，建立健康档案，责任医生走家入户，为农民建立个人健康档案，有了健康档案

Establish health records, doctors take responsibility for family home, establish personal health records for farmers, with health records, who is sick not sick, what disease, the responsibility of the doctor to see the file is very clear. To establish and improve the health records as the starting point, dynamic control, and changes in farmers' physical health risk factors related to chronic levels to achieve continuity of health and disease management.

, the establishment of health files, responsible doctors go home, for farmers to establish personal health files, with health files, who have no disease, what disease, responsible doctors at a glance. With the establishment and improvement of health files as the grasping hand, we can grasp the health status of farmers dynamically, as well as the change of the level of risk factors related to chronic diseases, and realize the continuous health and disease management.

, establish health files, and the responsible doctor will go home to establish personal health files for farmers. With health files, the responsible doctor will be clear at a glance about who is ill or not and what is ill. With the establishment and improvement of health records as the starting point, we can dynamically grasp the health status of farmers and the changes of chronic disease-related risk factors, so as to achieve continuous health and disease management.