前筛查与诊断管理分系统功能规范第一条产前筛查与诊断管理分系统是对产前筛查与诊断管理工作中产生的业务、管理等数据进行采集、处理、存储、分析、传输及交换的计算机应用系统。主要任务是记录孕妇的基本信息、产前筛查、产前诊断、登记与追踪等信息, 实现各产前诊断中心与筛查单位的信息共享。第二条制定本规范所依据的国家有关法律法规和规范、标准主要有: (一)《中华人民共和国母婴保健法》 (二)《中华人民共和国母婴保健法实施办法》 (三)卫生部《关于做好提高出生人口素质工作的意见》 (四)《中国提高出生人口素质、减少出生缺陷和残疾行动计划(2002-2010)》 (五)卫生部《产前诊断技术管理办法》 (六)卫生部《妇幼卫生工作条例》 第三条基本功能要求: (一)产前筛查信息登记完成孕妇基本情况、产前检查、仪器设备检查、实验室检查信息的处理。 1.能从《孕产期保健服务管理分系统》转入孕妇基本情况、产前检查、仪器设备检查信息; 2.能提供打印产前筛查报告单。 (二)产前诊断信息登记完成孕妇基本情况、产前诊断信息登记。 1.能从《孕产期保健服务管理分系统》转入孕妇基本情况; 2.诊断为高风险的孕妇,同时转入《孕产妇高危管理分系统》管理; 3.能够提供打印产前诊断报告单。 (三)阳性个案管理完成对阳性的孕妇召回通知,根据召回过程登记相关信息:通知时间、通知人员、通知形式、备注等。记录干预方案,包括孕妇保健指导、治疗、转诊、终止妊娠等。记录干预结果、妊娠结局及产后追访信息。 28 妇幼保健信息系统基本功能规范(试行) 1.能够打印筛查阳性召回通知单; 2.具备干预方案模板管理功能。 (四)预警预报对产前筛查与诊断,出现高风险或异常者相对集中的孕妇人群及地区进行预警。 (五)查询根据单个或多个条件组合查询孕妇卡片信息、筛查结果、产前筛查诊断、评价结果、召回、保健机构、干预措施等信息,采用一览表方式显示,支持条件查询。 (六)打印和数据导出1. 具备打印相关表单的功能; 2. 支持报表打印和查询结果的打印; 3. 可导出全部个案数据和报表数据,也可按查询结果导出; 4. 导出数据可供统计分析。 (七)统计报表能生成、打印各级医疗保健机构所需的统计报表,支持条件查询。第四条系统运行要求: (一)分系统应提供与《孕产期保健服务管理分系统》、《孕产妇高危管理分系统》、《计划生育技术服务管理分系统》的数据接口。 (二)支持与外部相关信息系统的接口。 29 妇幼保健信息系统基本功能规范(试行) 第九章孕产妇死亡报告管理分系统功能规范第一条孕产妇死亡报告管理分系统是对孕产妇死亡信息进行采集、处理、 存储、分析、传输及交换的计算机应用系统。主要任务是记录孕产妇死亡报告卡、 个案调查报告和各级死亡评审等信息,完善孕产妇死亡报告管理机制。第二条制定本规范所依据的国家有关法律法规和规范、标准主要有: (一)《中华人民共和国母婴保健法》 (二)《中华人民共和国母婴保健法实施办法》 (三)《中国妇女发展纲要(2001-2010)》 (四)卫生部《妇幼卫生工作条例》 (五)卫生部《全国妇幼保健调查制度》 (六)卫生部《全国妇幼卫生监测方案》 第三条基本功能要求: (一)孕产妇死亡报告卡登记完成孕产妇死亡报告卡和个案调查报告信息登记。孕产妇死亡报告卡包括孕产妇基本情况、孕产史、本次妊娠获得医疗保健服务情况、死亡原因等;个案调查报告信息包括孕期、产时、产后保健情况、死前症状、治疗经过及抢救措施。 1.孕产妇基本情况、孕产史、本次妊娠获得医疗保健服务情况等信息可以从《孕产期保健服务管理分系统》中自动转入; 2.对未进入孕产期保健服务管理的死亡者,提供完整的数据档案录入功能; 3.能够打印孕产妇死亡报告卡、个案调查报告; 4.审核确认通过的孕产妇死亡报告卡不允许修改; 5.对被驳回的数据提供修订功能,具备修改日志保存功能; 6.支持个案调查报告模板调用功能。 (二)孕产妇死亡报告卡审核完成对孕产妇死亡报告卡及个案调查表的逐级审核,登记审核意见,对审核未通过作驳回处理。 (三)孕产妇死亡评审30 妇幼保健信息系统基本功能规范(试行) 完成各级医疗保健机构对孕产妇死亡的评审结果记录。 (四)报告查重由系统自动对在案孕产妇死亡报告卡进行相似度检索判断,显示可疑重复报告列表。对重复死亡报告卡和相应的个案调查报告确认后删除。 (五)提醒预警1. 提供孕产妇死亡预警报告; 2. 提供上级驳回的死亡报告卡提醒功能。 (六)查询1.提供孕产妇死亡报告卡个案信息的查询,具备与《孕产期保健服务分系统》的关联查询功能。 2.根据单个或多个条件组合查询孕产妇死亡信息、驳回信息、审核信息、 评审信息、修改日志等。采用一览表方式显示,支持条件查询。 (七)打印和数据导出1. 可打印孕产妇死亡报告卡、个案调查报告等; 2. 支持报表打印和查询结果的打印; 3. 可导出全部个案数据和报表数据,也可按查询结果导出; 4. 导出数据可供统计分析。 (八)汇总分析对孕产妇死亡报告卡、个案调查报告和死亡评审进行汇总分析,应具备如下功能: 1.不同行政区域分布的汇总分析; 2.不同时间分布的汇总分析; 3.不同人群分布(包括流动人口和非流动人口分布等)的汇总分析; 4.上述三种条件任意组合的汇总分析。第四条系统运行要求: (一)分系统应提供与《孕产期保健服务管理分系统》、《计划生育技术服务管理分系统》的数据接口。 (二)支持与外部相关信息系统的接口。 31 妇幼保健信息系统基本功能规范(试行) 第十章新生儿疾病筛查管理分系统功能规范第一条新生儿疾病筛查管理分系统是对新生儿疾病筛查、随访、召回、治疗等过程产生的业务和管理数据进行采集、处理、存储、统计分析与传输交换的计算机应用系统。主要任务是记录新生儿基本信息、采血样本、实验室初检与复检等信息,实现各医疗保健机构与新生儿疾病筛查中心的数据共享。第二条分系统依据以下国家有关法律法规和规范、标准(一)《中华人民共和国母婴保健法》 (二)《中华人民共和国母婴保健法实施办法》 (三)《中国儿童发展纲要2001-2010》 (四)《中国提高出生人口素质、减少出生缺陷和残疾行动计划(2002-2010)》 (五)卫生部《新生儿疾病筛查技术规范》 第三条基本功能要求: (一)初检管理完成新生儿个案信息、初检数据的录入,打印初检结果报告和复检召回通知单。 1.具备由其它分系统转入新生儿个案信息、检测仪器结果导入的数据自动采集功能; 2.对录入或导入的数据进行合法性判断与审核,具备修改错误日志记录功能。 (二)复检管理完成对复检对象的复检结果数据录入,打印复检待排通知单、复检报告单。 (三)筛查阳性结果管理阳性结果的通知和接收、召回管理、确诊与排除管理。根据召回过程登记相关信息:通知时间、通知形式、备注、终结原因。 (四)治疗和随访管理对已确诊患儿追访其治疗过程,登记相关的治疗信息。治疗信息内容包括: 治疗信息、就诊医生、治疗时间、治疗结果、预约下次就诊时间、儿童姓名、确诊说明等。 32 妇幼保健信息系统基本功能规范(试行) (五)提醒管理设置标准参考值,对初检(复检)标本质量、检查结果阳性、召回复查、确诊随访等环节采用提醒功能。 (六)查询1.能够查询新生儿疾病筛查完整的专项档案,具备与《儿童健康体检管理分系统》的关联查询功能。 2.根据单个或多个条件组合查询新生儿疾病筛查卡片信息、初检、复检、 召回、治疗等信息。采用一览表方式显示。 (七)打印和数据导出1. 具备报告单批量打印功能; 2. 支持报表打印和查询结果的打印; 3. 可导出全部个案数据和报表数据,也可按查询结果导出; 4.导出数据可供统计分析。 (八)报表统计能生成、打印新生儿疾病筛查中心、各级卫生主管部门、医疗保健机构所需的统计报表。第四条系统运行要求: (一)传输与交换:医疗保健机构之间能按照统一的信息标准进行数据传输及交换,在共享权限范围内可查询、统计和打印相关数据信息。 (二)数据管理遵循属地分级管理的原则,能够根据需要建立本辖区的数据中心,各数据中心可根据需要进行数据交换。 (三)分系统应提供与《儿童健康体检管理分系统》、《体弱儿管理分系统》 的数据接口。 (四)支持与外部相关信息系统的接口。 33 妇幼保健信息系统基本功能规范(试行) 第十一章儿童健康体检管理分系统功能规范第一条儿童健康体检管理分系统是记录和管理七岁以下儿童的健康信息, 对儿童各期生长发育进行动态评价的计算机应用系统。主要任务记录儿童从零到七岁健康体检、营养指导、生长发育监测、眼保健、口腔保健、听力保健、心理保健等信息,建立完整的儿童系统管理档案,实现对七岁以下儿童的动态连续追踪管理。第二条制定本规范所依据的国家有关法律法规和规范、标准主要有: (一)《中华人民共和国母婴保健法》 (二)《中华人民共和国母婴保健法实施办法》 (三)《中国儿童发展纲要(2001-2010)》 (四)卫生部《城乡儿童保健工作要求》 (五)卫生部《托儿所、幼儿园卫生保健制度》 (六)卫生部《散居儿童保健管理制度》 第三条基本功能要求: (一)基本档案登记完成七岁以下儿童基本档案(包括儿童基本信息、父母及家庭信息)录入。可以从《妇女儿童基本档案管理分系统》、《孕产期保健服务管理分系统》转入。 (二)健康体检信息登记记录和管理儿童健康体检的个案信息,包括喂养方式、体格检查、辅助检查、 生长发育监测、眼保健、口腔保健、听力保健、心理保健、保健指导等信息。 1.根据体检信息生成生长发育评价,并绘制生长发育评价图; 2.提供儿童健康体检预约功能; 3.根据体弱儿管理范围,将检测出营养不良、贫血、佝偻病等疾病儿童转出至《体弱儿管理分系统》管理; 4.检出出生缺陷的儿童转出至《出生缺陷监测管理分系统》; 5.发现五岁以下儿童死亡的,转出至《五岁以下儿童死亡报告管理分系统》。 (三)查询34 妇幼保健信息系统基本功能规范(试行) 1.能够查询七岁以下儿童完整的健康体检档案,具备与《孕产期保健服务管理分系统》、《体弱儿管理分系统》、《出生缺陷监测管理分系统》、《新生儿疾病筛查管理分系统》、《出生医学证明管理分系统》的关联查询功能。 2.根据单个或多个条件组合查询七岁以下儿童基本情况、健康体检、评价信息、体检预约等。采用一览表方式显示。 (四)打印和数据导出1. 具备儿童健康体检报告和生长发育评价报告单打印功能; 2. 支持报表打印和查询结果的打印; 3. 可导出全部个案数据和报表数据,也可按查询结果导出; 4.导出数据可供统计分析。 (五)统计报表能生成、打印《七岁以下儿童保健工作情况调查表》等统计报表。第四条系统运行要求: (一)能从《妇女儿童基础档案管理系统》获取基础信息(二)遵循按属地分级的管理原则,以区(县)级妇幼保健机构为基本数据管理单位,各医疗保健机构将儿童健康体检的个案信息交换到属地县(区)级妇幼保健机构。各级妇幼保健机构负责汇总、分类统计数据,逐级上报和共享。 (三)分系统应提供与《孕产期保健服务管理分系统》、《体弱儿管理分系统》、 《出生缺陷监测管理分系统》、《新生儿疾病筛查管理分系统》、《出生医学证明管理分系统》、《五岁以下儿童死亡报告管理分系统》的数据接口。 (四)支持与外部相关信息系统的接口。 35 妇幼保健信息系统基本功能规范(试行) 第十二章体弱儿管理分系统功能规范第一条体弱儿管理分系统是协助保健机构开展体弱儿管理工作的计算机应用系统。主要任务是建立体弱儿专案管理,记录和管理体弱儿筛查、登记、追踪和结案信息,确保保健机构对其服务对象进行连续追踪管理和开展优质服务。第二条制定本规范所依据的国家有关法律法规和规范、标准主要有: (一)《中华人民共和国母婴保健法》 (二)《中华人民共和国母婴保健法实施办法》 (三)卫生部《妇幼卫生工作条例》 (四)卫生部《城乡儿童保健工作要求》 第三条基本功能要求: (一)基本信息登记完成七岁以下儿童基本信息录入,可以从《儿童健康体检管理分系统》转入。 (二)体弱因素评判由系统对儿童健康档案进行数据采集,并作体弱因素的动态评判。列出体弱因素,供医生审核、确诊体弱儿对象。体弱因素评判参照《体弱儿因素表》。 (三)体弱儿专案管理根据体弱儿的分类提供不同体弱儿专案指导方案,包括预约、治疗、指导等, 系统确定每种方案的实际管理对象。完成体弱儿的首诊登记和复诊登记,首诊和复诊记录包括临床症状、体格检查、实验室检查、治疗、转诊、指导及处理意见等。 1.具备体弱儿专案管理方案模板设定、读取和编辑功能; 2.发出预约通知单后,超过规定时间未来随诊者,系统自动给出提醒。 (四)体弱儿结案管理在下列情形下系统自动对体弱儿进行结案: 1.体弱因素消失; 2.超过儿童保健管理年龄; 3.体弱儿死亡,并在《五岁以下儿童死亡报告管理分系统》中建立档案。支持儿童多次进出分系统管理的情况。 36 妇幼保健信息系统基本功能规范(试行) (五)预警预报对体弱儿发生相对集中的人群及地区进行预警。 (六)查询1.能够查询体弱儿完整的专项档案,具备与《儿童健康体检管理分系统》、 《出生缺陷监测管理分系统》、《新生儿疾病筛查管理分系统》、《五岁以下儿童死亡报告管理分系统》的关联查询功能。 2.根据单个或多个条件组合查询体弱儿基本情况、追踪情况、预约情况、 结案信息等。采用一览表方式显示。 (七)打印和数据导出1. 具备打印已预约体弱儿清单、未管理体弱儿清单、未管理体弱儿通知单等功能; 2. 具备批量打印体弱儿预约通知单功能; 3. 支持报表打印和查询结果的打印; 4. 可导出全部个案数据和报表数据,也可按查询结果导出; 5. 导出数据可供统计分析。 (八)统计报表能生成、打印医疗保健机构所需的体弱儿管理统计报表。第四条系统运行要求: (一)能从《妇女儿童基础档案管理系统》获取基础信息,与《儿童健康体检管理分系统》共享基本信息。 (二)分系统遵循《儿童健康体检管理分系统》数据管理规范。 (三)分系统应提供与《儿童健康体检管理分系统》、《出生缺陷监测管理分系统》、《新生儿疾病筛查管理分系统》、《五岁以下儿童死亡报告管理分系统》的数据接口。 (四)支持与外部相关信息系统的接口。 37 妇幼保健信息系统基本功能规范(试行) 第十三章出生缺陷监测管理分系统功能规范第一条出生缺陷监测管理分系统是医疗保健机构对出生缺陷登记管理和出生缺陷人群监测工作的业务、管理等信息进行采集、处理、存储、分析、传输及交换的计算机应用系统。系统适用于各级医疗保健机构。主要任务是记录和管理出生缺陷登记和出生缺陷人群监测信息,完善出生缺陷监测管理机制。第二条制定本规范所依据的国家有关法律法规和规范、标准主要有: (一)《中华人民共和国母婴保健法》 (二)《中华人民共和国母婴保健法实施办法》 (三)《中国儿童发展纲要2001-2010》 (四)《中国提高出生人口素质、减少出生缺陷和残疾行动计划(2002-2010)》 (五)卫生部《全国妇幼保健调查制度》 (六)卫生部《全国妇幼卫生监测方案》 第三条基本功能要求: (一)出生缺陷信息登记完成患儿基本档案登记,包括患儿基本情况、出生情况、家庭情况、母亲孕早期情况、出生缺陷诊断、随访登记等。 1.具备由《儿童健康体检管理分系统》、《五岁以下儿童死亡管理分系统》、 《孕产期保健服务管理分系统》、《孕产妇高危管理分系统》导入数据; 2.对未进入系统管理对象提供完整档案录入功能; 3.审核确认通过出生缺陷登记卡不允许修改; 4.对被驳回的数据提供修订功能,具备修改日志保存功能。 (二)出生缺陷登记审核完成对出生缺陷登记卡和出生情况及婴儿随访登记表的逐级审核,登记审核意见,对审核未通过作驳回处理。 (三)重复报告检查由系统自动对在案出生缺陷登记卡进行相似度检索判断,显示可疑重复报告列表。对重复出生缺陷登记表确认后删除。 38 妇幼保健信息系统基本功能规范(试行) (四)提醒预警1. 提供高发和罕见出生缺陷预警提示; 2. 提供上级驳回的出生缺陷登记表提醒功能; 3. 对出生缺陷发生相对集中的人群及地区进行预警。 (五)查询1.提供出生缺陷登记表和出生情况及婴儿随访登记表的查询,支持与《儿童健康体检管理分系统》、《五岁以下儿童死亡管理分系统》、《孕产期保健服务管理分系统》、《孕产妇高危管理分系统》的关联查询功能。 2.根据单个或多个条件组合查询出生缺陷登记表、驳回信息、审核信息、 修改日志等。采用一览表方式显示。 (六)打印和数据导出1. 能够打印出生缺陷登记卡、出生情况及婴儿随访登记表; 2. 支持报表打印和查询结果的打印; 3. 可导出全部个案数据和报表数据,也可按查询结果导出; 4.导出数据可供统计分析。 (七)统计分析对出生缺陷登记卡进行汇总分析,应具备如下功能: 1.不同行政区域或者助产机构分布的汇总分析; 2.不同时间分布的汇总分析; 3.不同人群分布(包括流动人口和非流动人口分布等)的汇总分析; 4.上述三种条件任意组合的汇总分析; 5.能统计汇总出生缺陷人群分布表、出生缺陷类型分布表和相关统计指标(出生缺陷发生率、特征别发生率等)。第三条系统运行要求: (一)分系统应提供与《儿童健康体检管理分系统》、《五岁以下儿童死亡管理分系统》、《孕产期保健服务管理分系统》、《孕产妇高危管理分系统》的数据接口。 (二)支持与外部相关信息系统的接口。 39 妇幼保健信息系统基本功能规范(试行) 第十四章五岁以下儿童死亡报告管理分系统功能规范第一条五岁以下儿童死亡报告管理分系统是对五岁以下儿童死亡信息进行采集、处理、存储、分析、传输及交换的计算机应用系统。主要任务是记录和管理五岁以下儿童死亡报告信息,完善儿童死亡报告管理机制。第二条制定本规范所依据的国家有关法律法规和规范、标准主要有: (一)《中华人民共和国母婴保健法》 (二)《中华人民共和国母婴保健法实施办法》 (三)《中国儿童发展纲要(2001~2010 年)》 (四)卫生部《妇幼卫生工作条例》(1986 年) (五)卫生部《全国妇幼保健调查制度》 (六)卫生部《全国妇幼卫生监测方案》 第三条基本功能要求: (一)五岁以下儿童死亡报告卡登记完成五岁以下儿童死亡报告卡信息登记,包括儿童基本信息、家庭信息、死亡情况(治疗情况、死亡原因、死亡诊断)等。 1.儿童基本信息、家庭信息可以从《儿童健康体检管理分系统》、《孕产期保健服务管理分系统》中导入; 2.对未进入儿童系统管理的死亡者,提供完整的数据档案录入功能; 3.审核确认通过的五岁以下儿童死亡报告卡不允许修改; 4.对被驳回的数据提供修订功能,具备修改日志保存功能。 (二)五岁以下儿童死亡报告卡审核完成对儿童死亡报告卡的逐级审核,登记审核意见,对审核未通过作驳回处理。 (三)报告查重由系统对在案五岁以下儿童死亡报告卡进行相似度检索判断,显示可疑重复报告列表。对重复的死亡报告卡确认后删除。 (四)提醒预警40 妇幼保健信息系统基本功能规范(试行) 1. 提供五岁以下儿童死亡预警报告; 2. 提供上级驳回的死亡报告卡提醒功能。 (五)查询1.提供五岁以下儿童死亡报告信息的查询,支持与《儿童健康体检管理分系统》、《孕产期保健服务管理分系统》、《出生缺陷监测管理分系统》、《体弱儿管理分系统功能》的关联查询功能。 2.根据单个或多个条件组合查询五岁以下儿童死亡信息、驳回信息、审核信息、围产儿死亡评审信息、修改日志等。采用一览表方式显示。 (六)打印和数据导出1. 能够打印五岁以下儿童死亡报告卡;; 2. 支持报表打印和查询结果的打印; 3. 可导出全部个案数据和报表数据,也可按查询结果导出; 4.导出数据可供统计分析。 (七)汇总分析对五岁以下儿童死亡报告卡评审进行汇总分析,应具备如下功能: 1.不同行政区域分布的汇总分析; 2.不同时间分布的汇总分析; 3.不同人群分布(包括流动人口和非流动人口分布等)的汇总分析; 4.上述三种条件任意组合的汇总分析。第四条系统运行要求: (一)分系统应提供与《儿童健康体检管理分系统》、《孕产期保健服务管理分系统》、《出生缺陷监测管理分系统》、《体弱儿管理分系统功能》的数据接口。 (二)支持与外部相关信息系统的接口。 41 妇幼保健信息系统基本功能规范(试行) 第十五章妇幼卫生统计报表系统功能规范第一条妇幼卫生统计报表系统是以现阶段国家级妇幼卫生统计报表为主要内容,对妇女保健和儿童保健等信息系统所收集、管理的相关业务信息进行分类汇总、统计分析和网络传输上报等处理的计算机应用系统。主要任务是完成对妇幼保健各分系统数据统计,产生国家规定的妇幼卫生统计年报表,提高统计数据的准确性。第二条制定本规范所依据的国家有关法律法规和规范、标准主要有: (一)《中华人民共和国统计法》 (二)《中华人民共和国母婴保健法》 (三)卫生部《国家卫生统计调查制度》 (四)卫生部《全国妇幼保健调查制度》 第三条妇幼卫生统计报表系统的现阶段基本内容包括:孕产妇保健情况调查表(卫统39 表)、七岁以下儿童保健工作情况调查表(卫统40 表)、流动人口儿童与孕产妇健康状况调查表(卫统41 表)、妇女病普查情况调查表(卫统42 表)、计划生育技术服务数量和质量情况调查表(卫统43 表)、婚前保健情况调查表(卫统44 表)等国家级统计报表。第四条基本功能要求: (一)数据采集完成全部报表数据的采集,各分系统能够提供的统计数据直接从分系统数据统计转入。未在分系统管理范围内数据提供直接录入功能。 1.审核确认通过的数据不允许修改; 2.对被驳回的数据按权限提供修订功能; 3.具备修改日志保存功能。 (二)逻辑查错能设定报表内、报表间以及数据项本身的逻辑关系,具备数据自动检错功能。 1.能够打印逻辑查错报告; 2.能够修订逻辑关系变量。 42 妇幼保健信息系统基本功能规范(试行) (三)报表审核完成对报表数据的逐级审核,登记审核意见,对审核未通过作驳回处理。 (四)统计分析能按时间、部门、指标、数据项等统计要求生成和打印国家规定的统计报表及分析报表、图形,并支持数据导出。 (五)查询能提供单项和多项组合查询统计功能。 (六)动态监测能从指标的时间分布、空间分布和人群分布上实施动态监测,具备对异常指标和数据预警功能,并以图表形式展现。 (七)报表质量控制能根据报表补漏调查数据对报表进行修订,具备质量控制前后的数据保存与对比分析功能,计算相关的质量情况。第五条系统运行要求: (一)数据管理遵循分级管理原则。以区(县)级妇幼保健机构为基本数据管理单位,建立和管理本辖区的各项妇幼卫生统计数据,并逐级上报。省、市及县级能查询和统计到乡级的数据。 (二)支持栏目的可扩展性。 (三)系统应提供如下接口: 1.分系统应提供与《妇女儿童基础档案管理系统》、《婚前保健服务管理分系统》、《计划生育技术服务管理分系统》、《妇女病普查管理分系统》、《孕产期保健服务管理分系统》、《出生医学证明管理分系统》、《孕产妇高危管理分系统》、《产前筛查与诊断管理分系统》、《孕产妇死亡报告管理分系统》、 《新生儿疾病筛查管理分系统》、《儿童健康体检管理分系统》、《体弱儿管理分系统》、《出生缺陷监测管理分系统》、《五岁以下儿童死亡报告管理分系统》 的数据接口; 2.支持与其它外部信息系统的接口。 43 妇幼保健信息系统基本功能规范(试行) 44 附录妇幼保健信息系统基本功能规范(试行) 45 婚前保健服务管理分系统计划生育技术服务管理分系统妇女病普查管理分系统孕产期保健服务管理分系统孕产妇高危管理分系统出生医学证明管理分系统产前筛查与诊断管理分系统孕产妇死亡报告管理分系统新生儿疾病筛查管理分系统儿童健康体检管理分系统体弱儿管理分系统出生缺陷监测管理分系统五岁以下儿童死亡报告管理分系统妇女保健信息系统儿童保健信息系统妇幼卫生统计报表系统妇女儿童基础档案管理系统附录1:妇幼保健信息系统组成结构图妇幼保健信息系统基本功能规范(试行) 附录2:妇幼保健信息系统分系统业务功能流程图(一)婚前保健服务管理分系统(二)计划生育技术服务管理分系统服务对象病历基本信息登记手术记录开始查 统计报表孕产妇死亡报告管理分系统孕产期保健服务管理分系统服务对象基本信息、病史询问登记体格检查男科检查妇科检查实验室功能检查开始疾病诊断结果报告是转诊登记预约复查否高危对象管理统计报表查询结束随访记录结束46 妇幼保健信息系统基本功能规范(试行) (三)妇女病普查管理分系统服务对象基本信息登记检查记录预警预报结果报告统计报表查询结束开始(四)孕产期保健服务管理分系统5 岁以下儿童死亡报告管理分系统计划生育技术服务管理分系统孕产妇死亡报告管理分系统预约、访视提醒预警预报统计报表查询开始建卡登记产前筛查与诊断是管理分系统胎儿缺陷高危评判孕产妇高危管理是分系统高危评判产前检查出生医学证明管理分系统出生缺陷监测管理分系统产后42 天检查产后访视/新生儿访视分娩记录结束47 妇幼保健 息系统基本功能规范(试行) (五)孕产妇高危管理分系统预警预报干预管理方案开始查询统计报表预约随诊转诊登记高危确诊孕产期保健服务管理分系统否跟踪服务管理是孕产妇死亡报告结案管理管理分系统结束报告(六)出生医学证明管理分系统基本档案登记证件作废查询统计报表证件领用证件订购孕产期保健服务管理分系统证件补发登记证件签发打印证件补发打印儿童健康体检管理分系统证件接收结束开始48 妇幼保健信息系统基本功能规范(试行) (七)产前筛查与诊断管理分系统预警预报统计报表产前筛查登记查询产前诊断登记阳性与否否结果报告召回通知干预方案是孕产妇高危管理分系统孕产期保健服务管理分系统结束开始(八)孕产妇死亡报告管理分系统孕产妇死亡报告卡处理孕产妇死亡报告卡审核报告查重查询通过与否预警预报 是孕产妇死亡报告卡评审汇总分析孕产妇高危管理分系统孕产期保健服务管理分系统结束开始49 妇幼保健信息系统基本功能规范(试行) (九)新生儿疾病筛查管理分系统提醒管理统计报表初检管理查询复检管理阳性与否结果报告召回通知干预方案否是体弱儿管理分系统儿童健康体检管理分系统结束开始(十)儿童健康体检管理分系统预约、访视提醒统计报表查询孕产期保健服务管理分系统基本档案登记管理期满否是是出生缺陷诊断出生缺陷监测管理分系统生长育评价体弱儿因素评判是5 岁以下儿童死亡报告管理分系统体弱儿管理分系统健康体检结束开始50 妇幼保健信息系统基本功能规范(试行) (十一)体弱儿管理分系统预约随诊体弱儿专项管理方案查询统计报表否儿童健康体检管理分系统是跟踪服务管理体弱儿确诊结案管理5 岁以下儿童死 报告管理分系统转诊登记预警预报结束开始(十二)出生缺陷监测管理分系统汇总分析预警预报查询出生缺陷登记表报告查重出生缺陷登记表审核是通过与否5 岁以下儿童死亡报告管理分系统否体弱儿管理分系统儿童健康体检管理分系统结束开始51 妇幼保健信息系统基本功能规范(试行) (十三)五岁以下儿童死亡报告管理分系统汇总分析预警预报查询儿童死亡报告卡处理报告查重儿童死亡报告卡审核是通过与否出生缺陷监测管理分系统体弱儿管理分系统否围产儿死亡报告卡评审孕产期保健服务管理分系统儿童健康体检管理分系统结束
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