How to fill in the records of the follow-up guidance form of TCM health management for the elderly over 65 years old

Give you a few examples! Attachment Record Form of Follow-up Service for Hypertensive Patients Name:No. Date of Follow-up Year Month Year Month Year Month Day Follow-up Method 1 Outpatient 2 Family 3 Phone 1 Outpatient. 2 family 3 telephone □ 1 outpatient 2 family 3 telephone □ 1 outpatient 2 family 3 telephone □ symptoms 1 asymptomatic 2 headache, dizziness, nausea and vomiting, dizziness, tinnitus, dyspnea, palpitation, chest tightness, nosebleed, numbness of mmHg than 8 limbs, edema of 9 lower limbs □ □□□□□□□□□□□□□ Other life formulas refer to daily smoking (cigarettes)///daily drinking (two)//operation times/minutes/times/minutes/times/minutes/times/minutes/times/times/times/times/times/times/times/times/times/times (g/ day)//. Kloc-0/ Good 2 General 3 □ Medical Compliance 1 Good 2 General 2 3 Poor □ 1 Good 2 General 3 Poor □ 1 Good 2 General 3 Poor □ 1 Good 2 General 3 Poor Medication Compliance 1 Rule 2 Intermittent 3 No Medication □/Kloc-0 Rule 2 Intermittent 3 No medication □ 1 Rule 2 Intermittent 3 No medication □ Adverse drug reactions □ 1 None □ 1 None. 2 Yes □ 1 None 2 Yes □ This follow-up classification 1 control satisfaction 2 Control dissatisfaction 3 adverse reactions 4 complications□ 1 control dissatisfaction 3 adverse reactions 4 complications□/control dissatisfaction 2 Control dissatisfaction 3 adverse reactions 4 complications □1control satisfaction. 2 unsatisfactory control, 3 adverse reactions, 4 complications □ Drug situation, drug name 1 Usage: mg once a day, mg once a day, mg once a day, mg once a day, drug name 2 Usage: mg once a day, mg once a day, mg once a day. Drug name per milligram 3 Usage per milligram per day per milligram per day per milligram per day per milligram for other drugs Usage per milligram per day per milligram per day per milligram per day per milligram per day per milligram per day per milligram per day per milligram per day per milligram per day per day per milligram per day per day per day per day per referral to the original institution and the date of the next follow-up by the department. The follow-up doctor signed 1. This form is filled out by doctors when patients with hypertension receive follow-up service. Fill in the health check list of residents' health records after comprehensive evaluation every year. 2. Logo: BMI = weight (kg)/ height square (m2). If there are other positive signs, please fill in the "Other" column. Fill in the current situation before the diagonal of weight and heart rate, and fill in the target that should be adjusted in the next follow-up after the diagonal. 3. Lifestyle guidance: while asking about the patient's lifestyle, guide the patient's lifestyle and work out the next follow-up goal with the patient. Daily smoking quantity: fill in the current smoking quantity before the diagonal line, zero for non-smokers, xx cigarettes for smokers every day, and xx cigarettes after the diagonal line for smokers' next follow-up. Daily drinking amount: fill in the current drinking amount before the slash, and fill in "0" if you don't drink. The daily drinking amount of drinkers is equivalent to liquor×× 2 ",and the target drinking amount of drinkers is equivalent to liquor×× 2" after the slash. Liquor 1 is equivalent to 4 liang of wine, half a catty of yellow wine, beer 1 bottle and 4 liang of fruit wine. Exercise: fill in the number of times a week and how many minutes each time. That is, "xx times/week, xx minutes/time". Fill in the status quo on the horizontal line, and fill in the goals to be achieved in the next follow-up on the horizontal line. Salt intake: fill in the current salt intake before the diagonal, calculate the daily salt intake of ×g/ day according to the patient's diet, and fill in the target salt intake after the diagonal. Psychological adjustment: choose the corresponding options according to the doctor's impression. Compliance behavior: refers to whether patients follow the doctor's instructions to improve their lifestyle. 4. Auxiliary examination: record the auxiliary examination results of patients in various medical institutions between the last follow-up and this follow-up. 5. Medication compliance: "Regular" means taking medicine according to the doctor's advice, "intermittent" means not taking medicine according to the doctor's advice, and the number or quantity is insufficient. "No taking medicine" means that the doctor prescribed medicine, but the patient did not use it. 6. Adverse drug reactions: If the antihypertensive drugs taken by patients have obvious adverse drug reactions, specifically describe which drugs and which adverse reactions. 7. Classification of this follow-up: According to the classification results of this follow-up, the responsible doctor will choose one of the four classification results and fill in the corresponding number in □. "Satisfactory control" means that the blood pressure control is satisfactory and there is no other abnormality. "Poor control" means that the blood pressure control is not ideal and there is no other abnormality. "Adverse reactions" refers to the existence of adverse drug reactions, and "complications" refers to the emergence of new complications or abnormal complications. If the patient has several conditions at the same time, fill in the most serious one, determine the next follow-up time of the patient according to the last follow-up situation, and inform the patient. 8. Drug use: According to the patient's overall situation, make a prescription for the patient, fill in the name of the antihypertensive drug that the patient will take, and indicate the usage. 9. Referral: In case of referral, the medical institution and department category of referral should be stated, such as the Department of Cardiology of XX People's Hospital, and the reason for referral should be stated in the column of reasons. 10. signature of follow-up doctor: after the follow-up is completed, the follow-up doctor will sign it after verification. Attachment 2 Record Form of Follow-up Service for Type 2 Diabetes Mellitus Name:No. □□□□□□□□□□ Follow-up Date Follow-up Method 1 Outpatient 2 Family 3 Telephone □ 1 Outpatient 2 Family 3 Telephone □ 1 Door. Diagnosis: 2 family calls □ symptoms 1 asymptomatic 2 excessive drinking □ polyphagia □ polyuria □ 5 blurred vision □ infection 7 numbness of hands and feet 8 edema of lower limbs □/□/□ □/□ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Untouched 2Touched □ 1 Untouched 2Touched □ 1 Untouched 2Touched □ Other activity prescription refers to daily smoking quantity/cigarette/cigarette/cigarette/cigarette/cigarette/cigarette/cigarette/cigarette/cigarette/cigarette/cigarette/weekly minute/time/minute. Good 2 General 3 Poor □ Auxiliary examination Fasting blood glucose value mmol/l mmol/l Other examination * HbA 1c% Examination date: month/day HbA 1c% Examination date: month/day HbA 1c% Examination date: month/day medication compliance 1 Rule 2 Intermittent 3 no medication □ 65438+ 0 Rule 2 Intermittent 3 no medication □ 1 Rule 2 Intermittent 3 no medication □ 1 Rule 2 Intermittent 3 no medication □ 1 Rule 2 Intermittent 3 no medication □/hypoglycemia reaction □ 1 no 2 occasionally 3. No 2 occasionally has 3 frequencies □ 1 no 2 occasionally has 3 frequencies □ this follow-up classification 1 control satisfaction 2 control dissatisfaction 3 adverse reactions 4 complications□1control satisfaction 2 control. Dissatisfaction 3 adverse reactions 4 complications □ 1 control satisfaction 2 control dissatisfaction 3 adverse reactions 4 complications □ 1 control satisfaction 2 control dissatisfaction 3 adverse reactions 4 complications □ drug use 1 usage: mg once a day, mg once a day, Mg once a day mg once a day mg drug name 2 usage daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg daily mg the signature of the follow-up doctor on the next follow-up date referred by the institutions and departments of islet etiology indicates that this form is 1. This form is filled out by doctors when patients with type 2 diabetes receive follow-up service. The annual comprehensive evaluation fills in the health check list of residents' health records. 2. Logo: BMI = weight (kg)/ height square (m2). If there are other positive signs, please fill in the "Other" column. Fill in the current situation before the diagonal of the weight, and fill in the target to be adjusted in the next follow-up after the diagonal. 3. Lifestyle guidance: ask the patient's lifestyle, give the patient lifestyle guidance at the same time, and work with the patient to set the next follow-up goal. Daily smoking quantity: fill in the current smoking quantity before the slash, zero for non-smokers, xx cigarettes for smokers every day, and xx cigarettes after the slash for smokers' next follow-up. Daily drinking amount: fill in the current drinking amount before the slash, and fill in "0" if you don't drink. The daily drinking amount of drinkers is equivalent to liquor×× 2 ",and the target drinking amount of drinkers is equivalent to liquor×× 2" after the slash. Liquor 1 is equivalent to 4 liang of wine, half a catty of yellow wine, beer 1 bottle and 4 liang of fruit wine. Exercise: fill in the number of times a week and how many minutes each time. That is, "xx times/week, xx minutes/time". Fill in the status quo on the horizontal line, and fill in the goals to be achieved in the next follow-up on the horizontal line. Staple food: according to the actual situation of patients, estimate the intake of staple food (rice, pasta, biscuits and other starchy foods). It is the total measurement of eating every day. Psychological adjustment: choose the corresponding options according to the doctor's impression. Compliance behavior: refers to whether patients follow the doctor's instructions to improve their lifestyle. 4. Auxiliary examination: fasting blood glucose examination was performed on patients and the examination results were recorded. If the patient goes to various medical institutions for glycosylated hemoglobin or other auxiliary examinations between the last follow-up and this follow-up, it should be recorded truthfully. 5. Medication compliance: "Regular" means taking medicine according to the doctor's advice, "intermittent" means not taking medicine according to the doctor's advice, and the number or quantity is insufficient. "No taking medicine" means that the doctor prescribed medicine, but the patient did not use it. 6. Adverse drug reactions: If the patient has obvious adverse drug reactions after taking the above drugs, specifically describe which drugs and which adverse reactions. 7. Hypoglycemia reaction: According to the hypoglycemia reaction between the last follow-up and this follow-up. 8. Classification of this follow-up: According to the classification result of this follow-up, the follow-up doctor will choose one of the four classification results and fill in the corresponding number in □. "Satisfactory control" means that the blood sugar control is satisfactory and there is no other abnormality. "Poor control" means that blood sugar control is not ideal, and there are no other abnormalities. "Adverse reactions" refers to the existence of adverse drug reactions, and "complications" refers to the emergence of new complications or abnormal complications. If the patient has several conditions, fill in the most serious one, decide the next follow-up time of the patient according to the last follow-up situation, and inform the patient. 9. Medication: According to the overall situation of the patient, give the patient a prescription, fill in the name of the hypoglycemic drug that the patient will take, and indicate the usage. Insulin specifies the type, time and dosage of insulin. 10. Referral: In case of referral, the medical institution and department category of the referral should be stated, such as the Department of Cardiology of XX People's Hospital, and the reason for the referral should be stated in the column of reasons. 1 1. signature of follow-up doctor: after the follow-up is completed, the follow-up doctor will sign it. Attachment 1 Name of Personal Information Supplementary Form for Patients with Severe Mental Illness:No. □□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□ □ Previous treatment □ Outpatient service 1 Untreated □ 2 Intermittent outpatient service □ Continuous outpatient service □ Hospitalization in psychiatric hospital/latest diagnosis and diagnosis in psychiatric department of general hospital. The date of hospital diagnosis was confirmed. The latest treatment effect is 1. Recovery 2, improvement 3, no change 4, aggravation □ The influence of illness on family and society is 1. Minor troubles 2 accidents 4 self-mutilation 5 attempted suicide 6 unlocked 1 unlocked 2 unlocked 3 unlocked □ Date and year of filling in the form. Instructions for medical students to sign the form 1. For patients with severe mental illness, this form should be filled out in addition to the personal basic information form when establishing residents' health records. When personal information changes during follow-up, it should be revised in time. 2. Name of guardian: the person who is currently exercising guardianship duties according to law. 3. Guardian's address and guardian's telephone number: fill in the current residential address of the patient's guardian and the telephone number that can be contacted at any time. 4. Time of first onset: the time when the patient first developed mental symptoms. 5. Past main symptoms: According to the patient's situation from the first onset to the time of filling out the form, fill in the main symptoms that the patient had. 6. Previous treatment: fill in according to the outpatient and inpatient treatment received by the patient. If you have never been to a mental hospital or a general hospital, please fill in "0" and the number of times you have been to the hospital. 7. Recent diagnosis: fill in the name of the patient's latest diagnosis of mental illness, and fill in the name of the hospital and the date of diagnosis. 8. The influence of illness on family and society: according to the patient's situation from the first onset to the time of filling in the form, if it does not happen, fill in "0"; If it happens, fill in the corresponding number of times. Slight trouble-making: refers to cases in which the public security organs go to the police but only make general education, such as patients hitting people, cursing others or disturbing the order, but without causing damage to life and property, which belongs to this category. Accident: refers to the behavior of patients who violate China's public security administration punishment law but not the criminal law, such as beating, wounding, destroying items, etc. , but it will not cause minor or serious injuries to the victim. Picking up trouble: It means that the patient's behavior violates the criminal law and belongs to a criminal act. 9. Locking: Locking refers to the use of certain tools (such as ropes, chains, iron cages, etc.). ) Restrict patients' freedom of movement for non-medical purposes. Attachment 2 Record Form of Follow-up Service for Patients with Severe Mental Illness Name:No. □□□□□□□□□□ Follow-up Date Month Day Current Symptoms 1 Illusion 2 Communication Difficulties 3 Suspicion 4 Moodiness 5 Weird Behavior 6 Excited Speech 7 Hurting People and Destroying Things 8 Pessimism. 9 Going out for no reason 10 self-mockery 1 1 loneliness and laziness 12 Others □/□ /□ □ Epiphany 1 Epiphany Complete 2 Epiphany Incomplete 3 Epiphany Lack □ Sleep 1 Good 2 General 3 Poor □ 3 poor □ social function □ personal life cooking 1 good 2 average 3 poor □ housework 1 good 2 average 3 poor □ productive labor and work 1 good 2 average 3 poor 9 This item is not applicable □ learning ability 1 good 2 average 3 poor □ social interpersonal communication 1 good 2 average 3 poor. □ Influence of the disease on family and society 1 Mild distress 2 times, 3 times, 4 times of self-injury, 5 times of attempted suicide, 6 times of no laboratory examination, medication compliance 1 regularity, 2 times of interruption and 3 times of no medication. □ Adverse Drug Reaction 1 No 2 Yes □ Efficacy 1 Cure 2 Improvement 3 No Change 4 Aggravation □ Follow-up classification is 1 Stable 2 Basically Stable 3 Unstable □ Whether to refer to 1 No 2 Yes. □ reason: institutions and departments: drug use: drug 1: usage: mg drug twice a day (monthly) 2: usage: mg drug twice a day (monthly) 3: usage: daily (monthly) mg rehabilitation measures per dose 1 life and work ability 2 vocational training 3 learning ability 4 social interaction 5 others □ /□ □ Current symptoms: fill in what happened from the last follow-up to this follow-up. 2. Self-knowledge: it is the ability of patients to understand their mental state. Self-awareness is complete: the patient's mental symptoms disappear, he truly realizes that he is sick, can thoroughly understand what the pathological manifestations are, and thinks that he needs treatment. Incomplete insight: patients admit that they are ill, but lack the ability to correctly understand and analyze their pathological manifestations. Lack of insight: the patient denies that he is sick. 3. The influence of the disease on family and society: fill in the situation from the last follow-up to this follow-up. If it does not happen, fill in "0"; If it happens, fill in the corresponding number of times. Slight trouble-making: refers to cases in which the public security organs go to the police but only make general education, such as patients hitting people, cursing others or disturbing the order, but without causing damage to life and property, which belongs to this category. Accident: refers to the behavior of patients who violate China's public security administration punishment law but not the criminal law, such as beating, wounding, destroying items, etc. , but it will not cause minor or serious injuries to the victim. Picking up trouble: It means that the patient's behavior violates the criminal law and belongs to a criminal act. 4. Laboratory examination: record the latest laboratory examination results (within 3 months), including the examination in the superior hospital or other hospitals. 5. Medication compliance: "Regular" means taking medicine according to doctor's advice, and "intermittent" means not taking medicine according to doctor's advice, and the frequency or quantity of taking medicine is insufficient. "Not taking medicine" means that the doctor prescribed medicine, but the patient was useless. 6. Adverse drug reactions: If the drug taken by the patient has obvious adverse drug reactions, it should be specifically described which drug and which adverse reactions. 7. Classification of this follow-up: Choose according to the overall situation of patients from the last follow-up to this follow-up. 8. Referral: According to the patient's follow-up, determine whether to refer. If the patient is recommended for referral, fill in the specific name of the referral hospital. 9. Drug use: according to the overall situation of the patient, fill in the name of the antipsychotic drug that the patient will take, and indicate the usage. 10. Rehabilitation measures: according to the patient's follow-up, the rehabilitation measures that should be taken are given, and multiple choices can be made. 1 1. Next follow-up date: The next follow-up time will be determined according to the patient's condition.