我国老龄化及老年人健康问题日益凸显，居家养老成为我国老年人养老的主要形式。目前，我国缺少一套标准化和规范化的居家老年人健康管理系统。本研究将在需求分析和国内外相关研究的基础上，采用美国护士学会认可的标准化护理语言CCC（临床护理分类系统，Clinical Care Classification ），构建基于CCC的居家老年人健康管理系统，旨在实现存储个人健康信息、生成标准化健康管理服务报告、效果评价以及统计分析等功能，为居家老年人实施健康管理提供系统、高效、标准的工具；并运用PDCA质量管理理论，对所构建的系统逐步完善、优化，使其更便于实践应用。本研究首次在国内将CCC用于居家老年人健康管理系统的构建，可以使医院-社区-家庭的健康信息互联互通，构建适合我国国情的、标准化的居家老年人健康管理系统具有积极的理论和实践意义。

The aging and health problems of the aged are increasingly prominent in China, and the home-based care for the elderly is becoming the main trend. Currently China lacks a set of health management system for the elderly people living at home that runs in a standardized way. Based on the requirement analysis and the review of related researches home and abroad, the research adopts CCC system (Clinical Care Classification System, acknowledged by the American Nurses Association) to construct a set of health management system for Chinese elderly people living at home. The main functions of the program are the storage of personal health information, the generation of standard reports of health management service, the performance evaluation of the program and statistical analysis of health information. Therefore, this program is a systematic, efficient and standard tool for the elderly people’s health management. In addition, PDCA quality management theory is adopted to improve and optimize the system so that it can be better practiced. Initially applying CCC in the construction of a health management system in China, the research also ensures the exchange of health information among the hospital, the community and the family and thus has the theoretical and practical significance for the construction of health management program suitable to China’s national conditions for Chinese elderly people living at home.