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 remain 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, and the focus of chronic disease prevention and treatment is on basic health services. Prevention of chronic diseases is the most effective means of chronic disease prevention, and the quality of chronic disease prevention is directly related to the effect of chronic disease prevention. Our hospital fully realizes the importance of prevention and treatment of chronic diseases. At present, the prevention and treatment of hypertension and diabetes have been included in the focus of basic public health services, and a special person has been appointed to manage them, and a chronic disease team has been established. This year's chronic disease management plan is formulated as follows:
I. Work objectives
1. Arrange the public health team to take turns to go to the countryside to measure blood pressure for free, and use various methods such as free physical examination for the elderly and screening for chronic diseases over 35 years old to find patients with hypertension and diabetes early, so as to improve the early diagnosis rate and early treatment rate of hypertension and diabetes.
2. 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 of outpatients over 35 years old, improve the standardized management rate and control rate of hypertension and diabetes, improve the self-management knowledge and skills 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 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 community residents' health records, and the filing rate of the service population in the jurisdiction reaches 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
Newly discovered and registered 1 and 150 patients with hypertension and 20 patients with diabetes;
2. Standardize the management of at least 972 patients with hypertension and 165 patients with diabetes, with the blood pressure control rate ≥ 60%;
3, found and registered at least 30 high-risk groups;
4.50% of the high-risk population have their blood pressure measured at least four times a year;
5. The intervention of high-risk groups is recorded and evaluated.
Baren zhelimu center hospitals
20 10 March 15