Chronic disease management work plan 1 In order to further improve the chronic disease health management service project, improve the chronic disease management rate and standardized management rate, and better protect people's health, according to the national basic public health service management standards, combined with the actual situation of our center, the 20XX chronic disease work plan is specially formulated.
I. Work objectives
Solidly carry out comprehensive prevention and control of chronic diseases. The registration rate of hypertension and diabetes is over 70%, the standardized management rate is over 80%, and the control rate is over 30%. Establish a self-management team and standardize self-management activities, with a coverage rate of over 30%; The coverage rate of blood pressure measurement of outpatients over 35 years old is 100%, the reporting rate of chronic diseases is over 95%, the health check-up rate of patients with hypertension and diabetes under management is over 95%, and the coverage rate of active monitoring and core indicators monitoring of high-risk groups is 100%.
(A) hypertension work objectives
1, more than 800 hypertensive patients were found and registered;
2. Standardize the management of at least 700 patients with blood pressure control rate ≥ 60%;
3. Discover and register at least 100 high-risk groups;
4.50% of the high-risk population measured their blood pressure at least 1 time every year;
5. The intervention of high-risk groups is recorded and the effect is evaluated;
6.60% residents over 35 years old have their blood pressure measured at least 1 time every year;
7. The awareness rate of hypertension prevention knowledge among residents is 60%.
(B) diabetes work objectives
1, at least 240 diabetic patients were found and registered;
2. Standardize the management of at least 200 diabetic patients, and the blood sugar control rate reaches 60%;
3. 30 high-risk people were found and registered, and the ratio of blood sugar 1 time was at least 40% every year;
4. The awareness rate of prevention and control knowledge among high-risk groups is 60%;
5, high-risk groups and the general population health education records and effect evaluation;
6. The awareness rate of diabetes prevention knowledge among residents is 50%.
Second, the main contents and tasks
1. Discovery and intervention of high-risk groups: The registration system for blood pressure measurement of outpatients over 35 years old was further strengthened. Outpatient blood pressure measurement coverage rate 100%, blood pressure measurement registration rate 100%, and the utilization rate of blood pressure measurement information and treatment information of patients with chronic diseases is over 95%. Taking community and village clinics as units, we will complete the active monitoring and core indicators monitoring of high-risk groups of chronic diseases within our jurisdiction, timely discover patients with hypertension and diabetes, and conduct early management and control.
2. Patient management: the registration rate of patients with hypertension and diabetes is over 70%, and the card establishment rate is100%; Follow-up service is mainly outpatient follow-up, supplemented by family follow-up, and routine management of patients with chronic diseases who have been documented is done well. Provide multiple follow-up services every year, and the follow-up service information is true; Continue to carry out self-management activities for patients with chronic diseases, consolidate the achievements of self-management activities for chronic diseases in 20XX years, standardize the coverage rate of the jurisdiction where self-management activities are carried out, and improve the management quality with the information utilization rate of self-management activities of 100%; Carry out 1 comprehensive health check-up for hospitalized patients with hypertension and diabetes, which can be combined with health check-up or follow-up services for the elderly over 65 years old; Do a good job in systematic, standardized and dynamic management of patients with chronic diseases. The standardized management rate is over 85%, and the blood pressure and blood sugar control rate is over 30%.
Community chronic disease management work plan:
1, community health service stations should have part-time staff responsible for chronic disease management, and there is a community station-neighborhood Committee prevention and control network.
2. According to the results of community census, establish statistical data of chronic diseases in community stations, and make annual work plans and work summaries.
3. Establish health records for residents free of charge as required, implement classified management for patients with chronic diseases, make regular home visits, and make detailed records. Computer management can be implemented if conditions permit.
4, community health service stations have publicity places for the prevention and treatment of chronic diseases, should have the blackboard, tables and chairs, tape recorders, televisions and other necessary publicity equipment.
5. Community health service stations regularly hold lectures on the prevention and treatment of chronic diseases for different groups of people; Conduct behavioral risk factors intervention activities for different groups of people; There should be detailed records; Regularly distribute publicity materials on chronic diseases.
6, community health service stations should set up a chronic disease hotline.
7. The community should have physical exercise places, formulate corresponding physical exercise plans for different residents, and organize patients with chronic diseases to carry out related fitness activities.
8, the establishment of chronic disease work registration records, and statistics report as required.
Chronic disease management work plan II With the development of economy, the change of lifestyle and the acceleration of aging process, the incidence and prevalence of chronic diseases such as hypertension, diabetes, coronary heart disease and malignant tumor are on the rise rapidly, and the disability rate and mortality rate are high, which seriously affects the physical and mental health of patients and brings a heavy burden to individuals, families and society. Therefore, the prevention and treatment of chronic diseases is particularly important, and the focus of chronic disease prevention and treatment is at the grassroots level. The prevention and treatment of chronic diseases at the grass-roots level is the most effective means of chronic disease prevention and treatment, and the quality of chronic disease prevention and treatment at the grass-roots level is directly related to the effect of chronic disease prevention and treatment. Therefore, our hospital will incorporate the prevention and treatment of chronic diseases into the assessment objectives of primary health clinics, create a supportive environment, and take the road of "combining prevention and treatment". According to the requirements of the documents related to the prevention and treatment of chronic diseases at higher levels, this year's chronic disease management work plan is specially formulated.
I. Work objectives
1. Establish a basic information system for chronic diseases, register and file newly diagnosed cases of diabetes and hypertension by using the existing network, and formulate a management system for chronic diseases. The leader is in charge of this work, and the responsibility is implemented to the people.
2, the use of residents' health records and organize residents to carry out health examination, early detection of hypertension and diabetes, improve the early diagnosis rate and early treatment rate of hypertension and diabetes.
3. Strengthen the follow-up management of patients with hypertension and diabetes at the grassroots level, improve the standardized management rate and control rate of hypertension and diabetes, improve the self-management and knowledge and skills of patients with hypertension and diabetes, and reduce or delay the occurrence of complications of hypertension and diabetes.
4. Taking our hospital as the core, village clinics as the foundation, focusing on prevention and treatment by groups and individual prevention and control, exploring the management mode and mechanism of establishing county CDC, evaluating our hospital to assist diagnosis and individualized treatment, providing technical support, and the follow-up management of hypertension and diabetes in village clinics.
5, strengthen health education and health promotion, regularly carry out lectures and publicity on hypertension and diabetes, popularize the knowledge of prevention and treatment of hypertension and diabetes among grassroots residents, control various risk factors, and improve people's health awareness.
6. Establish a standardized archives management system for hypertension and diabetes.
Second, the filing work objectives
1. Establish health records of grassroots residents, and the baseline survey rate of grassroots service population will reach over 90%.
2. Establish health records of patients with hypertension and diabetes, with follow-up records, treatment records and health education records.
Third, the implementation plan
Establish a working system for chronic diseases; Carry out prevention and control work for ordinary people at the grassroots level, patients with hypertension and diabetes, and establish a comprehensive prevention and control mechanism for hypertension and diabetes at the grassroots level.
1, detecting hypertension and diabetes.
Patients with hypertension and diabetes were found by establishing health records of grassroots residents, physical examination, diagnosis and treatment in grassroots hospitals, free blood pressure measurement and blood sugar measurement at grassroots level, active testing, and blood pressure measurement for the first time.
2. Registration of patients with hypertension and diabetes
Register, file and standardize the detected patients with hypertension and diabetes.
3. Follow-up management and referral of patients with hypertension
Collect the detailed medical history of patients with hypertension, carry out necessary physical examination and laboratory examination, carry out clinical evaluation according to the requirements of Basic Operating Specifications for Hypertension Prevention and Treatment, implement graded management and follow-up, and fill in the management card for patients with essential hypertension. Hypertensive patients receive drug therapy and non-drug therapy. When the patient has the situation stipulated in the Basic Operating Specification for Hypertension Prevention and Control, he will be referred to the superior general hospital in time, and then transferred back to the village clinic (station) for further treatment and follow-up after his condition is stable. Help patients make self-management plans and provide technical support for self-management of patients with hypertension.
4. Follow-up management and referral of diabetic patients.
According to the patient's clinical situation and comprehensive treatment plan, determine the management category required for patient follow-up and management, and fill out the Management Card for Patients with Primary Diabetes. Medication and non-medication for diabetic patients. When the patient has a condition that meets the referral situation, he will be referred to the superior general hospital in time, and then transferred back to the village clinic (station) for further treatment and follow-up after the condition is stable. Help diabetics make self-management plans and provide self-management support for diabetics.
Health guidance and intervention for high-risk population of hypertension and diabetes.
1, definition and detection of high-risk population of hypertension and diabetes.
According to the definition standards of high-risk groups of hypertension and diabetes, the high-risk groups of hypertension and diabetes were found through daily diagnosis and treatment, physical examination, establishment of health records and active screening.
2. Health guidance and intervention for high-risk groups of hypertension and diabetes.
Take the method of combining group and individual health guidance for high-risk groups, carry out health education to change unhealthy lifestyles, improve high-risk groups' understanding of hypertension, diabetes and risk factors through health education, give guidance on healthy lifestyles, and measure blood pressure and blood sugar regularly.
Health promotion of ordinary people at the grass-roots level
According to the health needs of grassroots people, widely publicize the knowledge of prevention and treatment of hypertension and diabetes, advocate a healthy lifestyle, encourage grassroots people to change bad lifestyles, reduce risk factors, and prevent and reduce the occurrence of hypertension and diabetes.
1, set up a publicity window for prevention and treatment of hypertension and diabetes in our hospital and village clinics, change the content 1 time every February, make a publicity leaflet for prevention and treatment of hypertension and diabetes, and distribute it to grassroots people through neighborhood committees and medical stations.
2, held once a month in the area of hypertension, diabetes knowledge lectures and healthy lifestyle lectures, free clinic and other activities.
3. Carry out free blood pressure measurement and blood sugar measurement activities in the villages under its jurisdiction.
Fourth, training.
In order to improve the management quality of hypertension and diabetes mellitus, doctors in village clinics were trained according to Basic Operating Rules for Hypertension Prevention, Guidelines for Hypertension Prevention in China and Guidelines for Diabetes Prevention in China.
Verb (abbreviation of verb) evaluation
1, process evaluation
Dynamic management of hypertension and diabetes, follow-up management of hypertension and diabetes, implementation of two-way referral, first blood pressure measurement of 35-year-old patients, patient satisfaction, etc.
2. Effect evaluation
Awareness rate of knowledge about prevention and treatment of hypertension and diabetes, change rate of risk behaviors related to hypertension and diabetes, blood pressure and blood sugar control rate of hypertension and diabetes, and standardized drug treatment rate.
Supervision and evaluation of intransitive verbs
1, our hospital is responsible for the supervision and assessment of village clinics (stations) within its jurisdiction, and the assessment opinions are timely fed back to the inspected units in order to improve the work in time.
2, the village clinic (station) to develop internal working system, workflow and quality control rules and regulations, strengthen self-examination.
Chronic disease management work plan 3 With the development of economy, the change of lifestyle and the acceleration of aging process, the incidence of chronic diseases such as hypertension, diabetes, coronary heart disease and malignant tumor is rising rapidly, and the disability rate and mortality rate are high, which seriously affects the physical and mental health of patients and brings a heavy burden to individuals, families and society. Therefore, the prevention and treatment of chronic diseases is particularly important, and the focus of chronic disease prevention and treatment is basic health services, and the prevention of chronic diseases is the effect of chronic disease prevention and treatment. Our hospital fully realizes the importance of prevention and treatment of chronic diseases. At present, the prevention and treatment of hypertension and diabetes has been included in the focus of basic public health services, and a special person has been appointed to manage it, and a chronic disease group has been established. This year's chronic disease management plan is formulated as follows:
I. Work objectives
1, 20xx March 3 1 hypertension 1938, 65438+February 3 1 3230.
2. In 20xx65438+February, a total of 538 people completed the diabetes declaration.
3. Arrange the public health team to take turns to go to the countryside to measure blood pressure free of charge, and use various methods such as free physical examination for the elderly and screening physical examination for chronic diseases over 35 years old to find patients with hypertension and diabetes as early as possible, so as to improve the early diagnosis rate and early treatment rate of hypertension and diabetes.
4. Strengthen the follow-up management of patients with hypertension and diabetes in the jurisdiction through telephone guidance, home visits, establishment of basic information of residents' health records and blood pressure measurement system for the first visit over 35 years old, improve the standardized management rate and vacancy rate of hypertension and diabetes, improve the knowledge and skills of self-management of patients with hypertension and diabetes, and reduce or delay the occurrence of complications of hypertension and diabetes.
5, strengthen health education and health promotion, regularly carry out lectures and publicity on hypertension and diabetes, popularize community residents' knowledge of prevention and treatment of hypertension and diabetes, control various risk factors, and improve people's health awareness.
Second, the filing work objectives
1, establish a chronic disease management health file, and the filing rate of the service population is 35%;
2. Establish complete health records of patients with hypertension and diabetes, with annual inspection records, follow-up records, treatment records and health education records.
Three, hypertension, diabetes work objectives
1. At least 2000 patients with hypertension and 200 patients with diabetes were newly discovered.
2. Standardize the management of patients with hypertension and diabetes, with the blood pressure control rate ≥ 70%; Blood sugar control rate ≥ 65%;
3.50% of the high-risk population receive hypertension examination at least 4 times a year;
4, the intervention of high-risk groups are recorded and evaluated.
Chronic disease management work plan 4 With the development of economy, the change of lifestyle and the acceleration of aging process, the incidence and prevalence of chronic diseases such as hypertension, diabetes, coronary heart disease and malignant tumor are on the rise rapidly, and the disability rate and mortality rate are high, which seriously affects the physical and mental health of patients and brings heavy burdens to individuals, families and society. Therefore, the prevention and treatment of chronic diseases is particularly important. To this end, our hospital will incorporate the prevention and treatment of chronic diseases into our comprehensive assessment objectives, create a supportive environment, and take the road of "combining prevention and treatment". According to the requirements of the higher authorities' documents on the prevention and treatment of chronic diseases, the work plan of chronic disease management in our hospital for 20xx years is specially formulated.
I. Work objectives
1. Establish the basic information registration of chronic diseases, register newly diagnosed cases of severe psychosis, diabetes and hypertension, and formulate the management system of chronic diseases. The vice president in charge is responsible for this work, the medical education department is responsible for implementation, and the responsibility is implemented to people.
2. Strengthen the primary screening of patients with hypertension and diabetes, improve the standardized management rate and control rate of hypertension and diabetes, improve the early diagnosis and treatment level of patients with hypertension and diabetes, and reduce or delay the occurrence of complications of hypertension and diabetes.
3. Strengthen health education and health promotion, regularly give lectures and hospitalization education to inpatients about hypertension and diabetes, popularize residents' knowledge about prevention and treatment of hypertension and diabetes, control various risk factors, and improve people's health awareness.
4, create a smoke-free hospital, smoke-free ward, according to our tobacco control system and reward and punishment scheme, hospital logistics staff and wards set up tobacco control supervisors, enter our public places for tobacco control publicity, persuade smokers, and each department set up a list of tobacco control supervisors, which is recorded.
5. Standardize the management of health canteens in our hospital, train employees on healthy lifestyles, distribute salt-controlled pots and oil-controlled pots to employees, and hold a health knowledge contest for our employees every year, with records.
Two. The goal of disease surveillance
Register cardiovascular and cerebrovascular events and tumor patients, monitor the cause of death of dead patients, register and report to Jinshan Community Sick Women's Station, measure the blood pressure of newly diagnosed patients over 35 years old, and register and report to Jinshan Sick Women's Station for corresponding management.
Third, the implementation plan
Establish a working system for chronic diseases; Carry out prevention and control work for the general population, patients with hypertension and diabetes, and establish a comprehensive prevention and control mechanism for hypertension and diabetes.
1. Detection of hypertension, diabetes and severe mental illness: Patients with hypertension and diabetes were found through patient consultation, physical examination, free blood pressure and blood sugar measurement in outpatient department, active detection and blood pressure measurement for the first time.
2. Registration of patients with hypertension and diabetes: register the detected patients with hypertension and diabetes and report them to Jinshan Community Sick Women Station.
3. The physical examination center shall report the physical examination unit and the total number of physical examinations every month, and register those who meet the diagnostic criteria of hypertension and diabetes in detail and report them to Jinshan Sick Women's Station for management.
4. Give lectures on chronic diseases to the community, participate in the education of chronic diseases in the Municipal Center for Disease Control and Prevention, conduct professional knowledge training for grassroots medical staff, and conduct chronic disease knowledge training for hospital staff every year.
5. Occasionally invite experts from higher hospitals to conduct business training for medical staff in our hospital.
Four, health guidance and intervention for high-risk groups of hypertension and diabetes.
1. Definition and detection of high-risk groups of hypertension and diabetes: According to the definition standards of high-risk groups of hypertension and diabetes, the high-risk groups of hypertension and diabetes were found through daily diagnosis and treatment, physical examination, establishment of health files and active screening.
2. Health guidance and intervention for high-risk groups of hypertension and diabetes: Take the method of combining group and individual health guidance for high-risk groups, carry out health education, change unhealthy lifestyles, improve high-risk groups' knowledge of hypertension and diabetes and risk factors through health education, give health guidance, and measure blood pressure and blood sugar regularly.
According to the health needs of grass-roots people, widely publicize the knowledge of prevention and treatment of hypertension and diabetes, advocate healthy lifestyles, encourage people to change unhealthy lifestyles, reduce risk factors, and prevent and reduce the occurrence of hypertension and diabetes. Make use of publicity days such as "Mental Health Day", "Hypertension Day" and "World Diabetes Day" to publicize the knowledge and concept of prevention and treatment of chronic non-communicable diseases, guide the society to pay attention to chronic non-communicable diseases, improve the people's awareness of knowledge of prevention and treatment of chronic diseases, continuously enhance the people's awareness of self-care, urge the people to improve their bad living habits, establish a healthy lifestyle and work style, eliminate or reduce related risk factors, and reduce the incidence, disability and mortality of chronic diseases.
4. Set up a publicity column on prevention and treatment of hypertension and diabetes, change the content of 1 time every 1 quarter, and distribute leaflets on prevention and treatment of chronic diseases such as hypertension and diabetes at the guidance desk.
5, held in the area of hypertension, diabetes knowledge lectures and healthy lifestyle lectures, free clinic and other activities.
6, in the area to carry out free blood pressure and blood sugar measurement activities.
Verb (abbreviation of verb) cultivation
In order to improve the management quality of hypertension and diabetes, medical staff in our hospital are trained in accordance with Basic Operating Rules for Hypertension Prevention, Guidelines for Hypertension Prevention in China and Guidelines for Diabetes Prevention in China.
Evaluation of intransitive verbs
1, process evaluation
Dynamic management of hypertension and diabetes, follow-up management of hypertension and diabetes, implementation of two-way referral, first blood pressure measurement of 35-year-old patients, patient satisfaction, etc.
2. Effect evaluation
Awareness rate of knowledge about prevention and treatment of hypertension and diabetes, change rate of risk behaviors related to hypertension and diabetes, blood pressure and blood sugar control rate of hypertension and diabetes, and standardized drug treatment rate.
Seven. Monitoring and evaluation
The medical education department of our hospital is responsible for the supervision and assessment of clinical departments, and timely feedback the assessment opinions to the inspected departments or individuals in order to improve the work in time.
Relevant departments in the village should formulate internal working systems, work processes and quality control rules and regulations, and strengthen self-inspection.
Work plan for chronic disease management 5 I. Work objectives
Give guidance to patients with chronic diseases such as hypertension and diabetes, and inhibit the first blood test for outpatients over 35 years old. Treat patients with hypertension and diabetes, and register and manage patients within the jurisdiction. Patients with hypertension are followed up once every three months, and patients with diabetes are followed up once every quarter, and the follow-up work must be implemented. Carry out a correct physical examination for patients and give health guidance on medication, diet, exercise and psychology. The management rate of patients with chronic diseases is over 30%, and the control rate is over 60%.
1. Establish a basic information system for chronic diseases, register and file newly diagnosed cases of diabetes and hypertension by using the existing network, and formulate a management system for chronic diseases. The leader is in charge of this work, and the responsibility is implemented to the people.
2, the use of residents' health records and organize residents to carry out health examination, early detection of hypertension and diabetes, improve the early diagnosis rate and early treatment rate of hypertension and diabetes.
3. Strengthen the follow-up management of patients with hypertension and diabetes in the community, improve the standardized management rate and control rate of hypertension and diabetes, improve the self-management and knowledge and skills of patients with hypertension and diabetes, and reduce or delay the occurrence of complications of hypertension and diabetes.
4. Taking our hospital as the core, village clinics as the foundation, focusing on prevention and treatment by groups and individual prevention and control, exploring the management mode and mechanism of establishing county CDC, evaluating our hospital to assist diagnosis and individualized treatment, providing technical support, and the follow-up management of hypertension and diabetes in village clinics.
5, strengthen health education and health promotion, regularly carry out lectures and publicity on hypertension and diabetes, popularize community residents' knowledge of prevention and treatment of hypertension and diabetes, control various risk factors, and improve people's health awareness.
6. Establish a standardized file management system for hypertension, diabetes and severe mental illness.
Second, the filing work objectives
1. Establish health records of community residents, and the baseline survey rate of community service population reaches 40%;
2. Establish health records of patients with hypertension and diabetes, with follow-up records, treatment records and health education records.
Third, the implementation plan
Establish a working system for chronic diseases; To carry out the prevention and control of the general population, hypertension and diabetes in the community, and establish a comprehensive prevention and control mechanism for hypertension and diabetes in the community.
1. Detection of hypertension and diabetes. Patients with hypertension and diabetes can be found by establishing community residents' health records, physical examination, diagnosis and treatment in community health service centers, free blood pressure measurement and blood sugar measurement in the community, active detection and first blood pressure measurement.
2. The registration of patients with hypertension and diabetes will register and file the detected patients with hypertension and diabetes, and standardize management.
3. Follow-up management and referral of patients with hypertension
Collect the detailed medical history of the detected hypertension patients, carry out necessary physical examination and laboratory examination, conduct clinical evaluation according to the requirements of the Basic Norms for Hypertension Prevention and Treatment, implement graded management and follow-up, and fill out the community hypertension patient management card. Hypertensive patients receive drug therapy and non-drug therapy. When the patient has the situation stipulated in the Work Standard for Prevention and Treatment of Hypertension at the Primary Level, he will be referred to the superior general hospital in time, and then transferred back to the village clinic for further treatment and follow-up after his condition is stable. Help patients make self-management plans and provide technical support for self-management of patients with hypertension.
4. Follow-up management and referral of diabetic patients. According to the patient's clinical situation and comprehensive treatment plan, determine the management category that patients need to follow up and manage, and implement drug and non-drug treatment for diabetic patients. When the patient has a condition that meets the referral situation, he will be referred to the superior general hospital in time, and then transferred back to the village clinic after the condition is stable, and continue treatment and follow-up. Help diabetics make self-management plans and provide self-management support for diabetics. Understand the knowledge and risk factors of blood pressure and diabetes, give guidance on health style, and measure blood pressure and blood sugar regularly.
Third, promote the health of the community.
According to the health needs of the community population, widely publicize the knowledge of prevention and treatment of hypertension and diabetes in the community, advocate a healthy lifestyle, encourage the community population to change unhealthy lifestyles, reduce risk factors, and prevent and reduce the occurrence of hypertension and diabetes.
1, set up a publicity window for prevention and treatment of hypertension and diabetes in our hospital and village clinics, and change the content 1 time every February, make a leaflet for prevention and treatment of hypertension and diabetes, and distribute it to the community through neighborhood committees and medical stations.
2, held once a month in the area of hypertension, diabetes knowledge lectures and healthy lifestyle lectures, free clinic and other activities.
3. Carry out free blood pressure measurement and blood sugar measurement activities in the villages under its jurisdiction.
Four. assess
1, process evaluation
Dynamic management of hypertension and diabetes, follow-up management of hypertension and diabetes, implementation of two-way referral, first blood pressure measurement of 35-year-old patients, patient satisfaction, etc.
2. Effect evaluation
Awareness rate of knowledge about prevention and treatment of hypertension and diabetes, change rate of risk behaviors related to hypertension and diabetes, blood pressure and blood sugar control rate of hypertension and diabetes, and standardized drug treatment rate. Our hospital is responsible for the supervision and evaluation of village clinics within its jurisdiction, and the evaluation opinions are timely fed back to the inspected units in order to improve the work in time.
Luojiawa hospitals
Xx，xx，XX，XX
Chronic disease management work plan 6 This plan is formulated in order to establish and improve the chronic disease management system that conforms to the social development level of our town, implement chronic disease intervention measures for urban and rural residents, reduce the exposure of major health risk factors, effectively prevent and control chronic diseases such as hypertension and diabetes, implement the national basic public health service standards and superior requirements, and combine the actual situation of our town:
I. Management of Residents' Health Records
1, find out the total number of households and population in the area.
2. Establish health records for residents in this area. Based on the filing rate of 30% in 20XX, it is required to complete 80% this year and strive to reach 100%.
3, through the file, grasp the situation of children 0~36 months, pregnant women, hypertension, type 2 diabetes, severe mental illness and the elderly over 65 years old, and implement classified guidance and management.
4, according to the requirements of standardized management, properly record, organize, save, report and update all kinds of data.
Second, the health management of the elderly over 65 years old
1, find out the base number of elderly people over 65 years old within the jurisdiction, and all health centers should register, record and keep the base number and report it to the health centers for summary.
2, the elderly over the age of 65 to conduct a health check every year, and make records.
3, the elderly over 65 years old for a free blood sugar test every year, and make records.
4. Establish health records through household surveys, require the village filing rate to reach over 95%, strive for 100%, and realize standardized management.
Three, hypertension patients health management (the Communist Youth League work plan)
1. Establish a blood pressure measurement system for people over 35 years old, screen and find patients with hypertension in time, and require the blood pressure measurement ratio of people over 35 years old to reach over 95%.
2. Establish a register of hypertensive patients over 35 years old and implement hierarchical management. The filing rate of each village is required to reach over 95%, and strive to reach 100%.
Patients with hypertension over 3.35 years old should have a health check-up and free blood sugar test every year.
4. Follow-up patients with hypertension who have been diagnosed clearly every three months, and timely follow-up special patients according to their condition. Follow-up records and file contents shall be updated in time, and items shall not be missed.
5. Seriously study service standards, master health knowledge such as health guidance and behavior intervention for patients with chronic diseases, and provide reasonable intervention guidance for patients.
6, according to the requirements of standardized management, properly record, organize, save, report and update all kinds of data.
Fourth, the health management of patients with type 2 diabetes
1, and find out the base number of patients with type 2 diabetes in the jurisdiction.
2. Establish a register of patients with type 2 diabetes, implement classified management, report and summarize it, and require that the filing rate in villages should reach over 95%, and strive for 100%.
3. Patients with type 2 diabetes receive health examination and free blood sugar test every year.