Establish a chronic disease management team and form a practical work network diagram. Village doctors in village clinics are specific staff, and the management team is responsible for business guidance. Next is my self-summary of chronic disease work, I hope it will help you ~

Self-summary of chronic diseases 1 20xx, with the strong support of hospital leaders and the cooperation of Qi Xin, a village doctor in each village clinic, we managed chronic diseases in our jurisdiction according to the Regulations on the Management of Chronic Diseases, and achieved standardized filing and standardized management.

The management of chronic diseases is summarized as follows:

First, leaders attach importance to strengthening leadership.

Convene regular meetings of the leading group for chronic diseases in the local area to discuss the chronic disease management scheme and scheme, communicate with the person in charge of the clinic, make detailed arrangements for the phased work, and strive for the support of the majority of villagers in the local area so as to successfully complete the work.

Second, the responsibility of network management lies with people.

Full-time chronic disease managers and chronic disease management teams have been set up, forming a feasible work network diagram. Village doctors in village clinics are specific staff, and the management team is responsible for business guidance.

Third, organize training for rural doctors on chronic diseases to improve their knowledge of chronic disease service management.

Regularly hold training for rural doctors on chronic disease management, and hold lectures on hypertension and diabetes in view of the high incidence of diseases in the jurisdiction.

Fourth, strengthen publicity and carry out health consultation.

Regularly carry out publicity and consultation activities on chronic disease health education every month. Make use of medical human resources, give full play to their respective specialties, carry out special consultation activities according to each person's characteristics, and voluntarily measure blood pressure for residents. By the end of 65438+February, * * * had organized 1 1 consultation activities, benefiting 660 people and distributing more than 3000 publicity materials, which achieved good results.

Five, the establishment of health records to implement systematic management.

According to the detailed rules for the management of chronic diseases, each village group has established detailed information on the clients of hypertension and diabetes, and requires township doctors to follow up regularly, and the management team regularly supervises the township doctors. At present, hypertension 1546 cases, diabetes 567 cases and psychosis 45 cases have been established. The management rate is 98%, the effective management rate is 98%, and the standardized management rate is 95%.

Six, to carry out education and monitoring of chronic diseases.

We will monitor chronic diseases, mainly hypertension and diabetes, publicize disease prevention among high-risk groups by distributing publicity materials and holding lectures, and strengthen the publicity and supervision of non-drug and drug treatment.

Seven, the annual chronic disease work summary

(1) Follow-up of hypertension:

1. At present, there are 2,995 hypertensive patients in our town (* see the roster of hypertensive patients), and 7,468 people have actually been followed up, including 4 1 16 people at home, 8 people by telephone 18 people and 3,334 people in outpatient department. The follow-up rate in the first half of the year was 79.6%. 7452 service coupons were recovered.

2. Among the patients who were followed up in the first half of the year, 2023 cases had stable blood pressure control and maintained drug treatment unchanged; 972 people were dissatisfied with blood pressure control and changed their drugs.

3. 1256 people have newly discovered hypertension, which has been included in the management of chronic diseases.

4. Compared with 20xx, the prevalence of hypertension decreased in the first half of 20xx.

(2) Follow-up of diabetes:

1. At present, there are 279 diabetic patients in our town (* see the roster of patients with hypertension), and 875 people have actually been followed up, including 5 13 people in the home, 2 people in the telephone and 360 people in the outpatient department. The follow-up rate was 93.3%. Recovered 873 service coupons.

2. Among the patients who were followed up this quarter, 236 patients had stable blood sugar control and maintained the same drug treatment; 43 people were dissatisfied with blood sugar control and changed their drugs.

3. 97 newly discovered diabetics have been included in the management of chronic diseases.

4. Compared with the first half of 20xx, the prevalence of diabetes decreased.

Self-summary of chronic disease work 2 In the next 20xx years, our chronic disease management team successfully completed related tasks with the cooperation of superior leaders and colleagues. In 20xx, we will continue to make efforts to make the prevention and control of chronic diseases better and better.

I. Development of prevention and treatment of chronic diseases in 20xx years

1, hypertension and diabetes management

Adhere to the blood pressure measurement of residents over the age of 35 at the first consultation, include the physical examination of residents and employees in the opportunistic screening, and find and register new patients with chronic diseases and high-risk groups at any time. This year, 74 1 hypertension files and 3 18 diabetes files were newly established, which effectively completed patient follow-up and annual evaluation.

On the basis of the original two chronic disease groups, a new self-management group for hypertension and diabetes was established, which continued the frequency of group activities last year, constantly increasing the content and updating the form of activities. This year, 2 1 group activities for hypertension and 0/9 group activities for diabetes were carried out.

Through lectures, outdoor publicity, free clinics and other forms, do a good job in publicity activities related to hypertension and diabetes day, including more than 500 free blood pressure tests and more than 350 free blood sugar tests; Distribute all kinds of publicity materials 10, about 1000.

2. Follow-up work of high-risk groups of stroke.

This year is the second year of stroke follow-up in our center. This year, our center continued to follow up 322 people with more than three risk factors four times a year. 456 people with 1-2 risk factors were followed up once a year; Up to now, * * * has been followed up161person-times, including 4 deaths, 773 lost visits and 29 referrals.

3. Follow-up of tumor patients

Through telephone follow-up and the help of neighborhood committees, 3 18 tumor patients were actually treated, including 7 patients from other places, 4 1 person lost to follow-up and 4 18 person died, which successfully completed the follow-up work of tumor patients this year.

4. National Healthy Lifestyle Action

Completed the establishment of our center demonstration unit and successfully passed the acceptance of district disease control and municipal disease control. In addition, actively prepare to create healthy trails, healthy huts and healthy canteens, and wait for acceptance next year.

Through the cooperation with family health workers, the recruitment and training of 33 healthy lifestyle instructors were completed, and a complete record of guidance training and activities was kept.

5, community diagnosis work

Since the community diagnosis was officially started in early June, the questionnaire survey and physical examination of 30 10 people in the jurisdiction have been successfully completed through cooperation with the streets, cooperation with neighborhood committees, appointment of outpatient clinics and online publishing. Blood tests of 2607 people and all data entry. Through community diagnosis, 346 people were screened negative for hepatitis B antigen antibody/kloc-0, and 979 people were vaccinated with hepatitis B vaccine for free. Hepatitis B antigen was positive in 9 1 person, and 45 people were referred to ditan hospital for further examination.

7, aspirin standardization action

In the general clinic, the use of aspirin was investigated among the target population for 3 weeks. * * * Completed the questionnaire 1000, and carried out two patient health education activities with four contents related to chronic diseases, reaching more than 200 people.

Second, the existing problems and main measures

1, the passive management of hypertensive diabetic patients, outpatient doctors should take the initiative to attack.

At present, the mode of community management of chronic diseases is that doctors chase patients. Patients' concern about diseases is limited to going to the hospital to see a doctor, prescribe drugs, give injections and infusions, and do not pay attention to intervention measures such as living habits, behavior patterns and risk factors. Therefore, the passive management of patients with chronic diseases is difficult, and it is also difficult to carry out chronic disease work.

In addition to hoping that the government will strengthen the propaganda of chronic diseases and raise residents' concern for their own health, our community doctors should also take the initiative, take pains to talk more and give more health guidance, and advise patients to participate in lectures, large classes and group activities organized by the hospital after seeing a doctor, and prescribe drugs for patients with new hypertension and diabetes or patients with unsatisfactory blood pressure and blood sugar control.

2. Follow-up of patients with high risk of stroke should be realistic.

Although our doctor calls to explain every follow-up, only half of the high-risk patients come for follow-up. Most patients refused to participate in the follow-up because of too few examination items, recent examination or other reasons. Even if they come for follow-up, a few people can come on the required date.

For such patients, we will first remind them of the time of the next follow-up, and suggest them to do a physical examination for the elderly with relatively complete items, or at the same time participate in some recent free examinations such as community diagnosis. At the same time, for the high-risk groups who come for follow-up, we will often inform them to attend lectures on chronic diseases such as stroke, so that residents can feel the concern of the community center and are willing to receive continuous follow-up. However, for those who did not come for follow-up after our sincere advice, we recorded them realistically and classified them as those who lost contact.

3. Long-term financial and material support is needed to support the creation of a healthy lifestyle throughout the country.

The establishment of health trails and demonstration canteens is difficult to complete only by community centers. During this period, we need not only the strong support of the government and streets, but also the long-term cooperation of neighborhood committees and relevant departments. As a technical support department, it is undoubtedly a challenge for the community center to independently complete the demonstration and creation work.

In addition, healthy lifestyle instructors have many difficulties from recruitment training to activities. This year's instructor training, our center completed the recruitment training only after cooperating with the family insurance staff. During the activity, more than half of the instructors can perform their duties and publicize well, but they always forget or don't do it or think they can't give corresponding information feedback.

4. Community diagnosis is a project that benefits the people, but sometimes it is not understood.

Community diagnosis should be regarded as a screening for benefiting the people, but there are also some things that can't be understood during the period: there are few inspection items, too few gifts and too many questionnaire questions. ...

Appointing residents to participate in community diagnosis through different platforms such as streets, neighborhood committees and the Internet will naturally bring various problems. In this process, we set up a person to be responsible for on-site arrangement, communication and coordination; Make appointments for residents in different regions and time periods; Different groups of people focus on personalized publicity ...

Three. 20xx work plan

First, focus on managing high-risk groups, achieve twice the result with half the effort, and accumulate patients.

Continue to do a good job in the management of patients with hypertension and diabetes, and improve the intervention management of high-risk groups such as stroke and hypertension; It is necessary to publicize the knowledge about the prevention and treatment of chronic diseases, and to enhance the attention of high-risk groups to their own diseases.

We will continue to adhere to the form of chronic disease self-management group activities, and strive to drive more patients to join the self-management team through these benefited group members to help more and more patients achieve self-management.

Second, do a good job in the follow-up of stroke and insist on seeking truth from facts.

For high-risk groups who can come for follow-up every time, make corresponding follow-up records; Those who refuse to follow up for various reasons, or who still can't get through after three or four calls, will be recorded one by one, and the lost follow-up will be marked to ensure the authenticity of the follow-up work of stroke.

Third, focus on the healthy lifestyle of the whole people and strengthen community intervention in chronic diseases.

Combined with the national healthy lifestyle action, we will carry out health intervention activities for the target population by means of demonstration units, healthy huts, healthy paths, etc., focusing on unhealthy lifestyles that lead to chronic diseases, and publicizing salt restriction, tobacco control, physical exercise and other contents. Make full use of "No Tobacco Day", "Hypertension Day", "Diabetes Day" and "Healthy Lifestyle Day" to carry out special publicity activities.

Fourth, strengthen the education of chronic diseases for white-collar workers and primary and secondary school students in enterprises.

Strengthen communication with enterprises, schools and other units in the jurisdiction, carry out propaganda and education activities in workplaces and schools, effectively give play to the economic and social benefits of health education and health intervention, and strengthen health education and health promotion for students' chronic disease prevention and treatment.

Five, strengthen the training of health management related knowledge.

Strengthen the clinical knowledge, prevention and health care knowledge of chronic disease managers by participating in weekly business study and daily internal study in the center. Combined with the training of CDC, let chronic disease managers participate in relevant health management training courses organized by higher authorities to effectively improve their health management capabilities.

Six, do other temporary work.

With the government's investment in the prevention and treatment of chronic diseases and the improvement of residents' health awareness, the proportion of community chronic disease management in community health services is increasing. We have summarized the experience and shortcomings of chronic disease management in 20xx, and we will continue to work hard in 20xx to improve the ability of chronic disease management and explore a new mode of chronic disease management suitable for our center.

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